Delayed diagnosis of DRESS syndrome in a patient with skin of color.

We describe a particularly severe case of drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome with hemodynamic instability, erythroderma, profound eosinophilia, and severe organ dysfunction. We attribute the severity in part to a delay in diagnosis due to patient's skin of color, as the erythroderma was not noticed until a dermatologist was consulted. This case highlights how even severe skin disease can present less conspicuously in patients with darker skin types. We outline several strategies that can help clinicians to recognize DRESS and other skin disease phenotypes in patients of color, thereby avoiding delays in diagnosis as seen in this case.

Understanding and Addressing Microaggressions in Medicine.

Microaggressions are directed unconsciously to people of color or other minority groups, and the accumulated experience of multiple microaggressions over a lifetime have detrimental effects on mental health. In the clinical setting, both physicians and patients can commit microaggressions. Patients experiencing a microaggression from their provider suffer emotional distress and distrust resulting in decreased service utilization, reduced adherence, and poorer physical and mental health. Physicians and medical trainees, particularly those of color, women and LGBTQIA members, have increasingly experienced microaggressions committed by patients. Learning to recognize and address microaggressions in the clinical setting creates a more supportive and inclusive environment.

Improving quality of care for persons with diabetes: an overview of systematic reviews - what does the evidence tell us?

BACKGROUND: Ensuring high quality care for persons with diabetes remains a challenge for healthcare systems globally with consistent evidence of suboptimal care and outcomes. There is increasing interest in quality improvement strategies to improve diabetes management as reflected by a growing number of systematic reviews. These reviews are of varying quality and dispersed across many sources. In this paper, we present an overview of systematic reviews evaluating the impact of interventions to improve the quality of diabetes care. METHODS: We searched for systematic reviews evaluating the effectiveness of any intervention intended to improve intermediate patient outcomes and process of care measures for patients with any type of diabetes. Two reviewers independently screened search results, appraised each systematic review using AMSTAR and extracted data from high quality reviews (AMSTAR score ≥ 5). Within reviews, we used vote counting by direction of effect to report the number of studies favouring an intervention for each outcome. We produced summaries of results for each intervention category. RESULTS: We identified 125 reviews of varying methodological quality and summarised key findings from 50 high quality reviews. We categorised reviews by quality improvement intervention. Eight reviews were broad based (involving a variety of strategies). Other reviews considered: patient education and support (n = 21), telemedicine (n = 10), provider role changes (n = 7), and organisational changes (n = 4). Reviews reported intermediate patient outcomes (e.g. glycaemic control) (n = 49) and process of care outcomes (n = 9). There was evidence of considerable overlap of included studies between reviews. CONCLUSIONS: There is consistent evidence from high quality systematic reviews that patient education and support, provider role changes, and telemedicine are associated with improvements in glycaemic and vascular risk factor control in patients. There is less evidence about the impact of quality improvement interventions on other key process measures such as screening patients for diabetic complications. This paper provides decision makers with a comprehensive overview of evidence from high quality systematic reviews about the effects of quality improvement interventions on improving diabetes care.

Overview of systematic reviews of the effectiveness of reminders in improving healthcare professional behavior.

OBJECTIVE: The purpose of this project was to conduct an overview of existing systematic reviews to evaluate the effectiveness of reminders in changing professional behavior in clinical settings. MATERIALS AND METHODS: Relevant systematic reviews of reminder interventions were identified through searches in MEDLINE, EMBASE, DARE and the Cochrane Library in conjunction with a larger project examining professional behavioral change interventions. Reviews were appraised using AMSTAR, a validated tool for assessing the quality of systematic reviews. As most reviews only reported vote counting, conclusions about effectiveness for each review were based on a count of positive studies. If available, we also report effect sizes. Conclusions were based on the findings from higher quality and current systematic reviews. RESULTS: Thirty-five reviews were eligible for inclusion in this overview. Ten reviews examined the effectiveness of reminders generally, 5 reviews focused on specific health care settings, 14 reviews concentrated on specific behaviors and 6 reviews addressed specific patient populations. The quality of the reviews was variable (median = 3, range = 1 to 8). Seven reviews had AMSTAR scores >5 and were considered in detail. Five of these seven reviews demonstrated positive effects of reminders in changing provider behavior. Few reviews used quantitative pooling methods; in one high quality and current review, the overall observed effects were moderate with an absolute median improvement in performance of 4.2% (IQR: 0.5% to 6.6%). DISCUSSION: The results support that modest improvements can occur with the use of reminders. The effect size is consistent with other interventions that have been used to improve professional behavior. CONCLUSION: Reminders appear effective in improving different clinical behaviors across a range of settings.

Decisions about lumping vs. splitting of the scope of systematic reviews of complex interventions are not well justified: a case study in systematic reviews of health care professional reminders.

