A new A4 amyloid mRNA contains a domain homologous to serine proteinase inhibitors

The amyloid proteins isolated from neuritic plaques and the cerebrovasculature of Alzheimer's disease are self-aggregating moieties termed A4 protein and beta-protein, respectively. A putative A4 amyloid precursor (herein termed A4(695] has been characterized by analysis of a human brain complementary DNA. We report here the sequence of a closely related amyloid cDNA, A4(751), distinguished from A4(695) by the presence of a 168 base-pair (bp) sequence which adds 57 amino acids to, and removes one residue from, the predicted A4(695) protein. The peptide predicted from this insert is very similar to the Kunitz family of serine proteinase inhibitors. The two A4-specific messenger RNAs are differentially expressed: in a limited survey, A4(751) mRNA appears to be ubiquitous, whereas A4(695) mRNA has a restricted pattern of expression which includes cells from neuronal tissue. These data may have significant implications for understanding amyloid deposition in Alzheimer's disease.

Oral vitamin D3 and calcium for secondary prevention of low-trauma fractures in elderly people (Randomised Evaluation of Calcium Or vitamin D, RECORD): a randomised placebo-controlled trial

BACKGROUND

Elderly people who have a fracture are at high risk of another. Vitamin D and calcium supplements are often recommended for fracture prevention. We aimed to assess whether vitamin D3 and calcium, either alone or in combination, were effective in prevention of secondary fractures.

METHODS

In a factorial-design trial, 5292 people aged 70 years or older (4481 [85%] of whom were women) who were mobile before developing a low-trauma fracture were randomly assigned 800 IU daily oral vitamin D3, 1000 mg calcium, oral vitamin D3 (800 IU per day) combined with calcium (1000 mg per day), or placebo. Participants who were recruited in 21 UK hospitals were followed up for between 24 months and 62 months. Analysis was by intention-to-treat and the primary outcome was new low-energy fractures.

FINDINGS

698 (13%) of 5292 participants had a new low-trauma fracture, 183 (26%) of which were of the hip. The incidence of new, low-trauma fractures did not differ significantly between participants allocated calcium and those who were not (331 [12.6%] of 2617 vs 367 [13.7%] of 2675; hazard ratio (HR) 0.94 [95% CI 0.81-1.09]); between participants allocated vitamin D3 and those who were not (353 [13.3%] of 2649 vs 345 [13.1%] of 2643; 1.02 [0.88-1.19]); or between those allocated combination treatment and those assigned placebo (165 [12.6%] of 1306 vs 179 [13.4%] of 1332; HR for interaction term 1.01 [0.75-1.36]). The groups did not differ in the incidence of all-new fractures, fractures confirmed by radiography, hip fractures, death, number of falls, or quality of life. By 24 months, 2886 (54.5%) of 5292 were still taking tablets, 451 (8.5%) had died, 58 (1.1%) had withdrawn, and 1897 (35.8%) had stopped taking tablets but were still providing data for at least the main outcomes. Compliance with tablets containing calcium was significantly lower (difference: 9.4% [95% CI 6.6-12.2]), partly because of gastrointestinal symptoms. However, potentially serious adverse events were rare and did not differ between groups.

INTERPRETATION

The findings do not support routine oral supplementation with calcium and vitamin D3, either alone or in combination, for the prevention of further fractures in previously mobile elderly people.

Regulatory role for macrophage migration inhibitory factor in acute respiratory distress syndrome

Migration inhibitory factor (MIF) is known to exert significant pro-inflammatory effects and has the potential to override the anti-inflammatory action of glucocorticoids. In this study we have identified significant quantities of MIF in the alveolar airspaces of patients with acute respiratory distress syndrome (ARDS). We show in alveolar cells from patients with ARDS that MIF augments pro-inflammatory cytokine secretion (TNF alpha and IL-8), anti-MIF significantly attenuates TNF alpha and IL-8 secretion and MIF overrides, in a concentration-related fashion, the anti-inflammatory effects of glucocorticoids. These findings suggest that MIF may act as a mediator sustaining the pulmonary inflammatory response in ARDS and that an anti-MIF strategy may represent a novel therapeutic approach in inflammatory diseases such as ARDS.

