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Cho HW, Jeong SH, Hong JS, Kim D, Park Y, Jeong SH. Evaluation of the Accuracy of Estimated Endpoint Titer of NOVA View in Indirect Immunofluorescent Antinuclear Antibody Testing. Diagnostics (Basel) 2024; 14:1580. [PMID: 39125456 PMCID: PMC11311674 DOI: 10.3390/diagnostics14151580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2024] [Revised: 07/18/2024] [Accepted: 07/22/2024] [Indexed: 08/12/2024] Open
Abstract
For antinuclear antibody (ANA) screening, the gold standard method is an indirect immunofluorescence assay (IIFA) using HEp-2 cells, and a serial dilution test is needed to determine the endpoint titer. We aimed to evaluate the accuracy of the estimated endpoint titer (eEPT) by the NOVA View system, by comparing it with the EPT by the serial dilution method (dEPT). The endpoint titers of a total of 1518 ANA positive cases with five major patterns including speckled, homogeneous, centromere, nucleolar, and nuclear dots patterns were determined using both the estimation function and the serial dilution method by the NOVA View system. A significant correlation between the light intensity unit (LIU) values and dEPTs was identified in all five patterns with high ρ values, ranging from 0.666 to 0.832. However, the overall exact match rate between dEPT and eEPT was 22.1% (336/1518), with the ±one-titer match rate being highest in the centromere pattern (62.8%, 81/129), and lowest in the homogeneous pattern (37.6%, 200/532). This suggests that while LIU values correlate well with dEPT, there are discrepancies in numerical agreement. Most cases that did not show an exact match, showed one-to-three-titer overestimations by eEPT. Therefore, adjusting eEPT downward significantly improved the concordance rates with dEPTs. Further investigation for an appropriate cutoff of LIU values for determining eEPT should be performed for clinical application and contribution to the standardization of the ANA titer.
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Affiliation(s)
- Hae Weon Cho
- Department of Laboratory Medicine, Yonsei University College of Medicine, Seoul 03722, Republic of Korea; (H.W.C.); (Y.P.); (S.H.J.)
- Research Institute of Bacterial Resistance, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
- Department of Laboratory Medicine, Myongji Hospital, Goyang 10475, Republic of Korea
| | - Soon-Ho Jeong
- Department of Laboratory Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 03722, Republic of Korea;
| | - Jun Sung Hong
- Department of Companion Animal Health and Science, Silla University, Busan 46958, Republic of Korea;
| | - Dokyun Kim
- Department of Laboratory Medicine, Yonsei University College of Medicine, Seoul 03722, Republic of Korea; (H.W.C.); (Y.P.); (S.H.J.)
- Research Institute of Bacterial Resistance, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
- Department of Laboratory Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 03722, Republic of Korea;
| | - Yongjung Park
- Department of Laboratory Medicine, Yonsei University College of Medicine, Seoul 03722, Republic of Korea; (H.W.C.); (Y.P.); (S.H.J.)
- Department of Laboratory Medicine, Yongin Severance Hospital, Yonsei University College of Medicine, Yongin 16995, Republic of Korea
| | - Seok Hoon Jeong
- Department of Laboratory Medicine, Yonsei University College of Medicine, Seoul 03722, Republic of Korea; (H.W.C.); (Y.P.); (S.H.J.)
