COVID-19 Crisis: The Pandemic Highlights the Unique Training and Skills of Military Physicians Afforded by Military-Specific Graduate Medical Education.

Military physicians trained in military Graduate Medical Education programs are uniquely prepared to lead in austere and chaotic environments based on formal and informal curricula taught in military treatment facilities. The coronavirus disease-2019 pandemic highlighted this reality when military-trained physician leaders were challenged to lead change directly from the front.

Out-of-Hospital Birth.

Since the 1970s, most births in the United States have been planned to occur in a hospital. However, a small percentage of Americans choose to give birth outside of a hospital. The number of out-of-hospital births has increased, with one in every 61 U.S. births (1.64%) occurring out of the hospital in 2018. Out-of-hospital (or community) birth can be planned or unplanned. Of those that are planned, most occur at home and are assisted by midwives. Patients who choose a planned community birth do so for multiple reasons. International observational studies that demonstrate comparable outcomes between planned out-of-hospital and planned hospital birth may not be generalizable to the United States. Most U.S. studies have found statistically significant increases in perinatal mortality and neonatal morbidity for home birth compared with hospital birth. Conversely, planned community birth is associated with decreased odds of obstetric interventions, including cesarean delivery. Perinatal outcomes for community birth may be improved with appropriate selection of low-risk, vertex, singleton, term pregnancies in patients who have not had a previous cesarean delivery. A qualified, licensed maternal and newborn health professional who is integrated into a maternity health care system should attend all planned community births. Family physicians are uniquely poised to provide counseling to patients and their families about the risks and benefits associated with community birth, and they may be the first physicians to evaluate and treat newborns delivered outside of a hospital.

Multiple sclerosis: a primary care perspective.

Multiple sclerosis (MS) is the most common permanently disabling disorder of the central nervous system in young adults. Relapsing remitting MS is the most common type, and typical symptoms include sensory disturbances, Lhermitte sign, motor weakness, optic neuritis, impaired coordination, and fatigue. The course of disease is highly variable. The diagnosis is clinical and involves two neurologic deficits or objective attacks separated in time and space. Magnetic resonance imaging is helpful in confirming the diagnosis and excluding mimics. Symptom exacerbations affect 85% of patients with MS. Corticosteroids are the treatment of choice for patients with acute, significant symptoms. Disease-modifying agents should be initiated early in the treatment of MS to forestall disease and preserve function. Two immunomodulatory agents (interferon beta and glatiramer) and five immunosuppressive agents (fingolimod, teriflunomide, dimethyl fumarate, natalizumab, and mitoxantrone) are approved by the U.S. Food and Drug Administration for the treatment of MS, each with demonstrated effectiveness and unique adverse effect profiles. Symptom management constitutes a large part of care; neurogenic bladder and bowel, sexual dysfunction, pain, spasticity, and fatigue are best treated with a multidisciplinary approach to improve quality of life.

Improving women's experience during speculum examinations at routine gynaecological visits: randomised clinical trial.

OBJECTIVES: To determine if a standardised method of leg positioning without stirrups reduces the physical discomfort and sense of vulnerability and increases the sense of control among women undergoing speculum examination as part of a routine gynaecological examination. DESIGN: Randomised clinical trial. SETTING: Family medicine outpatient clinic. PATIENTS: 197 adult women undergoing routine gynaecological examination and cervical smear. INTERVENTION: Examination with or without stirrups. MAIN OUTCOME MEASURES: Women's perceived levels of physical discomfort, sense of vulnerability, and sense of control during the examination, measured on 100 mm visual analogue scales. RESULTS: Women undergoing examination without stirrups had a reduction in mean sense of vulnerability from 23.6 to 13.1 (95% confidence interval of the difference - 16.6 to - 4.4). Mean physical discomfort was reduced from 30.4 to 17.2 (- 19.7 to - 6.8). There was no significant reduction in sense of loss of control. CONCLUSION: Women should be able to have gynaecological examinations without using stirrups to reduce the stress associated with speculum examinations. TRIAL REGISTRATION: US Army Central Investigation Regulatory Office. Trial No DDEAMC 05-11.