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IMPORTANCE Physical rehabilitation in the intensive care unit (ICU) may improve the outcomes of patients with acute respiratory failure. OBJECTIVE To compare standardized rehabilitation therapy (SRT) to usual ICU care in acute respiratory failure. DESIGN, SETTING, AND PARTICIPANTS Single-center, randomized clinical trial at Wake Forest Baptist Medical Center, North Carolina. Adult patients (mean age, 58 years; women, 55%) admitted to the ICU with acute respiratory failure requiring mechanical ventilation were randomized to SRT (n=150) or usual care (n=150) from October 2009 through May 2014 with 6-month follow-up. INTERVENTIONS Patients in the SRT group received daily therapy until hospital discharge, consisting of passive range of motion, physical therapy, and progressive resistance exercise. The usual care group received weekday physical therapy when ordered by the clinical team. For the SRT group, the median (interquartile range [IQR]) days of delivery of therapy were 8.0 (5.0–14.0) for passive range of motion, 5.0 (3.0–8.0) for physical therapy, and 3.0 (1.0–5.0) for progressive resistance exercise. The median days of delivery of physical therapy for the usual care group was 1.0 (IQR, 0.0–8.0). MAIN OUTCOMES AND MEASURES Both groups underwent assessor-blinded testing at ICU and hospital discharge and at 2, 4, and 6 months. The primary outcome was hospital length of stay (LOS). Secondary outcomes were ventilator days, ICU days, Short Physical Performance Battery (SPPB) score, 36-item Short-Form Health Surveys (SF-36) for physical and mental health and physical function scale score, Functional Performance Inventory (FPI) score, Mini-Mental State Examination (MMSE) score, and handgrip and handheld dynamometer strength. RESULTS Among 300 randomized patients, the median hospital LOS was 10 days (IQR, 6 to 17) for the SRT group and 10 days (IQR, 7 to 16) for the usual care group (median difference, 0 [95% CI, −1.5 to 3], P = .41). There was no difference in duration of ventilation or ICU care. There was no effect at 6 months for handgrip (difference, 2.0 kg [95% CI, −1.3 to 5.4], P = .23) and handheld dynamometer strength (difference, 0.4 lb [95% CI, −2.9 to 3.7], P = .82), SF-36 physical health score (difference, 3.4 [95% CI, −0.02 to 7.0], P = .05), SF-36 mental health score (difference, 2.4 [95% CI, −1.2 to 6.0], P = .19), or MMSE score (difference, 0.6 [95% CI, −0.2 to 1.4], P = .17). There were higher scores at 6 months in the SRT group for the SPPB score (difference, 1.1 [95% CI, 0.04 to 2.1, P = .04), SF-36 physical function scale score (difference, 12.2 [95% CI, 3.8 to 20.7], P = .001), and the FPI score (difference, 0.2 [95% CI, 0.04 to 0.4], P = .02). CONCLUSIONS AND RELEVANCE Among patients hospitalized with acute respiratory failure, SRT compared with usual care did not decrease hospital LOS.

T he heart has its reasons which the mind does not sus|>cct. In a survey of street parties in East London nothing was more remarkable than the complete inability of people to say why they thought important the occasion they were honouring with such elaborate ritual, and the newspapers naturally took for granted the behaviour on which this essay is a comment. What is perhaps more strange is that on the monarchy, at a Coronation or any other time, political sdence and phibophy too are silent. About this most august institution there is no serious discussion at all. Some political scientists, as if sure that the end of so many nineteenth century reformers has been achieved, tend to speak as if Britain is now an odd kind of republic,^ which happens to have as its chief functionary a Queen instead of a President. It seems that even the most eminent scholars lose their sureness of touch when they enter the presence of Royalty. Sir Ivor Jennings has nothing to say in his volume on Parliament,* and in his Cabinet Government,* pausing only to note that the Sovereign still possesses considerable influence on legislation and that the King is also an important part of the 'social structure', he gives nearly all his space on this subject to an historical treatment of the Victorian period. The late Professor Harold Laski was more discerning, even though his preferences belong to the more rationalistic phase of recent intellectual history. 'Eulogy of its habits', he says, speaking of the monarchy, 'has reached a level of intensity more comparable with the religious ecstasy of the seventeenth century, when men could still believe in the divine right of kings, than of the scientific temp>er of the twentieth, which has seen three great imperial houses broken, and the King of Spain transformed into a homeless wanderer'.* For the rest, while lightly attributing this change in attitude to the imperial propaganda conducted since Victoria was proclaimed Empress of India, he too devotes himself to constitutional history, with special reference to the tangled events of igi i and 1931. Recent British political philosophy is as applicable to a republic as it is to a monarchy, whose place in a modem society is a subject most studiously avoided.' 14 63 2 Edward Shils and Michael ToungKingsley Martin is almost the only modem political writer to concern himself with the theme to which Walter Bagehot gave such prominence when he set out in 1867 to trace 'how the actions of a retired widow and an unemployed youth become of such importance'.' Bagehot firmly recognized that the role ofthe Crown was not so much constitutional as 'psychological'. He supported the monarchy for the precise reason that republicans opposed it: because it enabled the educated ten thousand to go on governing as before. By commanding their unbounded loyalty, it tamed the uncouth 'labourers of Somersetshire* who, in their simplicity, needed a person to symbolize the State. In this way 'the English Monarchy strengthens our government with the strength of reliijion. ... It gi...

Publication of a trial demonstrating large mortality reductions using small tidal volume was associated with significant reductions in tidal volume delivered to patients with ALI/ARDS. However, wide variation in practice persists, and the proportion of patients receiving tidal volumes within recommended limits (< or =8 mL/kg) remains modest.