Highlights of this issue

Musculoskeletal pain in children

Musculoskeletal pain affects 10%–20% of schoolchildren. Peter Malleson and Richard Beauchamp review the diagnosis of this common presentation. It is important to determine whether the pain could be from trauma, infection or neoplasia, given the potential harm from delayed diagnosis. Trauma that does not stop a child's activity immediately and minor developmental variants are unlikely to produce limb pain or swelling. The “rheumatology screen” may be of limited use given the high rates of false-positive and false-negative results of tests for antinuclear antibodies and rheumatoid factor in children; focused tests and radiographs may be more helpful.The authors briefly describe the management of chronic inflammatory rheumatic diseases and conclude on a cautionary note.

See page 183

Quality of clinical practice guidelines

High-quality clinical practice guidelines have the potential to improve care and patient outcomes. Ian Graham and authors used a standardized guideline appraisal instrument to assess the quality of 217 guidelines related to drug therapy developed or endorsed by Canadian organizations from 1994 to 1998. Each guideline was scored by 3 appraisers on the rigour of the development process, the context and content, and the application or implementation of the guidelines. Overall, 64.6% of the guidelines were recommended with modification by at least 2 of the 3 appraisers, 9.2% were recommended without change, and 26.3% were not recommended. Quality varied significantly by developer, publication status and drug company sponsorship, and no substantial improvement in quality was observed over the 5-year study period. Steven Lewis comments on the appraisers' expectations and the ongoing challenge of implementing guidelines. A second commentary, by Walter Rosser and associates from the Guideline Advisory Committee, describe their efforts to identify and promote the use of well-developed guidelines in Ontario.

See pages 157, 180 and 181

Sentinel lymph node biopsy for breast cancer staging

The attractiveness of sentinel lymph node (SLN) biopsy as an alternative to axillary dissection for breast cancer staging rests in its substantially lower morbidity and potentially greater accuracy, in that a smaller amount of tissue can be examined in greater detail. As a result, SLN biopsy is being introduced in institutions before results from randomized controlled trials about its effectiveness have become available. In the latest article in the breast cancer series, the Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer reviews the evidence and makes recommendations for physicians and women considering SLN biopsy.

See page 166

Think positively

Most clinicians would tend to agree that what patients think will happen can influence their health outcomes. Michael Mondloch and coauthors conducted a systematic review to determine what evidence there was to support this belief. They found 16 relevant articles published between 1966 and June 1998 that provided at least moderate-quality evidence of an association between positive expectations and improved outcomes. The most commonly studied conditions were myocardial infarction, cardiac surgery, chronic pain and psychiatric conditions. The authors propose a variety of mechanisms to account for the association, although whether this is a causal or a predictive effect is uncertain.

See page 174

Catholic bioethics

Concerned with issues as wide-ranging as social justice, the right to health care, the duty to preserve life, the ethics of human reproduction and end-of-life decisions, contemporary Catholic bioethics remains grounded in core beliefs concerning the sanctity of life and in a metaphysical conception of the person as a composite of body and soul. In the latest addition to the Bioethics for Clinicians series, Hazel Markwell and Barry Brown use an extraordinary case to illustrate how Catholic bioethics might be applied in weighing the ethically permissible against the ethically obligatory.

See page 189