Evidence for safety and efficacy of DOTAP cationic liposome mediated CFTR gene transfer to the nasal epithelium of patients with cystic fibrosis

In cystic fibrosis (CF), mutation of the cystic fibrosis transmembrane conductance regulator (CFTR) gene results in defective transepithelial ion transport, leading to life shortening inflammatory lung disease. Before lung studies, we tested the safety and efficacy of gene delivery to the nasal epithelium of CF patients using pCMV-CFTR-DOTAP cationic liposome complex. A single dose of 400 micrograms pCMV-CFTR:2.4 mg DOTAP was administered in a randomised, double-blinded fashion to the nasal epithelium of eight CF patients, with a further eight receiving buffer only. Patients were monitored for signs and symptoms for 2 weeks before treatment and 4 weeks after treatment. Inflammatory cells were quantified in a nasal biopsy taken 3 days after treatment. There was no evidence for excess nasal inflammation, circulating inflammatory markers or other adverse events ascribable to active treatment. Gene transfer and expression were assayed by the polymerase chain reaction. Transgene DNA was detected in seven of the eight treated patients up to 28 days after treatment and vector derived CFTR mRNA in two of the seven patients at +3 and +7 days. Transepithelial ion transport was assayed before and after treatment by nasal potential difference during drug perfusion and by SPQ fluorescence halide ion conductance. Partial, sustained correction of CFTR-related functional changes toward normal values were detected in two treated patients. The level of gene transfer and functional correction were comparable to those reported previously using adenoviral vectors or another DNA-liposome complex, but here were sustained and uncompromised by false positives. These results justify further studies with pCMV-CFTR-DOTAP aimed at treating CF lung disease.

Precipitation casting of polycaprolactone for applications in tissue engineering and drug delivery

Microporous materials have been produced by gradual precipitation from solutions of poly(epsilon-caprolactone) (PCL) in acetone induced by solvent extraction across a semi-permeable PCL membrane which is formed in situ at the polymer solution/non-solvent interface. Microparticulates of hydroxyapatite and inulin polysaccharide, respectively, were incorporated in precipitation cast PCL matrices to illustrate potential applications in hard tissue repair and macromolecular drug release. Microporous PCL and HA filled PCL materials were found to provide a favourable surface for attachment and growth of primary human osteoblasts in cell culture. The in vitro degradation characteristics of microporous PCL and inulin/PCL materials in PBS at 37 degrees C were monitored over 45 months. Microporous PCL demonstrated zero weight loss, minor changes in molecular weight characteristics and a fairly constant indentation resistance of around 1 MN/m2. Inulin-loaded PCL materials exhibited a total weight loss of approximately 17% after 12 months in PBS. The indentation resistance decreased by 50% from an initial value of 28 MN/m2 in the first 2 months and then remained stable. Precipitation cast materials based on PCL are expected to be useful for formulating long-term, controlled release devices for bioactive molecules such as growth factors and hormones and extended-residence supports for cell growth and tissue development.

A workingperson's guide to deconvolution in light microscopy

Thefluorescence microscope is routinely used to study cellular structure in many biomedical research laboratories and is increasingly used as a quantitative assay system for cellular dynamics. One of the major causes of image degradation in the fluorescence microscope is blurring. Deconvolution algorithms use a model of the microscope imaging process to either subtract or reassign out-of-focus blur. A variety of algorithms are now commercially available, each with its own characteristic advantages and disadvantages. In this article, we review the imaging process in the fluorescence microscope and then discuss how the various deconvolution methods work. Finally, we provide a summary of practical tips for using deconvolution and discuss imaging artifacts and how to minimize them.

