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Social media are dynamic and interactive computer-mediated communication tools that have high penetration rates in the general population in high-income and middle-income countries. However, in medicine and health care, a large number of stakeholders (eg, clinicians, administrators, professional colleges, academic institutions, ministries of health, among others) are unaware of social media's relevance, potential applications in their day-to-day activities, as well as the inherent risks and how these may be attenuated and mitigated. We conducted a narrative review with the aim to present case studies that illustrate how, where, and why social media are being used in the medical and health care sectors. Using a critical-interpretivist framework, we used qualitative methods to synthesize the impact and illustrate, explain, and provide contextual knowledge of the applications and potential implementations of social media in medicine and health care. Both traditional (eg, peer-reviewed) and nontraditional (eg, policies, case studies, and social media content) sources were used, in addition to an environmental scan (using Google and Bing Web searches) of resources. We reviewed, evaluated, and synthesized 76 articles, 44 websites, and 11 policies/reports. Results and case studies are presented according to 10 different categories of social media: (1) blogs (eg, WordPress), (2) microblogs (eg, Twitter), (3) social networking sites (eg, Facebook), (4) professional networking sites (eg, LinkedIn, Sermo), (5) thematic networking sites (eg, 23andMe), (6) wikis (eg, Wikipedia), (7) mashups (eg, HealthMap), (8) collaborative filtering sites (eg, Digg), (9) media sharing sites (eg, YouTube, Slideshare), and others (eg, SecondLife). Four recommendations are provided and explained for stakeholders wishing to engage with social media while attenuating risk: (1) maintain professionalism at all times, (2) be authentic, have fun, and do not be afraid, (3) ask for help, and (4) focus, grab attention, and engage. The role of social media in the medical and health care sectors is far reaching, and many questions in terms of governance, ethics, professionalism, privacy, confidentiality, and information quality remain unanswered. By following the guidelines presented, professionals have a starting point to engage with social media in a safe and ethical manner. Future research will be required to understand the synergies between social media and evidence-based practice, as well as develop institutional policies that benefit patients, clinicians, public health practitioners, and industry alike.

Purpose - The aim of this review is to examine factors that may explain why other industries are considered ultrasafe while progress toward preventing adverse events in health care is not considered to have reached that level.Design methodology approach - The paper is a narrative review.Findings - Despite a decade of intense effort, the problem of patient harm in health care facilities remains a challenge. A recent study of ten hospitals in North Carolina, which have actively engaged in patient safety initiatives, reported rates of adverse events similar to those in the Institute of Medicine report, To Err Is Human in 1999. Seven key issues and their interaction are described.Research limitations implications - This review focuses on broad issues that likely impede progress generally, not on individual project or individual hospital program success stories.Originality value - The authors believe the difficulty in making significant headway on the patient safety agenda is due in part to the fact that it was always going to be a long (indeed never ending) struggle - aviation for example took almost 60 years to become ultra-safe - and in part to misunderstanding the nature of the dynamics that are involved in the generation of adverse events in risk critical industries. The paper reflects on the nature of the safety initiatives that health care has tended to focus on, but which have not sufficiently taken note of central concepts of safety science, as well as on features of the health care system itself that have impeded, in the authors' view, progress on enhancing patient safety.

IT is now possible to predict the probability of inheriting the gene for diseases such as Huntington's disease, 1 , 2 familial Alzheimer's disease, 3 and some types of familial cancer. 4 For these diseases, which are manifested primarily in adult life, DNA analysis can provide information about the likelihood that the disease will appear at some time in the future, but it currently provides no information about the patient's age at the onset of disease or the severity of the illness. Predictive testing is therefore unique and distinct from clinical diagnosis. To date, no large prospective studies have been reported that evaluate the effects . . .