- Research Institute of Bacterial Resistance, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
- Department of Laboratory Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul 03722, Republic of Korea;
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Carbone T, Pafundi V, Ciardo V, Infantino M, Muscella A, D'Angelo S. Harmonization of ANA testing challenge: quantification strategy to accurately predict end-point titers avoiding serial dilution. Immunol Res 2024; 72:96-102. [PMID: 37792145 DOI: 10.1007/s12026-023-09417-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 08/18/2023] [Indexed: 10/05/2023]
Abstract
Despite the advantages of automated systems for antinuclear antibody (ANA) analysis, the prediction of end-point titers avoiding serial dilutions is still in progress. The aims of this study were to set a conversion table providing discriminant ranges of fluorescence signal intensity values (FI) corresponding to the end-point titers and validate this tool in a real-life laboratory setting. Eight hundred ninety-four serum samples were analyzed for ANA using Image Navigator System. In order to classify FI into non-overlapping groups corresponding to conventional end-point titers, statistical discriminant analysis was used. Validation study was performed calculating agreement and error rates between visual readings and conversion table of 1119 routine ANA positive samples. Setting of FI ranges corresponding to the end-point titers for different staining patterns was computed. For samples showing single pattern, the overall agreement between visual readings and conversion table was 98.4% for all titers ranging from 1:160 to 1:2560, of which 68.0% had the same titer and 30.4% were within ± one titer difference. Concordance rates according to ANA patterns were as follows: (1) nuclear 98.4%, of which 67.0% had the same titer and 31.4% ± one titer; (2) cytoplasmic 100%, of which 72.7% had the same titer and 27.3% than ± one titer; (3) mitotic 66.6%, of which 33.3% had more ± one titer. Our study developed a quantification method for autoantibodies titers assessment based on just one single sample dilution instead of traditional serial dilution approach, providing significant advantages in routine laboratory in terms of reduction in hand-on time and harmonization of results.
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Affiliation(s)
- Teresa Carbone
- Immunopathology Laboratory, San Carlo Hospital, Potito Petrone St., 85100, Potenza, Italy
| | - Vito Pafundi
- Immunopathology Laboratory, San Carlo Hospital, Potito Petrone St., 85100, Potenza, Italy.
| | - Vito Ciardo
- Department of Biological and Environmental Science and Technologies, University of Salento, Lecce, Italy
| | - Maria Infantino
- Laboratorio Immunologia Allergologia, San Giovanni Di Dio Hospital, Firenze, Italy
| | - Antonella Muscella
- Department of Biological and Environmental Science and Technologies, University of Salento, Lecce, Italy
| | - Salvatore D'Angelo
- IReL - Rheumatology Institute of Lucania - San Carlo Hospital, Potenza, Italy
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Hu WT, Nayyar A, Kaluzova M. Charting the Next Road Map for CSF Biomarkers in Alzheimer's Disease and Related Dementias. Neurotherapeutics 2023; 20:955-974. [PMID: 37378862 PMCID: PMC10457281 DOI: 10.1007/s13311-023-01370-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2023] [Indexed: 06/29/2023] Open
Abstract
Clinical prediction of underlying pathologic substrates in people with Alzheimer's disease (AD) dementia or related dementia syndromes (ADRD) has limited accuracy. Etiologic biomarkers - including cerebrospinal fluid (CSF) levels of AD proteins and cerebral amyloid PET imaging - have greatly modernized disease-modifying clinical trials in AD, but their integration into medical practice has been slow. Beyond core CSF AD biomarkers (including beta-amyloid 1-42, total tau, and tau phosphorylated at threonine 181), novel biomarkers have been interrogated in single- and multi-centered studies with uneven rigor. Here, we review early expectations for ideal AD/ADRD biomarkers, assess these goals' future applicability, and propose study designs and performance thresholds for meeting these ideals with a focus on CSF biomarkers. We further propose three new characteristics: equity (oversampling of diverse populations in the design and testing of biomarkers), access (reasonable availability to 80% of people at risk for disease, along with pre- and post-biomarker processes), and reliability (thorough evaluation of pre-analytical and analytical factors influencing measurements and performance). Finally, we urge biomarker scientists to balance the desire and evidence for a biomarker to reflect its namesake function, indulge data- as well as theory-driven associations, re-visit the subset of rigorously measured CSF biomarkers in large datasets (such as Alzheimer's disease neuroimaging initiative), and resist the temptation to favor ease over fail-safe in the development phase. This shift from discovery to application, and from suspended disbelief to cogent ingenuity, should allow the AD/ADRD biomarker field to live up to its billing during the next phase of neurodegenerative disease research.
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Affiliation(s)
- William T Hu
- Department of Neurology, Rutgers Biomedical and Health Sciences, Rutgers-Robert Wood Johnson Medical School, 125 Paterson Street, Suite 6200, New Brunswick, NJ, 08901, USA.