Incidence of distal forearm fracture in British men and women

Fracture of the distal forearm is one of the most frequent osteoporotic fractures. However, there are few data concerning its incidence in Britain. The aim of this study was to determine the incidence of distal forearm fracture in adult British men and women. Six centers took part in the study: Aberdeen, Hull, Nottingham, Portsmouth, Southampton and Truro. At each center, men and women aged 35 years and over with an incident distal forearm fracture and who resided in the catchment area of the main hospital at that center, were identified during a 12 month period. Incident fractures were identified from all possible point-of-contact sources in each locality, including accident and emergency records, fracture clinics, ward listings and plaster room registers. The population at risk was defined geographically according to postcode and the denominator obtained from 1991 census data mapped to these postcodes. During the 12 month study period, 3161 individuals with distal forearm fracture were identified. The age-adjusted incidence, age 35 years and over, was 36.8/10,000 person-years in women and 9.0/10,000 person-years in men. In women, the incidence of fracture increased progressively with age from the perimenopausal period, while in men the incidence remained low until later life. Fractures were more frequently left-sided (55.6%) and 19.4% of subjects required hospitalization. On the basis of these data we estimate that 71,000 adult men and women sustain a distal forearm fracture in Britain each year. Compared with previous British surveys the pattern of incidence with age appears to have changed in women, the reason for this is unclear.

The management of acute acromioclavicular dislocation. A randomised prospective controlled trial

In a prospective study, 60 patients with acute acromioclavicular dislocation were randomly allocated to treatment with a broad arm sling or to reduction and fixation with a coracoclavicular screw. Of these 54 were followed for four years. Conservatively-treated patients regained movement significantly more quickly and fully, returned to work and sport earlier and had fewer unsatisfactory results than those having early operation. For severe dislocations, with acromioclavicular displacement of 2 cm or more, early surgery produced better results. Conservative management is best for most acute dislocations, but younger patients with severe displacement may benefit from early reduction and stabilisation.

Endobronchial and endoscopic ultrasound-guided real-time fine-needle aspiration for mediastinal staging

Accurate staging of the mediastinum in lung cancer is essential for optimising treatment strategies. Conventional transbronchial needle aspiration (TBNA) is a blind procedure, reliant upon prior computed tomography (CT) or ultrasound imaging, but has low sensitivity. The current study reports the initial experience of using a prototype endobronchial ultrasound (EBUS) probe that allows TBNA under real-time imaging. In 20 patients selected by CT scanning, a linear-array ultrasound bronchoscope was used to visualise paratracheal and hilar lymph nodes, and TBNA was performed under direct ultrasonic control. In seven cases, sequential endoscopic ultrasound (EUS) was used to assess postero-inferior mediastinal lymph nodes. All procedures were performed under conscious sedation. EBUS-TBNA was undertaken in 18 out of 20 cases and EUS-guided fine-needle aspiration in six out of seven cases. Cytology showed node (N)2/N3 disease in 11 out of 18 EBUS-TBNA cases and provided a primary diagnosis for eight patients. EBUS-TBNA cytology was negative in six cases, which was confirmed by mediastinoscopy or clinical follow-up in four. EUS provided additional information in all cases. There were no procedural complications. Sensitivity, specificity and accuracy for EBUS-TBNA were 85%, 100% and 89%, respectively. In conclusion, endobronchial ultrasound with real-time transbronchial needle aspiration offers improved sensitivity and accuracy for staging of the middle mediastinum, and, combined with endoscopic ultrasound, should allow investigation of the majority of the mediastinum.

