The strength of evidence is low but supports the association of IVC filter placement with a lower incidence of PE and fatal PE in trauma patients. Which patients experience benefit enough to outweigh the harms associated with IVC filter placement remains unclear. Additional well-designed observational or prospective cohort studies may be informative.

Background. Tuberculosis (TB) remains a global public health problem with known gender-related disparities. We reviewed the quantitative evidence for gender-related differences in accessing TB services from symptom onset to treatment initiation. Methods. Following a systematic review process, we: searched 12 electronic databases; included quantitative studies assessing gender differences in accessing TB diagnostic and treatment services; abstracted data; and assessed study validity. We defined barriers and delays at the individual and provider/system levels using a conceptual framework of the TB care continuum and examined gender-related differences. Results. Among 13,448 articles, 137 were included: many assessed individual-level barriers (52%) and delays (42%), 76% surveyed persons presenting for care with diagnosed or suspected TB, 24% surveyed community members, and two-thirds were from African and Asian regions. Many studies reported no gender differences. Among studies reporting disparities, women faced greater barriers (financial: 64% versus 36%; physical: 100% versus 0%; stigma: 85% versus 15%; health literacy: 67% versus 33%; and provider-/system-level: 100% versus 0%) and longer delays (presentation to diagnosis: 45% versus 0%) than men. Conclusions. Many studies found no quantitative gender-related differences in barriers and delays limiting access to TB services. When differences were identified, women experienced greater barriers and longer delays than men.

Background. Tuberculosis (TB) remains a significant global public health problem with known gender-related (male versus female) disparities. We reviewed the qualitative evidence (written/spoken narrative) for gender-related differences limiting TB service access from symptom onset to treatment initiation. Methods. Following a systematic process, we searched 12 electronic databases, included qualitative studies that assessed gender differences in accessing TB diagnostic and treatment services, abstracted data, and assessed study validity. Using a modified “inductive coding” system, we synthesized emergent themes within defined barriers and delays limiting access at the individual and provider/system levels and examined gender-related differences. Results. Among 13,448 studies, 28 studies were included. All were conducted in developing countries and assessed individual-level barriers; 11 (39%) assessed provider/system-level barriers, 18 (64%) surveyed persons with suspected or diagnosed TB, and 7 (25%) exclusively surveyed randomly sampled community members or health care workers. Each barrier affected both genders but had gender-variable nature and impact reflecting sociodemographic themes. Women experienced financial and physical dependence, lower general literacy, and household stigma, whereas men faced work-related financial and physical barriers and community-based stigma. Conclusions. In developing countries, barriers limiting access to TB care have context-specific gender-related differences that can inform integrated interventions to optimize TB services.

Background Interventions aimed at modifying behavior for promoting health and disease management are traditionally resource intensive and difficult to scale. Mobile health apps are being used for these purposes; however, their effects on health outcomes have been mixed. Objective This study aims to summarize the evidence of rigorously evaluated health-related apps on health outcomes and explore the effects of features present in studies that reported a statistically significant difference in health outcomes. Methods A literature search was conducted in 7 databases (MEDLINE, Scopus, PsycINFO, CINAHL, Global Index Medicus, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews). A total of 5 reviewers independently screened and extracted the study characteristics. We used a random-effects model to calculate the pooled effect size estimates for meta-analysis. Sensitivity analysis was conducted based on follow-up time, stand-alone app interventions, level of personalization, and pilot studies. Logistic regression was used to examine the structure of app features. Results From the database searches, 8230 records were initially identified. Of these, 172 met the inclusion criteria. Studies were predominantly conducted in high-income countries (164/172, 94.3%). The majority had follow-up periods of 6 months or less (143/172, 83.1%). Over half of the interventions were delivered by a stand-alone app (106/172, 61.6%). Static/one-size-fits-all (97/172, 56.4%) was the most common level of personalization. Intervention frequency was daily or more frequent for the majority of the studies (123/172, 71.5%). A total of 156 studies involving 21,422 participants reported continuous health outcome data. The use of an app to modify behavior (either as a stand-alone or as part of a larger intervention) confers a slight/weak advantage over standard care in health interventions (standardized mean difference=0.38 [95% CI 0.31-0.45]; I2=80%), although heterogeneity was high. Conclusions The evidence in the literature demonstrates a steady increase in the rigorous evaluation of apps aimed at modifying behavior to promote health and manage disease. Although the literature is growing, the evidence that apps can improve health outcomes is weak. This finding may reflect the need for improved methodological and evaluative approaches to the development and assessment of health care improvement apps. Trial Registration PROSPERO International Prospective Register of Systematic Reviews CRD42018106868; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=106868