- Center for Innovation in Health and Aging Research, Institute for Health, Health Care Policy, and Aging Research, Rutgers Biomedical and Health Sciences, Rutgers-Robert Wood Johnson Medical School, New Brunswick, NJ, 08901, USA.
| | - Ashima Nayyar
- Department of Neurology, Rutgers Biomedical and Health Sciences, Rutgers-Robert Wood Johnson Medical School, 125 Paterson Street, Suite 6200, New Brunswick, NJ, 08901, USA
| | - Milota Kaluzova
- Department of Neurology, Rutgers Biomedical and Health Sciences, Rutgers-Robert Wood Johnson Medical School, 125 Paterson Street, Suite 6200, New Brunswick, NJ, 08901, USA
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Wener MH, Fink SL, Morishima C, Chaudhary A, Hutchinson K. Anti-Nuclear Antibody Quantitation: Calibration and Harmonization Adjustment via Population Interrogation. J Appl Lab Med 2022; 7:46-56. [PMID: 34996081 DOI: 10.1093/jalm/jfab142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 10/21/2021] [Indexed: 11/14/2022]
Abstract
BACKGROUND The 2019 classification criteria for systemic lupus erythematosus (SLE) includes an initial criterion requiring the presence of an antinuclear antibody (ANA), positive at a titer of at least 1:80 on HEp-2 cells, or equivalent. However, results of ANA tests performed on HEp-2 cells vary when tested in different laboratories. Calibration of ANA assays by achieving a common specificity in healthy control populations offers the possibility of achieving harmonization via population interrogation, but the expected specificity in a healthy control population is not known. METHODS The studies used to determine the use of ANAs performed by immunofluorescence microscopy on HEp-2 cells as the entry criterion for classification of SLE were reanalyzed by a meta-analysis to determine the expected frequency of positive ANAs in healthy control populations at serum dilutions of 1:40 and 1:80. RESULTS Our meta-analysis demonstrated that the expected specificity in a healthy control population of ANA performed using serum diluted 1:80 is 91.3% (CI 86.1-94.7%). The expected specificity of ANA performed at 1:40 serum dilution is 79.2% (CI 72.3-84.8%). CONCLUSION One approach to achieving harmonization of ANA assays from different laboratories with each other and with expected performance would involve adjusting assays so that about 10% of a healthy control population has a positive ANA when tested at 1:80 dilution, and about 20% of the healthy control population has a positive ANA when tested at 1:40 dilution. This pragmatic approach to calibration and harmonization adjustment via population interrogation offers an opportunity for individual laboratories to be aligned with each other and with ANA performance expected for consistent categorization of patients with SLE.
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Affiliation(s)
- Mark H Wener
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA
- Rheumatology Division, Department of Medicine, University of Washington, Seattle, WA
| | - Susan L Fink
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA
| | - Chihiro Morishima
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA
| | - Anu Chaudhary
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA
| | - Kathleen Hutchinson
- Department of Laboratory Medicine and Pathology, University of Washington, Seattle, WA
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Carbone T, Picerno V, Pafundi V, Esposito E, Leccese P, Padula AA, D'Angelo S. Impact of the COVID-19 Pandemic on the Appropriateness of Diagnostic Pathways of Autoimmune Rheumatic Diseases. J Rheumatol 2021; 49:219-224. [PMID: 34654735 DOI: 10.3899/jrheum.210611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Early diagnosis of autoimmune rheumatic diseases (ARDs) is key to achieving effective treatment and improving prognosis. The coronavirus disease 2019 (COVID-19) pandemic has led to major changes in clinical practice on a global scale. We aimed to evaluate the impact of the COVID-19 pandemic on rheumatological clinical practice and autoimmunity testing demands. METHODS Data regarding the first rheumatological visits and new diagnoses, together with the autoimmunity laboratory testing volumes related to the COVID-19 pandemic phase (January-December 2020), were collected from medical records and the laboratory information system of a regional reference hospital (Basilicata, Italy) and compared with those obtained during the corresponding period in 2019. RESULTS A significant decrease in the 2020 autoimmunity laboratory test volume was found when compared with the same period in 2019 (9912 vs 14,100; P < 0.05). A significant decrease in first rheumatological visits and diagnosis (1272 vs 2336; P < 0.05) was also observed. However, an equivalent or higher percentage of positive autoimmunity results from outpatient services was recorded during 2020 when compared to the prepandemic state. Of note, COVID-19-associated decline in new diagnoses affected mainly less severe diseases. In contrast, ARDs with systemic involvement were diagnosed at the same levels as in the prepandemic period. CONCLUSION The COVID-19 pandemic has affected access to health services. However, our study highlighted that during the outbreak, greater appropriateness of the requests for laboratory tests and visits emerged, as shown by a greater percentage of positive test results and new diagnoses of more severe ARDs compared to the prepandemic period.
