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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">It is quite clear that medicine is biased towards positive results and the same applies to the practice of pathology&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a> One of the ubiquitous tests in autoimmunity&#44; the antinuclear antibody &#40;ANA&#41; suffers from this very same fate&#46; A number of guidelines report on the clinical utility of a positive ANA and dissuade clinicians from requesting this test in the setting of low pre-test probability for an ANA-associated autoimmune disorder &#40;AAD&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">2</span></a> This is certainly sound advice and prevents unnecessary investigations and healthcare expenditure&#46; Yet&#44; it is important to realise the clinical importance and pitfalls of a negative ANA results which sometimes becomes forgotten&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The internationally-accepted &#8220;gold standard&#8221; to measure ANA is via indirect immunofluorescence on HEp-2 cells&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">3</span></a> A negative ANA test on HEp-2 substrate usually means that there is no significant detection of IgG ANA &#40;in the nucleus&#41; at a specified dilution of serum &#8211; usually 1&#58;80 to 1&#58;160&#46; There is a move to also classify positive cytoplasmic and mitotic staining of the HEp-2 substrate as ANA positive&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">3&#44;4</span></a> This may improve the sensitivity of detecting AADs and prompt appropriate further testing and follow-up &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">3</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The high sensitivity and negative predictive value &#40;NPV&#41; for systemic lupus erythematosus &#40;SLE&#41; makes the ANA test a good &#8220;rule out&#8221; test to essentially exclude this disorder if it is negative&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">5</span></a> Indeed&#44; the most recent European League Against Rheumatism&#47;American College of Rheumatology guidelines for the diagnosis of SLE mandates a positive ANA &#40;<span class="elsevierStyleUnderline">&#62;</span>1&#58;80&#41; on the HEp-2 substrate to be considered for this diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">6</span></a> Sensitivities for detecting other AADs is low-moderate at best&#59; yet also demonstrates very high NPVs&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">7</span></a> Unless there has been a significant change in clinical picture or there is a suspicion of a laboratory issue&#44; there is little value in repeating an ANA that is initially negative&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">8</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">A pitfall is that ANA is a screening test and may&#44; in rare instances&#44; miss low-level specific autoantibodies&#47;anti-extractable nuclear antigens &#40;ENAs&#41; if more sensitive assays are not performed&#44;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">9</span></a> or miss anti-ENA that do not produce a characteristic ANA pattern e&#46;g&#46;&#44; anti-Ro52&#46; Therefore&#44; the substrate should be specified in the report since substrates such as the HEp-2000&#174; &#40;Immunoconcepts&#41; which has transfected Ro60 increase the detection of anti-Ro60 and hence&#44; a negative result makes the presence of anti-Ro60 less likely&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">10</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">If there is a high clinical suspicion for an AAD&#44; the clinician should request further anti-ENA tests and the overall clinical picture and physician&#39;s interpretation of the patient should prevail&#46; This is especially of importance since commercial HEp-2 substrates&#44; whilst generally demonstrating excellent inter-assay and inter-laboratory agreement&#44; display subtle staining differences that affect the microscopist&#39;s final interpretation&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">11</span></a> The significance of low levels of anti-ENA with negative ANA is not well established&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">To conclude&#44; clinicians should be aware of the value&#44; implications and pitfalls of a negative ANA result when considering AADs&#46; They should also be aware of their laboratory&#39;s definitions of a &#8220;negative&#8221; ANA result&#44; the substrate used and whether they report non-nuclear patterns which may have important implications for their patients&#46; Importantly&#44; the overall clinical picture of the patient should be taken into considerations when deciding on the relevancy of a negative ANA test&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0035" class="elsevierStylePara elsevierViewall">Nil&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflict of interests</span><p id="par0040" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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Letter to the Editor
The Value of a Negative Antinuclear Antibody (ANA) Test: An Often Forgotten Result
El valor de una prueba de anticuerpos antinucleares (ANA) negativa: un resultado a menudo olvidado