Although expenditures on health care are continually increasing and often said to be unsustainable, few studies have examined these trends at the level of services delivered to individual patients. We analyzed trends in the various components that contributed to changes in overall expenditures for physician services in British Columbia from 1985/86 to 1996/97. We obtained data on all fee-for-service payments to physicians in each study year using the British Columbia Linked Health Data set and analyzed these at the level of individual patients. We disaggregated overall billing levels by year into the following components: number of physicians seen by each patient, number of visits per physician, number of services rendered on each visit and average price of those services. We removed the effect of inflation on fees by adjusting to those in 1988. We used direct age-standardization to isolate and measure the effect of demographic changes. We used the Consumer Price Index to determine the effects of inflation. Total payments to fee-for-service physicians in British Columbia rose 86.3% over the study period. The increase was entirely accounted for by the combined effects of population growth (28.9%), aging (2.1%) and general inflation (41.4%). Service use per capita rose 10.5%; this increase was offset by a decline of 9.4% in inflation-adjusted fees. The average cost of age-adjusted per-capita services rendered by general or family practitioners (GP/FPs) increased very little (3.3%) over the 11-year period, compared with a nearly one-third (31.8%) increase for medical specialists. Although there was a dramatic increase in the number of GP/FPs seen on average by each patient (32.9%), this increase was offset by the combination of decreases in the number of visits per physician (-14.9%), the number of services provided per visit (-8.0%) and the \"real cost\" of each service provided (-3.5%). Visits to medical specialists increased by about 20% over the study period in all age groups. However, for each person 65 years of age or over receiving any services, the average fee-adjusted expenditures increased 24.8%, almost 4 times the rate of increase for people younger than 65. The use of surgical services grew 26.5% for seniors while declining -2.0% for people under age 65. These findings suggest a form of \"homeostasis\" in aggregate-level service use and cost. The supposed inflationary effects of population aging and increasing \"abuse of the system\" by patients were not found.

There has been considerable downsizing of acute care services in British Columbia over the past 2 decades. In this population-based study we examined changes in the proportion of elderly people who used acute care, long-term care and home care services between 1986-1988 and 1993-1995 to explore whether the downsizing has influenced use. Changes in death rates were also examined. The British Columbia Linked Health Database was used to select all British Columbia residents aged 65 years, 75-76 years, 85-87 years or 90-93 years as of Jan. 1, 1986 (cohort 1), and Jan. 1, 1993 (cohort 2). Each person was assigned to 1 of 6 mutually exclusive categories of health care use reflecting different intensities of use (i.e., hospital, long-term or home care). The proportions of people within each category were compared between the 2 periods, as were the age-standardized death rates. There were 79,175 people in cohort 1 and 92,320 in cohort 2. Overall, the relative proportion of people in each use category was similar between the 2 study periods. The most substantial changes were an increase of 2 percentage points in the proportion of people who received no facility or home care services and a decrease of 2 to 3 percentage points in the proportion who received some acute care but no facility-based continuing care. The age-adjusted all-cause death rates for the earlier and later cohorts were virtually identical (15.7% and 15.8% respectively), although the rate increased from 63.6% to 70.1% among those in the \"full-time facility with acute care\" group. Overall changes in health care use were small, which suggests that the repercussions of the decline in acute care services for elderly people have been minimal. The higher age-adjusted death rates in the later cohort in full-time care suggests that long-term stays are becoming reserved for a sicker group of elderly people than in the past.