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Affiliation(s)
- Teresa Carbone
- T. Carbone, PhD, Laboratory of Clinical Pathology, Azienda Sanitaria di Matera (ASM), Matera; V. Picerno, MD, P. Leccese, MD, A.A. Padula, MD, S. D'Angelo, MD, PhD, Rheumatology Institute of Lucania - San Carlo Hospital, Potenza; V. Pafundi, MD, Immunopathology Laboratory, San Carlo Hospital, Potenza; E. Esposito, MD, Health Department, Basilicata Region, Potenza, Italy. T. Carbone and V. Picerno contributed equally. The authors declare no conflict of interests relevant to this article. Address correspondence to Dr. V. Pafundi, Immunopathology Laboratory, San Carlo Hospital, Potito Petrone St., 85100 Potenza, Italy. . Accepted for publication September 30, 2021
| | - Valentina Picerno
- T. Carbone, PhD, Laboratory of Clinical Pathology, Azienda Sanitaria di Matera (ASM), Matera; V. Picerno, MD, P. Leccese, MD, A.A. Padula, MD, S. D'Angelo, MD, PhD, Rheumatology Institute of Lucania - San Carlo Hospital, Potenza; V. Pafundi, MD, Immunopathology Laboratory, San Carlo Hospital, Potenza; E. Esposito, MD, Health Department, Basilicata Region, Potenza, Italy. T. Carbone and V. Picerno contributed equally. The authors declare no conflict of interests relevant to this article. Address correspondence to Dr. V. Pafundi, Immunopathology Laboratory, San Carlo Hospital, Potito Petrone St., 85100 Potenza, Italy. . Accepted for publication September 30, 2021
| | - Vito Pafundi
- T. Carbone, PhD, Laboratory of Clinical Pathology, Azienda Sanitaria di Matera (ASM), Matera; V. Picerno, MD, P. Leccese, MD, A.A. Padula, MD, S. D'Angelo, MD, PhD, Rheumatology Institute of Lucania - San Carlo Hospital, Potenza; V. Pafundi, MD, Immunopathology Laboratory, San Carlo Hospital, Potenza; E. Esposito, MD, Health Department, Basilicata Region, Potenza, Italy. T. Carbone and V. Picerno contributed equally. The authors declare no conflict of interests relevant to this article. Address correspondence to Dr. V. Pafundi, Immunopathology Laboratory, San Carlo Hospital, Potito Petrone St., 85100 Potenza, Italy. . Accepted for publication September 30, 2021
| | - Ernesto Esposito
- T. Carbone, PhD, Laboratory of Clinical Pathology, Azienda Sanitaria di Matera (ASM), Matera; V. Picerno, MD, P. Leccese, MD, A.A. Padula, MD, S. D'Angelo, MD, PhD, Rheumatology Institute of Lucania - San Carlo Hospital, Potenza; V. Pafundi, MD, Immunopathology Laboratory, San Carlo Hospital, Potenza; E. Esposito, MD, Health Department, Basilicata Region, Potenza, Italy. T. Carbone and V. Picerno contributed equally. The authors declare no conflict of interests relevant to this article. Address correspondence to Dr. V. Pafundi, Immunopathology Laboratory, San Carlo Hospital, Potito Petrone St., 85100 Potenza, Italy. . Accepted for publication September 30, 2021
| | - Pietro Leccese