Adrian Y.S. Leea,b
a ICPMR & Department of Immunology, Westmead Hospital, Westmead, NSW, Australia
b Westmead Clinical School, The University of Sydney, Westmead, NSW, Australia
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">It is quite clear that medicine is biased towards positive results and the same applies to the practice of pathology&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a> One of the ubiquitous tests in autoimmunity&#44; the antinuclear antibody &#40;ANA&#41; suffers from this very same fate&#46; A number of guidelines report on the clinical utility of a positive ANA and dissuade clinicians from requesting this test in the setting of low pre-test probability for an ANA-associated autoimmune disorder &#40;AAD&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">2</span></a> This is certainly sound advice and prevents unnecessary investigations and healthcare expenditure&#46; Yet&#44; it is important to realise the clinical importance and pitfalls of a negative ANA results which sometimes becomes forgotten&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The internationally-accepted &#8220;gold standard&#8221; to measure ANA is via indirect immunofluorescence on HEp-2 cells&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">3</span></a> A negative ANA test on HEp-2 substrate usually means that there is no significant detection of IgG ANA &#40;in the nucleus&#41; at a specified dilution of serum &#8211; usually 1&#58;80 to 1&#58;160&#46; There is a move to also classify positive cytoplasmic and mitotic staining of the HEp-2 substrate as ANA positive&#46;<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">3&#44;4</span></a> This may improve the sensitivity of detecting AADs and prompt appropriate further testing and follow-up &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">3</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The high sensitivity and negative predictive value &#40;NPV&#41; for systemic lupus erythematosus &#40;SLE&#41; makes the ANA test a good &#8220;rule out&#8221; test to essentially exclude this disorder if it is negative&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">5</span></a> Indeed&#44; the most recent European League Against Rheumatism&#47;American College of Rheumatology guidelines for the diagnosis of SLE mandates a positive ANA &#40;<span class="elsevierStyleUnderline">&#62;</span>1&#58;80&#41; on the HEp-2 substrate to be considered for this diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">6</span></a> Sensitivities for detecting other AADs is low-moderate at best&#59; yet also demonstrates very high NPVs&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">7</span></a> Unless there has been a significant change in clinical picture or there is a suspicion of a laboratory issue&#44; there is little value in repeating an ANA that is initially negative&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">8</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">A pitfall is that ANA is a screening test and may&#44; in rare instances&#44; miss low-level specific autoantibodies&#47;anti-extractable nuclear antigens &#40;ENAs&#41; if more sensitive assays are not performed&#44;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">9</span></a> or miss anti-ENA that do not produce a characteristic ANA pattern e&#46;g&#46;&#44; anti-Ro52&#46; Therefore&#44; the substrate should be specified in the report since substrates such as the HEp-2000&#174; &#40;Immunoconcepts&#41; which has transfected Ro60 increase the detection of anti-Ro60 and hence&#44; a negative result makes the presence of anti-Ro60 less likely&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">10</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">If there is a high clinical suspicion for an AAD&#44; the clinician should request further anti-ENA tests and the overall clinical picture and physician&#39;s interpretation of the patient should prevail&#46; This is especially of importance since commercial HEp-2 substrates&#44; whilst generally demonstrating excellent inter-assay and inter-laboratory agreement&#44; display subtle staining differences that affect the microscopist&#39;s final interpretation&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">11</span></a> The significance of low levels of anti-ENA with negative ANA is not well established&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">To conclude&#44; clinicians should be aware of the value&#44; implications and pitfalls of a negative ANA result when considering AADs&#46; They should also be aware of their laboratory&#39;s definitions of a &#8220;negative&#8221; ANA result&#44; the substrate used and whether they report non-nuclear patterns which may have important implications for their patients&#46; Importantly&#44; the overall clinical picture of the patient should be taken into considerations when deciding on the relevancy of a negative ANA test&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Funding</span><p id="par0035" class="elsevierStylePara elsevierViewall">Nil&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflict of interests</span><p id="par0040" class="elsevierStylePara elsevierViewall">None declared&#46;</p></span></span>"
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