A type 2 (Th2-like) pattern of immune response predominates in the pulmonary interstitium of patients with cryptogenic fibrosing alveolitis (CFA)

CFA is an inflammatory condition of the lungs resulting in scarring, pulmonary failure and death. The etiology of the disease is unknown, but the pathogenesis is believed to involve a persistent immunological reaction to unidentified antigen in the lung resulting in tissue damage. Recent advances in our understanding of the immune system have shown that different patterns of stimulatory cytokines are produced at sites of inflammation by a range of cell types. Patterns of cytokine reproduction by inflammatory cells are recognized to be associated with different patterns of immunological response, and these have been described as type 1 (or Th1-like) and type 2 (or Th2-like) on this basis. We have studied cytokine expression in the intestinal inflammatory cell infiltrate in lung tissue from patients with CFA using mRNA in situ hybridization and immunohistochemistry. Our results show that while there is evidence for both a type 1 (characterized by interferon-gamma (IFN-gamma) and type 2 (characterized by IL-4 and IL-5) response present in CFA, the type 2 (or Th2) pattern of cytokines appears to predominate. This would be consistent with a possible role for the humoral immune response in the pathogenesis of this condition. In addition, recent evidence suggests that IL-4 and IFN-gamma may be important regulatory factors for pulmonary fibroblasts. The relative paucity of IFN-gamma may contribute to the excessive fibroblast activation, deposition of collagen and scar formation that occurs in CFA.

Outcome after hemiarthroplasty for three- and four-part fractures of the proximal humerus

We reviewed 27 patients who had sustained displaced three- or four-part fractures of the proximal humerus and who were treated with a humeral hemiarthroplasty. Seventeen patients had a three-part fracture, and 10 had a four-part fracture. The mean follow-up period was 39 months (12 to 94 months). All fractures were classified according to Neer's classification. The Constant score was used for their follow-up evaluation. The median Constant score at follow-up was 51 for the three-part fractures and 46 for the four-part fractures. The median range of movement for all the patients in flexion was 70 degrees, abduction 70 degrees, internal rotation 50 degrees, and external rotation 45 degrees. Nine patients still had moderate or severe pain. Eight patients had moderate or severe disability. Our results were disappointing, and further studies on open reduction and fixation are therefore justified.

The increasing incidence of fractures of the proximal femur: an orthopaedic epidemic

The number of patients with fractures of the proximal femur admitted to the orthopaedic trauma unit in Nottingham has risen from 290 in 1971 to 612 in 1981. From 1971 to 1977 the rate of increase in incidence was approximately 6% per year but since 1977 it has risen to 10% per year. Between 1977 and 1981 the elderly population of Nottingham increased by less than 2% per year. Analysis of hospital admissions reveals a disproportionate increase in fractures of the proximal femur in women over the age of 75 years. The incidence of hip fractures in women over the age of 75 has increased from 8/1000/year in 1971 to 16/1000/year in 1981. Work is urgently required to establish prophylactic treatment for this group of patients.

Conservative treatment of fractures and fracture-dislocations of the upper end of the humerus

This paper reports a prospective study of 72 consecutive patients with fractures or fracture-dislocations of the upper end of the humerus, treated during 1981. Most were elderly and treatment was conservative. Of the 72 patients 64 were followed up for a period of six months. Observations were made on the type of fracture, the speed and pattern of recovery of shoulder movements, on the time of commencement of physiotherapy, and on its duration. We found that with conservative treatment alone, 94% of our patients had good or satisfactory results at six months from injury. The criteria for manipulation are discussed and the literature is reviewed.

Increased synthesis and accumulation of heat shock 70 proteins in Alzheimer's disease

Postmortem cortical tissues from Alzheimer's disease cases were found to contain significantly higher levels of the heat shock proteins hsp 72 and hsp 73 than control cortical tissues. This elevation was associated with the disease pathology in that it was not observed in Alzheimer's disease cerebella and was not correlated with perimortem characteristics such as age or cause of death of the patient or postmortem interval of the brain tissue. Examination of polysome translation products on two dimensional gels and by immunoprecipitation indicated that the syntheses of hsp 72/73 were increased in Alzheimer's disease tissues. In addition, immunoprecipitation of newly synthesized hsp 72 showed that numerous other nascent polypeptides were co-precipitated, which indicates an irreversible cotranslational association with the hsp 72. These results indicate that induction of specific heat shock proteins is associated with Alzheimer's disease and that cotranslational processes are affected by this induction.