- T. Carbone, PhD, Laboratory of Clinical Pathology, Azienda Sanitaria di Matera (ASM), Matera; V. Picerno, MD, P. Leccese, MD, A.A. Padula, MD, S. D'Angelo, MD, PhD, Rheumatology Institute of Lucania - San Carlo Hospital, Potenza; V. Pafundi, MD, Immunopathology Laboratory, San Carlo Hospital, Potenza; E. Esposito, MD, Health Department, Basilicata Region, Potenza, Italy. T. Carbone and V. Picerno contributed equally. The authors declare no conflict of interests relevant to this article. Address correspondence to Dr. V. Pafundi, Immunopathology Laboratory, San Carlo Hospital, Potito Petrone St., 85100 Potenza, Italy. . Accepted for publication September 30, 2021
| | - Angela Anna Padula
- T. Carbone, PhD, Laboratory of Clinical Pathology, Azienda Sanitaria di Matera (ASM), Matera; V. Picerno, MD, P. Leccese, MD, A.A. Padula, MD, S. D'Angelo, MD, PhD, Rheumatology Institute of Lucania - San Carlo Hospital, Potenza; V. Pafundi, MD, Immunopathology Laboratory, San Carlo Hospital, Potenza; E. Esposito, MD, Health Department, Basilicata Region, Potenza, Italy. T. Carbone and V. Picerno contributed equally. The authors declare no conflict of interests relevant to this article. Address correspondence to Dr. V. Pafundi, Immunopathology Laboratory, San Carlo Hospital, Potito Petrone St., 85100 Potenza, Italy. . Accepted for publication September 30, 2021
| | - Salvatore D'Angelo
- T. Carbone, PhD, Laboratory of Clinical Pathology, Azienda Sanitaria di Matera (ASM), Matera; V. Picerno, MD, P. Leccese, MD, A.A. Padula, MD, S. D'Angelo, MD, PhD, Rheumatology Institute of Lucania - San Carlo Hospital, Potenza; V. Pafundi, MD, Immunopathology Laboratory, San Carlo Hospital, Potenza; E. Esposito, MD, Health Department, Basilicata Region, Potenza, Italy. T. Carbone and V. Picerno contributed equally. The authors declare no conflict of interests relevant to this article. Address correspondence to Dr. V. Pafundi, Immunopathology Laboratory, San Carlo Hospital, Potito Petrone St., 85100 Potenza, Italy. . Accepted for publication September 30, 2021
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Cinquanta L, Bizzaro N, Pesce G. Standardization and Quality Assessment Under the Perspective of Automated Computer-Assisted HEp-2 Immunofluorescence Assay Systems. Front Immunol 2021; 12:638863. [PMID: 33717188 PMCID: PMC7947926 DOI: 10.3389/fimmu.2021.638863] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 01/18/2021] [Indexed: 12/11/2022] Open
Abstract
The recent availability of automated computer-assisted diagnosis (CAD) systems for the reading and interpretation of the anti-nuclear antibody (ANA) test performed with the indirect immunofluorescence (IIF) method on HEp-2 cells, has improved the reproducibility of the results and initiated a process of harmonization of this test. Furthermore, CAD systems provide quantitative expression of fluorescence intensity, allowing the introduction of objective quality control procedures to the monitoring of the entire process. The calibration of the reading systems and the automated image interpretation are essential prerequisites for obtaining reproducible and harmonized IIF test results and form the basis for standardization, regardless of the computer algorithms used in the different systems. The use of automated CAD systems, facilitating control procedures, represents a step forward for the quality certification of the laboratory.
