Unplanned extubation in the ICU: a marker of quality assurance of mechanical ventilation

One of the most frequent complications associated with endotracheal intubation itself in intensive care units is unplanned extubation, which represents a potentially serious complication given that many patients may need reintubation while in poor condition. This scenario may account for an increase in morbidity and even in mortality. To be able to compare the rates of unplanned extubation in clinical practice, unplanned extubation should be expressed as incidence density of days at risk. Also, this complication (unplanned extubation and reintubation rates) may be used as a marker of quality of weaning care in intensive care units

Auge y colapso de la demanda de viviendas en España : factores determinantes

En este artículo se presenta un modelo de demanda de viviendas que permite analizar las causas que motivaron el boom inmobiliario protagonizado por la economía española, así como su posterior colapso. Según nuestro modelo, el boom tuvo su origen en el alza especulativa de precios, que produjo un doble efecto. Por un lado, el aumento de la riqueza inmobiliaria incrementó la capacidad financiera familiar, induciendo una mayor propensión al endeudamiento y a la inversión residencial. Por otro, el hecho de que la revalorización de la vivienda superara por momentos la cuota hipotecaria indujo un incremento adicional de la demanda de aquéllas. Sin embargo, estas fuerzas comenzaron a jugar en sentido contrario tras la explosión de la burbuja, provocando un brusco desplome de las compraventas. El modelo pone de relieve que la secular preferencia de los españoles por la vivienda en propiedad tenía un fundamento económico que ahora ha desaparecidoThis article presents a model for the demand for housing which allows one to analyze the determinants of the housing boom and bust experienced by the Spanish economy. According to this model, the boom was caused by a speculative increase in prices, which yielded two effects: on the one hand, the rise in wealth associated with the value of real estate increased households’ financial capacity, leading to a higher propensity to engage in debt and to invest in real estate. On the other hand, the fact that the appreciation in the value of housing was larger at certain times than the value of the mortgage to be paid, led to an even larger increase in the demand for housing. However, these forces began to act in the opposite direction after the bust of the housing bubble, causing an abrupt reduction in the demand for real estate. The model shows that the long term preference of Spaniards for house ownership rested on economic foundations which have now disappeare

Auge y colapso de la demanda de viviendas en España : factores determinantes

En este artículo se presenta un modelo de demanda de viviendas que permite analizar las causas que motivaron el boom inmobiliario protagonizado por la economía española, así como su posterior colapso. Según nuestro modelo, el boom tuvo su origen en el alza especulativa de precios, que produjo un doble efecto. Por un lado, el aumento de la riqueza inmobiliaria incrementó la capacidad financiera familiar, induciendo una mayor propensión al endeudamiento y a la inversión residencial. Por otro, el hecho de que la revalorización de la vivienda superara por momentos la cuota hipotecaria indujo un incremento adicional de la demanda de aquéllas. Sin embargo, estas fuerzas comenzaron a jugar en sentido contrario tras la explosión de la burbuja, provocando un brusco desplome de las compraventas. El modelo pone de relieve que la secular preferencia de los españoles por la vivienda en propiedad tenía un fundamento económico que ahora ha desaparecidoThis article presents a model for the demand for housing which allows one to analyze the determinants of the housing boom and bust experienced by the Spanish economy. According to this model, the boom was caused by a speculative increase in prices, which yielded two effects: on the one hand, the rise in wealth associated with the value of real estate increased households’ financial capacity, leading to a higher propensity to engage in debt and to invest in real estate. On the other hand, the fact that the appreciation in the value of housing was larger at certain times than the value of the mortgage to be paid, led to an even larger increase in the demand for housing. However, these forces began to act in the opposite direction after the bust of the housing bubble, causing an abrupt reduction in the demand for real estate. The model shows that the long term preference of Spaniards for house ownership rested on economic foundations which have now disappeare

La influencia de la riqueza financiera sobre el consumo privado : análisis de la experiencia española durante la “Gran Recesión”

En línea con la teoría dominante del consumo agregado, los estudios llevados a cabo en España sobre el comportamiento del consumo privado han confirmado el papel determinante de la renta real disponible y la riqueza real en la explicación de la evolución de este componente fundamental de la demanda global. Sin embargo, un análisis de las fluctuaciones que ha registrado el consumo privado en nuestro país durante la llamada Gran Recesión, si bien ratifica la relevancia explicativa de las variables señaladas, pone también de relieve que la riqueza total no parece el complemento idóneo para explicar las fluctuaciones recientes de esta variable. En contraste con los resultados de los últimos modelos del Banco de España, y en consonancia con los obtenidos por otros autores, nuestro análisis confirma, en efecto, que, junto con la renta real disponible, la evolución de la riqueza financiera resulta decisiva para explicar la evolución del consumo privado en España durante la última crisis, lo cual revaloriza el papel de las teorías que otorgan a las magnitudes financieras una influencia determinante en la generación de las fluctuaciones económicas. Esta conclusión es relevante para la política económica española, ya que la mejora que está experimentando la riqueza financiera en España, como consecuencia entre otras cosas de la reducción de la prima de riesgo, abre una válvula de escape, adicional a la de las exportaciones, en el círculo vicioso conformado por la secuencia “bajo consumo - bajo empleo – baja renta disponible – bajo consumo” que según el diagnóstico tradicional estaría cercenando cualquier posibilidad de recuperación autónoma por parte de nuestra economíaIn line with the main core of the theory of aggregate consumption, different studies undertaken in Spain confirm the leading role of real disposable income and real wealth in explaining the evolution of this important component of aggregate demand. However, an in-depth analysis of the fluctuations experienced by private consumption during the Great Recession shows that, while these variables are indeed very relevant when trying to explain the evolution of such consumption, it also shows that total wealth is not the most adequate complement to explain the most recent fluctuations of this variable. In contrast with the results of the latest models of the Bank of Spain and in line with what has been suggested by other authors, our analysis confirms that the evolution of financial wealth is, together with real disposable income, a decisive variable for explaining the evolution of private consumption during Spain’s last long crisis. This finding lends credit to the theories which attribute to financial variables a determining influence on the generation of economic cycles. This conclusion is relevant for Spanish economic policy, since the great expansion that financial wealth is experiencing as a results, among other things, from the reduction of the risk spread, opens a safety valve, along with exports, within the vicious cycle formed by the sequence “low consumption-low employment-low disposable income-low consumption” which, according to traditional diagnoses, would hinder any possibility for the autonomous recovery of our econom

Update in the management of severe traumatic brain injury

Traumatic brain injury is the main cause of death and disability in the young population, which presumes a large number of years of potential life lost and a great economic impact. Vital and functional outcomes after suffering a traumatic brain injury depend both on the severity of the initial biomechanical impact (primary injury) and on the presence and the severity of systemic or intracranial insults that magnify and/or produce new brain injuries, the so-called secondary injuries. Currently, no treatment in effective in improving functional recovery, except for usual medical care. Therefore, the main purpose of the care provided to a patient with severe cranial trauma is based on preventing and treating secondary brain injuries by maintaining an adequate cerebral perfusion and oxygenation. Increased intracranial pressure is associated with mortality and with unfavorable functional outcomes is patients with severe traumatic brain injury. The main clinical practice guidelines recommend using a number of staggered therapeutic measures. However, although these measures seem to be efficient in reducing intracranial pressure, this effect is not often translated into clinical improvement. This review describes the essential principles of the management of patients with severe traumatic brain injury in intensive care units

The implausibility of ‘usual care’ in an open system: sedation and weaning practices in Paediatric Intensive Care Units (PICUs) in the United Kingdom (UK)

Background: The power of the randomised controlled trial depends upon its capacity to operate in a closed system whereby the intervention is the only causal force acting upon the experimental group and absent in the control group, permitting a valid assessment of intervention efficacy. Conversely, clinical arenas are open systems where factors relating to context, resources, interpretation and actions of individuals will affect implementation and effectiveness of interventions. Consequently, the comparator (usual care) can be difficult to define and variable in multi-centre trials. Hence outcomes cannot be understood without considering usual care and factors that may affect implementation and impact on the intervention. Methods: Using a fieldwork approach, we describe PICU context, ‘usual’ practice in sedation and weaning from mechanical ventilation, and factors affecting implementation prior to designing a trial involving a sedation and ventilation weaning intervention. We collected data from 23 UK PICUs between June and November 2014 using observation, individual and multi-disciplinary group interviews with staff. Results: Pain and sedation practices were broadly similar in terms of drug usage and assessment tools. Sedation protocols linking assessment to appropriate titration of sedatives and sedation holds were rarely used (9 % and 4 % of PICUs respectively). Ventilator weaning was primarily a medical-led process with 39 % of PICUs engaging senior nurses in the process: weaning protocols were rarely used (9 % of PICUs). Weaning methods were variably based on clinician preference. No formal criteria or use of spontaneous breathing trials were used to test weaning readiness. Seventeen PICUs (74 %) had prior engagement in multi-centre trials, but limited research nurse availability. Barriers to previous trial implementation were intervention complexity, lack of belief in the evidence and inadequate training. Facilitating factors were senior staff buy-in and dedicated research nurse provision. Conclusions: We examined and identified contextual and organisational factors that may impact on the implementation of our intervention. We found usual practice relating to sedation, analgesia and ventilator weaning broadly similar, yet distinctively different from our proposed intervention, providing assurance in our ability to evaluate intervention effects. The data will enable us to develop an implementation plan; considering these factors we can more fully understand their impact on study outcomes