OBJECTIVES: Lumping and splitting refer to the scope of a systematic review question, where lumped reviews are broad and split are narrow. The objective was to determine the frequency of lumping and splitting in systematic reviews of reminder interventions, assess how review authors justified their decisions about the scope of their reviews, and explore how review authors cited other systematic reviews in the field. STUDY DESIGN AND SETTING: A descriptive approach involving a content analysis and citation bibliometric study of an overview of 31 systematic reviews of reminder interventions. RESULTS: Twenty-four of 31 reminder reviews were split, most frequently across one category (population, intervention, study design, outcome). Review authors poorly justified their decisions about the scope of their reviews and tended not to cite other similar reviews. CONCLUSION: This study demonstrates that for systematic reviews of reminder interventions, splitting is more common than lumping, with most reviews split by condition or targeted behavior. Review authors poorly justify the need for their review and do not cite relevant literature to put their reviews in the context of the available evidence. These factors may have contributed to a proliferation of systematic reviews of reminders and an overall disorganization of the literature.

The Rx for Change database: a first-in-class tool for optimal prescribing and medicines use.

BACKGROUND: Globally, suboptimal prescribing practices and medication errors are common. Guidance to health professionals and consumers alone is not sufficient to optimise behaviours, therefore strategies to promote evidence-based decision making and practice, such as decision support tools or reminders, are important. The literature in this area is growing, but is of variable quality and dispersed across sources, which makes it difficult to identify, access, and assess. To overcome these problems, by synthesizing and evaluating the data from systematic reviews, we have developed Rx for Change to provide a comprehensive, online database of the evidence for strategies to improve drug prescribing and use. METHODS: We use reliable and valid methods to search and screen the literature, and to appraise and analyse the evidence from relevant systematic reviews. We then present the findings in an online format which allows users to easily access pertinent information related to prescribing and medicines use. The database is a result of the collaboration between the Canadian Agency for Drugs and Technologies in Health (CADTH) and two Cochrane review groups. RESULTS: To capture the body of evidence on interventions to improve prescribing and medicines use, we conduct comprehensive and regular searches in multiple databases, and hand-searches of relevant journals. We screen articles to identify relevant systematic reviews, and include them if they are of moderate or high methodological quality. Two researchers screen, assess quality, and extract data on demographic details, intervention characteristics, and outcome data. We report the results of our analysis of each systematic review using a standardised quantitative and qualitative format. Rx for Change currently contains over 200 summarised reviews, structured in a multi-level format. The reviews included in the database are diverse, covering various settings, conditions, or diseases and targeting a range of professional and consumer behaviors. CONCLUSIONS: Rx for Change is a novel database that synthesizes current research evidence about the effects of interventions to improve drug prescribing practices and medicines use.

Asymmetric synthesis of bis(tertiary arsines): highly stereoselective alkylations of diastereomers of a chiral phosphine-stabilized bis(arsenium triflate).

The addition of organolithium reagents to an equilibrating mixture of diastereomers of a phosphine-stabilized 1,2-ethanediylbis(phenylarsenium triflate) containing chiral arsenic stereocenters and an enantiomerically pure, atropisomeric tertiary phosphepine derived from lithiated (aR)-2,2'-dimethyl-1,1'-binaphthalene generates unequal mixtures of diastereomers and enantiomers of chelating 1,2-ethanediylbis(tertiary arsines), chiral at arsenic, with liberation of the (aR(P))-phosphepine. Thus, the addition of methyllithium in diethyl ether at -95 degrees C to a dichloromethane solution of the complex (R*(As),R*(As))-(+/-)/(R*(As),S*(As))-1,2-[(R(3)P)PhAsCH(2)CH(2)AsPh(PR(3))](OTf)(2), where R(3)P is (aR(P))-[2-(methoxymethyl)phenyl]phosphepine, generates (R*(As),R*(As))-(+/-)-1,2-ethanediylbis(methylphenylarsine) in 78% diastereoselectivity and 95% enantioselectivity in favor of the (R(As),R(As)) enantiomer. Under similar conditions, the addition of n-butyllithium in hexanes to a solution of the bis(phosphepine-stabilized)-diarsenium triflate at -95 degrees C gives the corresponding (R*(As),R*(As))-(+/-)-1,2-ethanediylbis[(n-butyl)phenylarsine) in 77% diastereoselectivity and 93% enantioselectivity in favor of the (R(As),R(As)) enantiomer.

Tertiary arsine-stabilised arsenium salts: syntheses and comparisons with phosphine analogues.

The first tertiary arsine-stabilised arsenium salts, [(L)AsMePh]OTf (L = Ph3As, Me2PhAs, [2-(MeOCH2)C6H4]Ph2As, [2-(MeOCH2)C6H4]Me2As), have been prepared by chloride abstraction from chloromethylphenylarsine with trimethylsilyl triflate in the presence of the arsine. The complexes have been characterised by crystallography and 1H NMR spectroscopy. The chiral cations in the complexes have structures based on the trigonal pyramid in which the arsine is coordinated orthogonally to the prochiral, six-electron MePhAs+ ion that forms the base of the pyramid. The NMR data for the complexes in dichloromethane-d2 are consistent with rapid exchange of the arsine on the arsenium ion, even at 183 K. The corresponding phosphine-stabilised complexes are considerably more stable than their arsine counterparts in dichloromethane-d2 with the free energy of activation DeltaG = ca. 60 kJ mol(-1) being calculated for phosphine exchange in [(Me2PhP)AsMePh]OTf at 281 K; for [(Me2[2-(MeOCH2)C6H4]P)AsMePh]OTf in the same solvent, DeltaG = ca. 70 kJ mol(-1) at 323 K.