Amyloid precursor protein in the cerebral cortex is rapidly and persistently induced by loss of subcortical innervation

Lesions of the cholinergic nucleus basalis of Meynert elevate the ex vivo synthesis of beta amyloid precursor protein (beta-APP) in the cerebral cortex, a major projection region. We have found that this elevation is reflected by increased levels of beta-APP mRNA. The induction is rapid (occurring 60 min after placement of the lesion) and persistent (remaining for at least 45 days after lesioning). Two other subcortical lesions, which result in reductions of cortical adrenergic and serotonergic innervation, similarly induced cortical beta-APP. The beta-APP induction is reversible and does not require loss of the subcortical neurons. Infusion of lidocaine, a calcium antagonist that disrupts neurotransmitter release, into the nucleus basalis of Meynert leads to the temporary reduction of released acetylcholine in the cortex. In this model, beta-APP mRNA levels are elevated shortly after the infusion of lidocaine (90 min) but return to preinfusion levels 7 days after the lidocaine treatment. However, metabolic stresses of the brain, including chronic physostigmine, glucocorticoid, and diabetogenic treatments, fail to induce the beta-APP response. These results suggest that the induction of beta-APP is a specific response to the loss of functional innervation in the cortex. Importantly, these studies show that cortical beta-APP is induced by lesions that mimic the neurochemical deficits most frequently observed in Alzheimer disease.

Differential effects of CD18, CD29, and CD49 integrin subunit inhibition on neutrophil migration in pulmonary inflammation

Neutrophil migration to lung alveoli is a characteristic of lung diseases and is thought to occur primarily via capillaries rather than postcapillary venules. The role of adhesion molecules CD18 and CD29 on this migration in a mouse model of lung inflammation has been investigated. The number of neutrophils present in bronchoalveolar lavage fluid was determined 4 h after intratracheal instillation of LPS (0.1-1 microg) or murine recombinant KC (CXC chemokine, 0.03-0.3 microg). Both stimuli produced a dose-related increase in neutrophil accumulation. Intravenous anti-mouse CD18 mAb, 2E6 (0.5 mg/mouse), significantly (p < 0.001) attenuated LPS (0.3 microg)- but not KC (0.3 microg)-induced neutrophil accumulation. The anti-mouse CD29 mAb, HM beta 1-1 (0.02 mg/mouse), significantly (p < 0.05) inhibited both LPS (0.3 microg)- and KC (0.3 microg)-induced neutrophil migration. A second mAb to CD18 (GAME-46) and both F(ab')(2) and Fab of HM beta 1-1 produced similar results to those above, while coadministration of mAbs did not result in greater inhibition. Electron microscopy studies showed that CD29 was involved in the movement of neutrophils from the interstitium into alveoli. The effect of mAbs to CD49 (alpha integrin) subunits of CD29 was also examined. mAbs to CD49e and CD49f inhibited both responses, while anti-CD49b and CD49d significantly inhibited responses to KC only. These data suggest that CD29 plays a critical role in neutrophil migration in pulmonary inflammation and that CD49b and CD49d mediate CD18-independent neutrophil accumulation.

The geometry of the humeral head and the design of prostheses

The articular surface of the humeral head is usually described as facing posteromedially, making an angle of between 16 degrees and 35 degrees with the transepicondylar plane. At hemiarthroplasty the articular surface also appears to be offset posteriorly with respect to the humeral shaft. Coracoid impingement may occur if this offset is not accommodated. An analysis was made of 29 cadaveric humeri using an industrial co-ordinate measuring machine. The position of the centre of the head was defined with respect to the humeral shaft and transepicondylar plane. The humeral articular surface was found to be retroverted by 21.4 degrees and its centre offset posteriorly by 4.7 mm. Previous interpretation of retroversion did not take into account the posterior displacement, and this may be of importance in improving future prosthetic design.