Previous studies have suggested that desmopressin may reduce the bleeding diathesis that often complicates open-heart surgery. To pursue this question further, we performed a double-blind, randomized, placebo-controlled trial to determine whether the previously reported beneficial effect of desmopressin on hemostasis during complex cardiac surgery was applicable to all elective cardiac surgical procedures involving cardiopulmonary bypass. In 150 consecutive patients, most of whom underwent primary coronary-artery bypass grafting, we compared the effects of intravenous desmopressin (0.3 μg per kilogram of body weight) with those of saline placebo on postoperative blood loss and the need to replace blood products. The median amount of blood lost within the first 24 hours after operation was similar in the desmopressin and placebo groups (865 vs. 738 ml; P = 0.26). The postoperative use of blood replacement products did not differ significantly between the groups (1025 ml [95 percent confidence interval, 300 to 4140 ml] in the desmopressin group and 860 ml [247 to 5346 ml] in the placebo group). Desmopressin is believed to exert its hemostatic effect by releasing von Willebrand factor. The level of ristocetin cofactor, a functional index of the level of von Willebrand factor, was increased approximately twofold from base line in both treatment groups 90 minutes and 24 hours after the administration of medication. Similarly, the levels of von Willebrand factor multimers increased uniformly in both groups. These findings may be consistent with a normal stress response of von Willebrand factor to major surgery and could explain our failure to detect a therapeutic effect of desmopressin. We conclude that the majority of patients who undergo elective cardiac surgery receive no hemostatic benefit from the use of desmopressin. (N Engl J Med 1989;321:1437–43.) DURING the first 24 hours after cardiac surgery, a tendency to bleed is commonly observed. This often requires the transfusion of blood products. Many factors have been implicated in postoperative bleeding, including surgical causes of bleeding, dilutional coagulopathy, thrombocytopenia, qualitative platelet defects, inadequate reversal of heparin anticoagulation, and excesssive administration of protamine. 1 2 3 4 5 6 7 8 Two recent reports have suggested that desmopressin (l-desamino-8-D-arginine vasopressin) is useful in reversing this bleeding tendency and may reduce the need for blood products in selected patients who undergo complex cardiac procedures and in patients who have severe bleeding after cardiopulmonary bypass. 9 , 10 The precise mechanism by which desmopressin . . .

A pilot-tested questionnaire was mailed to 325 obstetricians, pediatricians, family practitioners and general practitioners of a British Columbian maternity hospital to measure aspects relating to physicians' attitudes toward breastfeeding counselling. Response rate was 67.3%. The measures of self-efficacy, knowledge and beliefs were added to a regression model containing measures of gender, specialty, years in practice and personal or spousal breastfeeding experience to determine whether additional variance in counselling behaviour could be accounted for. Physicians attempted to convince women to breastfeed if: 1) they believed in the immune properties of breastmilk (OR = 1.23, SE = 0.07) and 2) they were confident in their own breastfeeding counselling (OR = 1.88, SE = 0.36). Likewise, encouraging women to continue breastfeeding in the face of breastfeeding problems was related to confidence in breastfeeding counselling (OR = 1.22, SE = 0.10) and belief in the immune properties of breastmilk (OR = 2.83, SE = 0.45). Différents aspects relatifs à l'attitude des médecins par rapport à l'allaitement maternel ont été déterminés par un questionnaire préalablement vérifié qui a été expédié à 325 obstétriciens, pédiatres, médecins de famille et généralistes affiliés à une maternité de la Colombie Brittanique. Le taux de réponse était de 67,3 %. Les paramètres de la confiance en soi, des connaissances et des croyances ont été ajoutés au modèle de régression en tenant compte des paramètres du genre, de la spécialité, du nombre d'années d'expérience et de l'expérience de l'allaitement, personnelle ou de l'épouse, pour déterminer si certaines variances pourraient être attribuées au comportement de counselling. Les médecins ont tenté de convaincre les femmes d'allaiter lorsqu'ils avaient confiance dans les qualités immunologiques du lait maternel (RRE = 1,23, ET = 0,07) ainsi que dans leur aptitude en counselling de l'allaitement (RRE = 1,88, ET = 0,36). Pour les mêmes raisons, les médecins ont encouragé les femmes à poursuivre l'allaitement si des problèmes surgissaient (respectivement RRE = 2,83, ET = 0,45 et RRE = 1,22, ET = 0,10).

