Highlights of this issue

Elective cesarean sections

Figure. Photo by: Tracy Dominey / Science Photo Library

An increasing number of women are requesting cesarean section without having traditionally accepted medical indications. Studies are underway to compare outcomes of vaginal birth and planned elective cesarean delivery. In a commentary, Hannah argues that the issue is more complex than a simple head-to-head comparison of these delivery methods, because vaginal deliveries may require emergency cesarean section, which carries the greatest risks to the mother and fetus. In the absence of good evidence, the author concludes that a woman's request for elective cesarean section should be supported if she understands the potential risks and benefits.

See pages 775 and 813

Psychosocial impact of SARS

The SARS outbreak in 2003 had a dramatic impact on the health care system in Toronto. In a survey of staff at the Sunnybrook and Women's College Health Sciences Centre conducted during the first phase of the outbreak, Nickell and colleagues found that almost two-thirds experienced concern for their health and that of their families. In addition, almost one-third of a subset of employees who completed a 12-item General Health Questionnaire scored above the threshold, which indicated probable emotional distress. The authors identify factors significantly associated with an increased level of concern for personal or family health, along with factors associated with emotional distress. They suggest that these substantial impacts on hospital staff highlight the need for greater support and educational intervention during such crises. In a related commentary, Sim and Chua emphasize the need for further research into the psychosocial impact of infectious disease outbreaks.

See pages 793 and 811

Protecting patient and physician information in pharmacy records

The potential uses of large electronic databases have not been lost on consumer-based industries. However, the ease with which databases can be linked may result in ready identification of unsuspecting consumers, even after names have been removed. The Personal Information Protection and Electronics Documents Act (PIPEDA) was designed to address this issue and mandates that consent be obtained to disclose personal information from such databases. In a commentary, Zoutman and colleagues point out that, in the past, pharmacies in Canada have sold patient and physician information to pharmaceutical companies and recommend that this practice be reviewed in light of this new legislation.

See page 815

Low-dose oral vitamin K therapy for asymptomatic elevation of INRs

Figure.

Asymptomatic elevation of the international normalized ratio (INR) is a common clinical problem that carries a significant risk of bleeding. Clinicians often struggle to reduce the INR promptly without over-correcting it and increasing the risk of thrombosis. Common strategies for INR reduction are withholding warfarin or giving vitamin K. Wilson and colleagues reviewed the literature on the use of oral vitamin K therapy to reverse excessive anticoagulation. They found that it is effective in promptly reducing elevated INRs and that 1.0 mg seems to be the most appropriate dose to safely reduce INRs between 4.5 and 6. There remains a theoretical risk of thrombosis from over-correction of the INR with vitamin K therapy, but how to balance this with the risk of hemorrhage secondary to a persistently elevated INR is unclear. In Canada, there is no tablet form of vitamin K, but the parenteral form can be taken orally and presents a promising option for patient self-management in anticoagulation control.

See page 821