BACKGROUND Background: Mobile applications can deliver more efficiently behavior change interventions that are traditionally resource-intensive and difficult to scale. OBJECTIVE Objectives: To summarize the evidence of app-driven behavior change interventions on health outcomes and identify whether certain features contribute to improved outcomes. METHODS Methods: We conducted a literature search in seven databases (MEDLINE; Scopus; PsycINFO, CINAHL, Global Index Medicus; Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews). Five reviewers independently screened and extracted sample characteristics. We used a random-effects model to calculate pooled effect size estimates for meta-analysis. Sensitivity analysis was conducted based on follow-up time, stand-alone app interventions, level of personalization, and pilot studies. Logistic regression was used to examine the structure of app features. RESULTS Results: From the database searches, 8230 records were initially identified. Of these, 172 met inclusion criteria. Studies were predominantly conducted in high-income countries (164, 94.3%). The majority had follow-up periods of six months or less (143, 83.1%). Over half of the interventions were delivered by a standalone app (106, 61.6%). Static/one size fits all (97,56. 4.0%) was the most common level of personalization. Intervention frequency was mostly at least daily (123, 71.5%). A total of 156 studies involving 21,422 participants reported continuous health outcome data. The use of a behavior change app (either as a stand-alone or as part of a larger intervention) confers a slight/weak advantage over standard care in health interventions [standardized mean difference = 0.38 (95% CI: 0.31-0.45), I2 = 80%] though heterogeneity is high. CONCLUSIONS Conclusion: Rigorous evaluation of behavior-change related intervention apps is increasing substantially. The evidence that behavior change apps improve health outcomes is weak, which may reflect the need for improved methodological and evaluative approaches to assessment of healthcare improvement apps. CLINICALTRIAL PROSPERO, CRD42018106868

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A girl weighing 775 g was born at 31 weeks gestation and delivered via emergency cesarean performed for late decelerations to a 19-year-old primigravida. Fetal ultrasound at 28 weeks was significant for oligohydramnios, intrauterine growth retardation, prominent cisterna magna with dolicocephaly, and echogenic fetal bowel. Apgars were 8 1 /9 5. At birth, head circumference, length, and weight were below the third percentile. She had sternal retractions and was placed on nasal continuous positive airway pressure and intravenous antibiotics. Examination was significant for hepatosplenomegaly and an ectopic urethra. Over the next few days, she received platelet transfusions for persistent thrombocytopenia, a packed red blood cell transfusion, and phototherapy. She developed abdominal distension with non-bloody diarrhea; ultrasound showed echogenic kidneys, bilateral hydronephrosis, and distended bowel loops. Head ultrasound showed streaks of echogenic lines in both thalami. By day 7, her creatinine was 2.3 mg/dL (0.8 at birth) and her total and direct bilirubin were 7.7 and 3.8 mg/dL, respectively. She developed apnea, bradycardia, was intubated, and subsequently expired. This neonate had disseminated congenital cytomegalovirus (CMV) infection confirmed at autopsy with liver, kidneys, lungs, pituitary, thyroid, pancreas, and intestines showing typical histology (Figures 1 and 2; Figure 2 available at www.jpeds. com). The ability of CMV to produce widespread organ disease outside the skin, central nervous system, and reticuloendothelial system is underappreciated. It should be considered in the differential diagnosis of neonatal sepsis unresponsive to antibiotics, along with other viruses, including herpes simplex and enteroviruses. Although 90% of congenital infections are asymptomatic, life-threatening disease can occur, affecting mostly premature infants and infants with primary immune disorders of T-cells or natural killer cells. 1 Emerging data on CMV serum antibody avidity assays in diagnosing recent infection, 2 ongoing investigation of monthly maternal CMV hyperimmune globulin administration in preventing vertical transmission, 3 along with recent neonatal dosing recommendations for oral valganciclovir 4 may provide intriguing new options in the prevention and treatment of CMV. n

Background and Objectives: Patient identifiers are used in the opening lines of case presentations and written documentation in health care and medical education settings. These identifiers can reflect physicians’ implicit biases, which are known to impact patient care. Yet, no clear recommendations for the use of patient identifiers to reduce bias and stigma in patient care and medical education learning environments currently exist. We describe a process and outcomes for articulating such recommendations.Methods: The University of Washington School of Medicine convened a group of diverse stakeholders to create patient identifier recommendations for use in the undergraduate medical education program. After a literature review, 22 recommendations for the use of patient identifiers were articulated. These underwent public comment periods reaching 11,150 potential respondents across our 5-state institution. Feedback from 437 respondents informed modifications to the recommendations. We used consensus methodology with three rounds of surveys and an expert group of 27 stakeholders to adopt recommendations with an a priori threshold of 90% agreeing the recommendation should be used. Results: We adopted 12 recommendations for patient identifiers for age, gender/sex, race/ethnicity, sexual orientation, ability, size, and stigma; nine in round one, three in round two, and none in the third round. Discussion: Our institution vetted these patient identifier recommendations via public comment and consensus methodology. Next steps include implementation across the undergraduate medical education program, including classroom and clinical settings. Other institutions could consider similar processes as key steps to reduce bias and stigma in their medical education programs.