Objectives To examine medical care use and costs, patterns of morbidity and co-morbidity, and other patient characteristics of high users of physician services in British Columbia. Methods: This population-based study uses physician claims, hospital discharge summaries and vital statistics data linked at the level of the individual to compare characteristics of high users, other users and non-users of physician services in the Province of British Columbia, Canada. The study included all enrolled adults in the universal health care plan during fiscal year 1996/97. High users were defined as the most costly 5% of users of fee-reimbursed services. Key variables included age, sex, an ecological socio-economic status indicator and a comprehensive set of morbidity indicators, derived from the diagnoses recorded on the utilization records. Results: The top 5% of users consumed a disproportionate 30% of spending on physician services. High users were overwhelmingly characterized by a significant burden of morbidity. Over 80% had at least six different types of morbidity during the study year compared with fewer than 20% of other users. High users were also much more likely to have major diagnoses that were both acute and chronic in nature. Co-morbidity involving psychosocial and chronic medical conditions was also very common. Conclusions: High users of physician services are overwhelmingly characterized by multiple and complex health problems. Policy tools based on a philosophy of deterrence such as cost-sharing are unlikely to have much impact on their costs and will likely do considerable harm.

Background: Sexually transmitted infections are leading causes of morbidity for Canadian Aboriginal women. To date, very few initiatives have been successful in screening, treating, and limiting these infections among these populations. Objectives: To evaluate the efficacy of universal screening, treatment and contact tracing as a means of capturing a more accurate count of chlamydia and gonorrhea prevalence and limiting transmission among Inuit communities. Methods: 181 participants were screened for chlamydia and gonorrhea and interviewed in a cross-sectional survey (Aug-Sept/03). Information was collected on demographics, use of health services, sexual histories and STI knowledge among others. A random sample (n = 100) from the cross-sectional group was selected for the longitudinal cohort. Individuals were followed every two months post baseline for four visits (Oct/03-May/04). At each visit, participants were screened for chlamydia/gonorrhea. All positive cases and their partners were treated and contact tracing completed. Logistic Regression analysis and the McNemar Test of Correlated Proportions were used to analyze the data. Results: Overall, 35 cases of chlamydia were detected, with 21 detected at baseline and 14 during follow-up. The baseline prevalence was 11.6% in comparison with 2.7% that was previously estimated. No gonorrhea was detected. The strongest factor associated with a positive chlamydia was having recent STI (OR 9.82, CI: 2.70, 35.77). Conclusions: Consistent with the literature, the results support the use of universal screening followed by prompt treatment and contact tracing in populations with greater than 10% chlamydia prevalence.

As the availability of both health utilization and outcome information becomes increasingly important to health care researchers and policy makers, the ability to link person-specific health data becomes a critical objective. The integration of populationbased administrative health databases has been realized in British Columbia by constructing an historical file of all persons registered with the health care system, and by probabilistically linking various program files to this 'coordinating' file. The linkages have achieved a high rate of success in matching service events to person-specific registration records. This success has allowed research projects to be proposed which would otherwise not have been feasible, and has initiated the development of policies and procedures regarding research access to linked data. These policies and procedures include a framework for addressing the ethical issues surrounding data linkage. With continued attention to confidentiality issues, these linked data present a valuable resource for health services research and planning. L'accès aux données concernant l'utilisation des services de santé et l'impact des interventions devient de plus en plus important pour les chercheurs en services médicaux et les élaborateurs de politiques de santé. La capacité de lier les données d'identification individuelle devient un objectif essentiel. L'intégration de larges banques de données a été réalisée en Colombie-Britannique en constituant un dossier historique (de coordination) de toutes les personnes enregistrées avec le système de services médicaux. Ceci permet de créer un lien entre plusieurs banques de données d'utilisation des services et les données d'identification individuelle. Ce succès a permis la soumission de nouveaux projets de recherche qui ne seraient autrement pas possible, et le développement de politiques et procédures en ce qui concerne l'accès aux données liées. Ces politiques et procédures incluent une structure pour traiter les questions d'éthique concernant les données liées. En tenant compte des questions de confidentialité, les données liées sont présentement une ressource de grande valeur pour la recherche et la planification des services de santé.