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Affiliation(s)
- Luigi Cinquanta
- Laboratorio di Patologia Clinica, IRCCS S.D.N., Napoli, Italy
| | - Nicola Bizzaro
- Laboratorio di Patologia Clinica, Ospedale San Antonio, Tolmezzo—Azienda Sanitaria Universitaria Integrata di Udine, Udine, Italy
| | - Giampaola Pesce
- Laboratorio Diagnostico di Autoimmunologia, IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Dipartimento di Medicina Interna e Specialità Mediche (DIMI), Università Degli Studi di Genova, Genova, Italy
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Infantino M, Carbone T, Manfredi M, Grossi V, Antico A, Panozzo MP, Brusca I, Alessio MG, Previtali G, Platzgummer S, Cinquanta L, Paura G, Deleonardi G, Trevisan MT, Radice A, Castiglione C, Imbastaro T, Fabris M, Pesce G, Porcelli B, Terzuoli L, Sorrentino MC, Tampoia M, Abbracciavento L, Villalta D, Conte M, Barberio G, Gallo N, Benucci M, Bizzaro N. A new diagnostic algorithm for pattern-oriented autoantibody testing according to the ICAP nomenclature: A pilot study. Autoimmun Rev 2020; 19:102588. [PMID: 32540447 DOI: 10.1016/j.autrev.2020.102588] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 02/14/2020] [Indexed: 12/31/2022]
Abstract
The commercial tests currently available as second-level tests to detect ANA sub-specificities are generally used independently from the ANA immunofluorescence (IIF) pattern. The aim of this study was to evaluate the efficacy of the use of a customizable pattern-oriented antigenic panel by immunoblot (IB) using the International Consensus on ANA Patterns (ICAP) classification scheme, in order to introduce a novel and updated autoimmune diagnostic flowchart. 710 sera referred for routine ANA testing were selected on the basis of the ANA pattern according to the ICAP nomenclature (nuclear speckled AC-2,4,5; nucleolar AC-8,9,10,29; cytoplasmic speckled AC-18,19,20) and on an IIF titer ≥1:320. They were then assayed by three experimental IB assays using a panel of selected antigens. ICAP-oriented IB detected 515 antibody reactivities vs. 457 of traditional anti-ENA in the nuclear speckled pattern group, 108 vs. 28 in the nucleolar pattern group, and 43 vs. 34 in the cytoplasmic speckled pattern. This pilot study may lead the way for a new approach introducing an ICAP pattern-oriented follow up testing as a valid alternative to the existing standard panels, thus enabling more patients with autoimmune rheumatic disease to be accurately diagnosed.
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Affiliation(s)
- Maria Infantino
- Laboratorio Immunologia Allergologia, Ospedale San Giovanni di Dio, Firenze, Italy.
| | - Teresa Carbone
- IReL, Istituto Reumatologico Lucano, Ospedale San Carlo, Potenza, Italy
| | - Mariangela Manfredi
- Laboratorio Immunologia Allergologia, Ospedale San Giovanni di Dio, Firenze, Italy
| | - Valentina Grossi
- Laboratorio Immunologia Allergologia, Ospedale San Giovanni di Dio, Firenze, Italy
| | | | | | - Ignazio Brusca
- Patologia Clinica, Ospedale Buccheri La Ferla FBF, Palermo, Italy
| | | | - Giulia Previtali
- Laboratorio Analisi Chimico Cliniche, ASST Papa Giovanni XXIII, Bergamo, Italy
| | | | - Luigi Cinquanta
- Laboratorio centralizzato (HUB) SDN Spa, Gruppo SYNLAB, Pagani, SA, Italy
| | - Giusy Paura
- Autoimmmunologia e allergologia diagnostica di laboratorio, OORR San Giovanni di Dio e Ruggi d'Aragona, Salerno, Italy
| | - Gaia Deleonardi
- Laboratorio Unico Metropolitano, Ospedale Maggiore, Bologna, Italy
| | | | - Antonella Radice
- UOC Microbiologia e Virologia, Presidio Ospedaliero San Carlo Borromeo, Milano, Italy
| | | | | | - Martina Fabris
- SOC Istituto di Patologia Clinica, Azienda Sanitaria Universitaria Integrata, Udine, Italy
| | - Giampaola Pesce
- Laboratorio Diagnostico di Autoimmunologia IRCCS Ospedale Policlinico San Martino Genova Dipartimento di Medicina Interna e specialità mediche (DIMI), Università di Genova, Genova, