Does Immersion in Water during Labor Decrease the Likelihood of Perineal Tears?

OBJECTIVE: The objective of this review is to determine whether or not “Does water immersion in the course of labor decrease the risk of perineal injury during vaginal delivery?”STUDY DESIGN: Review of three English Language primary studies published in 1996, 2001 and 2002.DATA SOURCES: Two Randomized, Double-Blind, Controlled trials as well as One Case Control Study which evaluated Maternal and Neonatal Outcomes during labor and delivery were found using PubMed and Cochrane Databases.OUTCOME MEASURED: Each study looked at women who used water immersion during labor and those that did not. The outcomes measured were those regarding maternal and neonatal outcomes, including Perineal Trauma of varying degrees. Visual Inspection was the method employed by experienced clinicians evaluating the women after giving birth to determine the extent, if any, of damage to the perineum. Women were given a rating of Intact, Episiotomy, First, Second, Third, and in one study, Fourth degree tear. P-values were employed to assess clinical significance of outcomes measured.RESULTS: All of the studies showed that immersion in water during labor does not significantly reduce the likelihood of perineal tearing.CONCLUSION: Results of the studies measuring perineal tears in women using water immersion during labor demonstrate that water immersion during labor has no effect on the likelihood of perineal injury. The only study in which women were allowed to give birth into the water itself showed a significant decrease in the risk of vaginal trauma in women who give birth in water. Further research is warranted to determine whether actual delivery into water vs. land has a beneficial outcome for women with regard to perineal trauma and long-term sequelae

The optimal rating philosophy for the rating of SMEs

The objective of this research is to determine the optimal rating philosophy for the rating of SMEs, and to describe the consequences of the chosen philosophy on several related aspects. As to our knowledge, this is the first paper that studies the considerations of financial institutions on what rating philosophy to adopt for specific portfolios. The importance for banks to have a solid risk framework to predict credit risk of their counterparties is well reflected by the quality and the quantity of research on this subject. Moreover, a good risk framework is vital to become compliant with the new Basel II framework. Problem is that financial institutions nearly always neglect the first step in the rating model development process: the determination of the rating philosophy. It is very important for financial institutions to decide whether they want their internal rating systems to grade borrowers according to their current condition (point-in-time), or their expected condition over a cycle and in stress (through-the-cycle), because the rating philosophy influences many aspects such as: credit approval, pricing, credit and portfolio monitoring, the regulatory and internal capital requirements and the competitive position of a bank. This makes the question which rating philosophy to use very important. Moreover, many different modelling techniques exist to determine credit risk, but few attempts have been devoted to credit risk assessment of small commercial loans, although SME exposures are relatively important for European banks. SMEs have specific characteristics that influence the rating philosophy and therefore the development and use of credit risk models. These SME characteristics are taken into account in the analysis to determine the optimal rating philosophy. Keywords: rating philosophy, small business, Basel II, credit rating, banks JEL classification codes: D82, E32, G20, G28, G3

Selective Variceal Decompression: Current Status

Since its introduction into clinical practice in 1967, selective variceal decompression by means of a distal splenorenal shunt (DSRS) has become one of the more commonly performed portal-systemic shunting procedures in the treatment of variceal hemorrhage throughout the world. In addition to selective decompression of gastroesophageal varices, the DSRS provides the advantages of preservation of portal perfusion of the liver and maintenance of intestinal venous hypertension. Many large, uncontrolled series and the majority of controlled randomized studies have demonstrated a lower incidence of encephalopathy after the DSRS than after nonselective shunt procedures. A secondary advantage of the DSRS is that the hepatic hilum is avoided, thus making subsequent liver transplantation a less formidable procedure. None of the studies have shown an advantage to this shunt with respect to longterm survival in patients with alcoholic cirrhosis. However, some of the large, uncontrolled series have shown that survival is significantly improved in patients with non-alcoholic cirrhosis compared to nonselective shunt procedures in the same population. Controlled trials comparing the DSRS to endoscopic sclerotherapy have shown that chronic endoscopic variceal sclerosis is an appropriate initial therapy for most patients as long as shunt surgery is readily available if sclerotherapy fails

Emergency Portacaval Shunts: Is Orloff Correct?

A prospective randomized trial was conducted in unselected, consecutive pateints with bleeding esophageal varices resulting from cirrhosis comparing (1) emergency portacaval shunt performed within 8 hr of initial contact (21 patients) with (2) emergency medical therapy (intravenous vasopressin and esophageal balloon tamonade) followed in 9 to 30 days by elective portacaval shunt in survivors (22 patients). All patients underwent the same diagnostic workup within 3 to 6 hr of initial contact, and received indentical supportive therapy initially. All patients were followed up for atleast 10 hr. The protocol contained no escape or crossover provisions. There were no statistically significant differences between the two treatment groups in the incidence of any of the clinical variables, results of laboratory tests or degree of portal hypertension. Child's risk classes in the shunt group were A-2 patients, B-8 patients and C-11 patients, whereas in the medical group they were A-10 patients, B-5 patients, and C-7 patients, a significant difference (p<0.01) that might have favored emergency medical treatment. Bleeding was controlled initially and permanently by emergency shunt in every patient, but by medical therapy in only 45% (p<0.001). Mean requirement for blood transfusion was 7.1±2.6 units in the shunt group and 21.4±2.6 units in the medical group (p<0.001). Eighty-one percent of the pateints in the shunt group were discharged alive compared with 45% in the medical group (p=0.027). Five- and 10-yr observed survival rates were 67% and 57%, respectively, after emergency shunt compared with 18% and 18%, respectively, after the combination of emergency medical therapy and elective shunt (p<0.01). These survival rates produced by emergency shunt performed within 8 hr of initial contact confirm the effectiveness of this procedure observed in our previous unrandomized studies

Factors Associated with Poly Drug Use in Adolescents

Poly drug use in adolescents represents a significant public health issue, heightening risk for abuse, dependency, and a variety of short- and long-term psychological, psychosocial, and health consequences. However, past studies have typically examined just one or two substances in isolation and there is a lack of research that has comprehensively examined possible predictors of poly drug use in adolescents. To inform the development of comprehensive prevention programs that can simultaneously target multiple substances, the present study sought to identify psychological, environmental, and demographic factors that are most strongly associated with alcohol, tobacco, and cannabis poly drug use. Adolescents aged 15 to 17 years (n = 1661; 50.9% male) completed a survey on their use of alcohol, tobacco, and cannabis over the last 30 days. Various psychological, environmental, and demographic factors were also assessed. Weighted multiple-level logistic regression was conducted to assess the factors associated with poly drug use. In total, 20.3% of respondents had used at least one substance, 6.7% reported using two substances, and 3.3% reported using all three substances. The most common combined pattern of use was alcohol and tobacco, followed by alcohol and cannabis. Several factors emerged as significant, with conduct problems, depression, and the school environment accounting for the most variance. Specific psychological and environmental factors appear to be particularly important domains to target in adolescent substance use prevention programs. Early identification of adolescent depression and conduct problems and the development of programs that address these symptoms in youth may be effective approaches to delaying or preventing poly drug use in this population