Impact-absorbing properties of the human knee

A biomechanical study has been carried out on 20 cadaveric knees to investigate their load-absorbing mechanism. The impact load was applied using a weight falling onto the transected proximal femur and the force transmitted through the knee was measured at the transected distal tibia using a load transducer. The peak force transmitted increased as, sequentially, meniscus, articular cartilage and subchondral bone were damaged or removed. The most striking result was found in an implanted knee replacement where the transmitted force reached 180% of that in the intact knee. The results show that the joint has an impact-absorbing property in each segment and that in the osteoarthritic knee there is less absorption of shock than in the normal knee. The high impact force in an implanted knee suggests that microfractures of the cancellous bone might be expected and may produce loosening.

Development of IgE and allergy in infancy

Serum IgE levels were followed throughout the first year of life in a sample of 34 infants from atopic and nonatopic families. Their parents' serum IgE levels were also measured. Neonatal levels ranged from 0 to 10 U/ml. Half of the study group, which included a high proportion of infants from atopic families, maintained serum IgE levels below 10 U/ml until 1 yr of age. In the remainder, the serum IgE exceeded 10 U/ml before 1 yr of age, but the time of increase and the rate of increase varied from infant to infant; the sooner the IgE started to increase, the higher was the serum IgE level at 1 yr of age. The relationship of serum IgE level to the development of atopic disease and to other parameters was analyzed. Elevation of serum IgE level at or before 1 yr of age was highly correlated with atopic disease in the first 2 yr of life. The elevation preceded the manifestation of atopy.

Trends in dental fluorosis and dental caries prevalences in Newburgh and Kingston, NY

A study was undertaken in New York State to determine the changes in dental fluorosis prevalence from 1955 to 1986 in fluoridated Newburgh and non-fluoridated Kingston children. The frequency and severity of dental fluorosis among 884 7-14-year-old children were measured by two dentists utilizing Dean's Index. Data regarding residential and fluoride history were obtained from the parents of participants. Among the Newburgh residents, the prevalence of dental fluorosis (very mild to moderate) varied from a low of 5 per cent for the 9-10-year-old group to a high of 9.4 per cent for 11-12-year-olds. Except for the 13-14-year-old group, children in non-fluoridated Kingston had the lowest dental fluorosis prevalence rates. A comparison of Dean's Community Fluorosis Indices to the 1955 baseline data obtained from studies conducted after 10 years of fluoridation in Newburgh revealed no changes of consequence among Newburgh residents. However, the changes are apparent for Kingston residents, indicating the availability of fluorides in non-fluoridated areas. The increased risk for dental fluorosis for Kingston residents appears to be from the use of fluoride tablets. An analysis of dental caries data revealed that caries prevalence declined substantially in both fluoridated and non-fluoridated areas.

A controlled prospective trial of a foot orthosis for juvenile hallux valgus

In a survey of 6000 children between 9 and 10 years of age, 122 were found to have unilateral or bilateral hallux valgus. These children were randomly assigned to no treatment or to the use of a foot orthosis. About three years later 93 again had radiography. The metatarsophalangeal joint angle had increased in both groups but more so in the treated group. During the study, hallux valgus developed in the unaffected feet of children with unilateral deformity, despite the use of the orthosis.

Early femoral loosening in one design of cemented hip replacement

We have studied aseptic loosening of the femoral component in 76 patients with primary total hip replacement using the Capital prosthesis. The mean follow-up was 26 months (10 to 37). Twelve femoral components (16%) were definitely and eight (10%) were possibly loose. They were characterised by a thin cement mantle (p < 0.001) and excessive residual cancellous bone in the proximomedial region (p < 0.01). We recommend that the cement mantle around the prosthesis should be 2 to 3 mm and that further long-term studies are needed to evaluate the wear properties of titanium-nitride-coated titanium femoral heads.

