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ACP develops three different types of clinical recommendations:

Clinical Practice Guidelines, Clinical Guidance Statements, and Best Practice Advice. ACP's goal is to provide clinicians with recommendations based on the best available evidence; to inform clinicians of when there is no evidence; and finally, to help clinicians deliver the best health care possible.

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Our goal is to help clinicians deliver the best health care possible.

The American College of Physicians (ACP) established its evidence-based clinical practice guidelines program in 1981. The ACP clinical practice guidelines and guidance statements follow a multistep development process that includes a systematic review of the evidence, deliberation of the evidence by the committee, summary recommendations, and evidence and recommendation grading.


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A 42-year-old man is evaluated during a routine follow-up visit. He was diagnosed with rheumatoid arthritis 1 year ago. At that time, the patient had evidence of early erosions of the metacarpophalangeal joints and positive anti-cyclic citrullinated peptide antibodies. Disease activity persisted on methotrexate but resolved approximately 6 months ago after the addition of adalimumab. The patient now reports no morning stiffness, pain, swelling, or fatigue. He has not had any illnesses or been in contact with sick persons.

On physical examination today, vital signs are normal. Musculoskeletal examination reveals no deformities and no joint swelling or tenderness. Erythrocyte sedimentation rate and C-reactive protein level are normal.

Laboratory studies (9 months ago):

Hepatitis B surface antibody

Positive

Hepatitis B surface antigen

Negative

Hepatitis C virus antibody

Nonreactive

Tuberculin skin testing

Negative

Q.

Which of the following is the most appropriate diagnostic test to perform next?

Bilateral radiographs of the hands and wrists are indicated for this patient who was diagnosed with rheumatoid arthritis 1 year ago. At that time, radiographs revealed evidence of early erosions of the metacarpophalangeal joints. Control of his disease activity was subsequently achieved, but the erosions may have progressed during the period of ongoing disease activity or even more recently when he has seemed clinically quiescent. Repeat radiographs of the hands and wrists allow for reevaluation of the early erosive changes and establishment of a new baseline. Evidence of progressive erosive changes in the future would suggest the need to change this patient's medical regimen, despite what appears to be clinical control of disease activity otherwise.

The presence of antibodies to anti-cyclic citrullinated peptide (anti-CCP) can be important in the diagnosis and prognosis of rheumatoid arthritis, but CCP titers are not helpful in monitoring disease activity.

There is no recommendation for testing for tuberculosis or hepatitis C virus titers at shorter intervals than 1 year unless there is a particular concern for an exposure or clinical manifestations concerning for an active infection.

The presence of varicella virus antibodies correlates with prior exposure to varicella and protection against varicella infection, although the sensitivity and specificity of available serologic tests is imperfect. Health care workers without serologic evidence of IgG antibodies to varicella virus may benefit from vaccination against varicella, but routine screening for US-born adults is not advised given the high prevalence of seropositivity in this population. The zoster vaccine is indicated for prevention of shingles in many older persons. Varicella vaccine and zoster vaccine are both live, attenuated strains of the varicella-zoster virus. Live vaccines are contraindicated in immunosuppressed patients, including those using tumor necrosis factor a inhibitors, given the risk of disseminated infection due to the vaccine.

Key Point

  • Repeat radiographs allow for reevaluation of early erosive changes and establishment of a new baseline for patients with rheumatoid arthritis.
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