Experiences of breast feeding at work for physicians, residents and medical students: a scoping review.

OBJECTIVE: To review and summarise the available literature regarding breastfeeding experiences of medical students, residents and physicians. ELIGIBILITY CRITERIA: Articles of any design, including non-peer reviewed data that examine the experiences of breast feeding of medical students, residents and staff physicians. INFORMATION SOURCES: Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations and Daily, Ovid EMBASE, Scopus and Web of Science. RISK OF BIAS: All peer-reviewed studies underwent risk-of-bias assessment using relevant tools, depending on the study design. INCLUDED STUDIES: We included 71 citations; 51 surveys, 3 narrative descriptions, 9 editorials or letters to the editor, and 3 reviews. SYNTHESIS OF RESULTS: Included articles were heterogeneous with respect to their study design, target population and outcomes reported. Most articles had a high risk of bias. Only five articles reported the impact of an intervention. DESCRIPTION OF EFFECT: Despite heterogeneity, the majority of articles described important barriers to breast feeding for physicians, residents and medical students. These barriers were similar across studies, and included inadequate and inaccessible space, time constraints and inflexible scheduling, and lack of colleague support. The consequences of these barriers included low milk supply and early discontinuation of breast feeding. STRENGTHS AND LIMITATIONS OF EVIDENCE: Due to the observed heterogeneity of articles identified in this review, we are unable to assess trends in barriers or duration of breastfeeding over time. INTERPRETATION: Interventions to overcome systemic and cultural barriers to breast feeding are needed to meet legal obligations of workplaces for physicians and trainees. These interventions should be formally evaluated using implementation science or quality improvement methods.

Prediction of Early Adverse Events in Emergency Department Patients With Acute Heart Failure: A Systematic Review.

BACKGROUND: Acute heart failure (AHF) accounts for a substantial proportion of Emergency Department (ED) visits and hospitalizations. Previous studies have shown that emergency physicians' clinical gestalt is not sufficient to stratify patients with AHF into severe and requiring hospitalization vs nonsevere and safe to be discharged. Various prognostic algorithms have been developed to risk-stratify patients with AHF, however there is no consensus as to the best-performing risk assessment tool in the ED. METHODS: A systematic review of Medline, PubMed, and Embase up to May 2016 was conducted using established methods. Major cardiology and emergency medicine conference proceedings from 2010 to 2016 were also screened. Two independent reviewers identified studies that evaluated clinical risk scores in adult (ED) patients with AHF, with risk prognostication for mortality or significant morbidity within 7-30 days. Studies included patients who were discharged or admitted. RESULTS: The systematic review search generated 2950 titles that were screened according to title and abstract. Nine articles, describing 6 risk prediction tools met full inclusion criteria, however, prognostic performance and ease of bedside application is limited for most. Because of clinical heterogeneity in the prognostic tools and study outcomes, a meta-analysis was not performed. CONCLUSIONS: Several risk scores exist for predicting short-term mortality or morbidity in ED patients with AHF. No single risk tool is clearly superior, however, the Emergency Heart Failure Mortality Risk Grade might aid in prognostication of mortality and the Ottawa Heart Failure Risk Score might provide useful prognostic information in patients suitable for ED discharge.

Leg Lift Valsalva Maneuver for Treatment of Supraventricular Tachycardias.

Clinical question Can conversion to sinus rhythm for a supraventricular tachycardia be enhanced by a postural modification to the Valsalva maneuver? Article chosen Appelboam A, Reuben A, Mann C, et al. Postural modification of the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial. Lancet 2015;386(10005):1747-53. 1 OBJECTIVE: To determine effectiveness of a postural modification of the Valsalva involving leg elevation and supine positioning.