Intra-articular distension and steroids in the management of capsulitis of the shoulder

OBJECTIVE

To determine whether there is any synergistic effect in the administration of intraarticular steroids with distension in the management of early capsulitis of the shoulder.

DESIGN

Prospective randomised trial of three treatments--namely distension only, steroid only, and steroid with distension.

SETTING

Academic department of orthopaedic and accident surgery at Queen's Medical Centre, Nottingham.

SUBJECTS

47 patients (30 women) with capsulitis affecting 50 shoulders.

INTERVENTIONS

Three intra-articular injections into the shoulder given at six week intervals by the same technique.

MAIN OUTCOME MEASURES

Passive range of abduction, forward flexion, and external rotation; results of shoulder dynamometry measuring work done and torque produced; pain levels at rest and with resisted movement.

RESULTS

All patients reported improvement during the study. Analysis of the mean improvements in abduction and forward flexion showed these to be significantly greater in the steroid with distension and steroid only groups than in the distension only group (mean improvements in abduction (degrees/week (95% confidence interval)) 4.3 (3.4 to 5.2), 3.4 (2.4 to 4.5), and 1.0 (-0.8 to 2.8) in the three groups respectively; mean improvements in flexion (degrees/week (95% confidence interval)) 3.6 (3.2 to 4.0), 3.3 (2.3 to 4.3), and 1.5 (0.5 to 2.5) respectively). Shoulder dynamometry failed to show a significant difference among the treatment groups. No severe complications occurred as a result of the injections, but two patients reported facial flushing related to the use of steroids.

CONCLUSION

Intra-articular steroid injections have a useful role in the outpatient management of early capsulitis.

Outcomes in post-ICU mechanical ventilation: a therapist-implemented weaning protocol

BACKGROUND

Therapist-implemented protocols have been used to extubate or wean patients in the ICU setting. Barlow Respiratory Hospital (BRH) functions as a center for weaning patients from prolonged mechanical ventilation (PMV) in the post-ICU setting of a long-term acute-care (LTAC) facility. A therapist-implemented patient-specific (TIPS) weaning protocol was developed at BRH to standardize weaning from PMV.

STUDY DESIGN

Prospective cohort study with historical control.

METHODS

A weaning protocol incorporating the procedures and pace of LTAC weaning was developed using available scientific evidence and expert consensus. After training of staff, collection and analysis of pilot data, and revisions and refinement of the protocol, the TIPS protocol was implemented hospital-wide. It was monitored for outcome, variance, and respiratory care practitioner (RCP) and physician compliance.

RESULTS

Forty-six RCPs worked with eight pulmonologists treating 271 consecutive patients admitted for weaning from PMV during an 18-month period. Nineteen patients were excluded from weaning attempts by any method after initial physician evaluation. The remaining 252 patients (9,135 total ventilator days) were compared with a group of 238 patients treated by the same physicians in the 2 years before instituting protocol weaning. Median time to wean declined significantly from 29 days in historical control subjects to 17 days for TIPS protocol patients (p < 0.001). Outcomes (scored at discharge) were comparable for the two groups (TIPS group vs control group): weaned, 54.7% vs 58.4%; ventilator-dependent, 17.9% vs 10.9%; died, 27.4% vs 30.7% (p = 0.10). Variances incurred by physicians and RCPs were 324 and 136, respectively, for the 9,135 ventilator days.

CONCLUSIONS

Patients weaned from PMV using a new therapist-implemented protocol at BRH, an LTAC facility specializing in weaning, had significantly shorter time to weaning than historical control subjects, with comparable outcomes. The weaning outcome data collected after the implementation of the TIPS protocol are in fact attributable to its use, as we found a high degree of compliance with the protocol.