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Antinuclear Antibody, Rheumatoid Factor, and Cyclic-Citrullinated Peptide Testing for the Evaluation of Musculoskeletal Complaints in Pediatric Populations

• CME Information
• Faculty Biographies & Disclosures
• References
• Course Presentations
• CME Posttest

CME Information

Course Overview Educational Objectives Target Audience Method of Participation

Accreditation Statement Term of Approval Peer Review Program Director

Disclaimer Disclosure Acknowledgement of Support

Course Overview

Musculoskeletal pain (MSK) is common in children and adolescents and can affect physical, psychological, and social function. However, MSK is often nonspecific which can make it difficult for a physician to arrive at an accurate diagnosis. This type of pain is predominantly due to nonrheumatic causes. Yet, pediatric rheumatic conditions are not rare and may affect approximately 300,000 children and adolescents in the United States. Rheumatic causes of musculoskeletal complaints, while infrequent, are chronic, and require timely diagnosis and effective intervention to prevent progression and long-term damage. Common rheumatic causes of childhood MSK include juvenile idiopathic arthritis (JIA) and pediatric systemic lupus erythematosus (pSLE).

Complete patient history and physical examination are generally considered the best ways to diagnose a rheumatic cause of MSK. The presence of specific clinical characteristics such as morning stiffness, joint swelling, malar rash and cytopenias may lead to a high suspicion of a pediatric rheumatic condition. Serological tests such as antinuclear antibody, rheumatoid factor, and anti-cyclic-citrullinated peptide tests have low sensitivities and are not appropriate for broad screening of JIA and systemic lupus erythematosus (SLE). In spite of their high specificity, these tests are of limited diagnostic value due to the low prevalence of JIA and pSLE in the target population (children with MSK). The presence of the clinical characteristics described above may increase the pre-test probability of the rheumatic diseases in question.

This CME activity will inform clinicians’ discussions of options with parents of children with MSK and assist in decisionmaking along with consideration of a patient’s values and preferences. It covers data from a systematic review and meta-analysis of existing research, conducted by The University of Alberta Evidence-based Practice Center, to evaluate the level of evidence to support the use of antinuclear antibody (ANA), rheumatoid factor, and anti-cyclic-citrullinated peptide tests for diagnosing rheumatic etiologies of undiagnosed MSK in children and adolescents.

Educational Objectives

At the conclusion of this activity, the participant should be able to:

• Evaluate the utility of ordering Rheumatoid Factor (RF), Antinuclear Antibody (ANA), or anti-Cyclic-Citrullinated Peptide (CCP) tests for children who present with musculoskeletal pain in view of the documented pattern of poor sensitivity and strong specificity associated with these tests.
• Consider the prevalence of musculoskeletal pain complaints and of inflammatory etiologies in children and adolescents when conducting clinical assessment of musculosketal pain.
• Summarize the evidence on the likelihood of test positivity of RF, ANA, anti-CCP tests when administered to healthy children and adults.

Target Audience

This CME activity is designed to meet the educational needs of primary care physicians and specialists who treat patients with musculoskeletal pain.

Method of Participation

This activity is in PowerPoint file format and is accompanied by talking points and references linked to PubMed abstracts.

To receive a maximum of 1.0 AMA PRA Category 1 Credit(s)™ you should:

• View the presentations in this enduring material.
• Complete the posttest (you must answer 8 out of 9 questions correctly).
• Complete and submit the CME registration and evaluation forms.

The estimated time to complete this activity, including review of the materials, is 1.0 hour(s).

Hardware/software requirements: Activities should be run with recent versions of common browsers, including Internet Explorer, Firefox, and Google Chrome.

If you have questions about the participation process, please e-mail the Office of Continuing Medical Education, cme@bcm.edu or phone 713.798.8237.

Accreditation/Credit Designation

Baylor College of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Baylor College of Medicine designates this enduring material activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.    

Term of Approval

July 2012 through July 2015. Original release date: July 2012

Peer Review

In March 2012, this continuing medical education online enduring material was reviewed by David D. Sherry, MD, Professor of Pediatrics, University of Pennsylvania and Chief, Rheumatology Section, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania. To ensure the continued scientific relevance of this enduring material, its content will be reviewed again in July 2015.

Disclosures:  Nothing to disclose.

Program Director

Michael Fordis, MD
Sr. Associate Dean
Director, Center for Collaborative and Interactive Technologies
Director, John M. Eisenberg Center for Clinical Decisions and Communications Science
Baylor College of Medicine
Houston, Texas

Disclosures: Nothing to disclose.

Disclaimer

This CME activity is designed for use by healthcare professionals for educational purposes only. Information and opinion offered by the contributors represent their viewpoints. Conclusions drawn by the participant should be derived from careful consideration of all available scientific information. Prescription information and use of medical devices should be undertaken only after confirmation of information by consulting the FDA-approved uses and information.

Baylor College of Medicine makes every effort to have accurate information presented, no warranty, expressed or implied, is offered. The participant should use his/her clinical judgment, knowledge, experience, and diagnostic decision-making before applying any information, whether provided here or by others, for any professional use.

Links are provided to other Internet sites solely for the convenience of users. Once you link to another site, you are subject to the site's terms and conditions of use including copyright and licensing restrictions.

Disclosure

The Office of Continuing Medical Education (OCME) makes every effort to develop CME activities that are scientifically based, accurate, current, and objectively presented. In accordance with the Accreditation Council for Continuing Medical Education Standards for Commercial Support ^SM, Baylor College of Medicine (BCM) has implemented a mechanism requiring everyone in a position to control the content of an educational activity (e.g., directors, planning committee members, contributors, peer reviewers) to disclose any relevant financial relationships with commercial interests (drug/device companies) and manage/resolve any conflicts of interest prior to the activity. Individuals must disclose to participants the existence or non-existence of financial relationships: l) at the time of the activity or within 12 months prior; and 2) of their spouses/partners.

Baylor College of Medicine does not view the existence of interests or relationships with commercial entities as implying bias or decreasing the value of a presentation. It is up to the participants to determine whether the interests or relationships influence the presenter with regard to exposition or conclusions.

If at any time during this activity you feel that there has been commercial or promotional bias, please inform us by using the commercial bias comments box in the evaluation form. Please answer the questions about balance in the CME activity evaluation candidly.

The following individual(s) has/have reported financial or other relationship(s) with commercial entities whose products/services may relate to the educational content of this activity:

Donna M. Dryden, PhD, Contributor: Nothing to disclose.
Kim L. Farina, PhD, Medical Writer: Nothing to disclose.
Michael Fordis, MD, Activity Director: Nothing to disclose.
Andrea D. Humphries, PhD, Medical Writer: Nothing to disclose.
Eyal Muscal, MD, MS, Contributor: Nothing to disclose.
David D. Sherry, MD, Peer Reviewer: Nothing to disclose.

Some drugs/devices identified during this activity may have United States Food and Drug Administration (FDA) clearance for specific purposes only or for use in restricted research settings. The FDA has stated that it is the responsibility of the individual physician to determine the FDA status of each drug or device that he/she wishes to use in clinical practice and to use the products in compliance with the applicable law.

Baylor College of Medicine requires that all contributors disclose an unlabeled use or investigational use (not yet approved for any purpose) of pharmaceutical and medical device products, and provide adequate scientific and clinical justification for such use. Physicians are urged to fully review all the available data on products or procedures before using them to treat patients.

Acknowledgement of Support

This CME activity is supported by a contract, HHSA290200810015C, from the Agency for Healthcare Research and Quality.

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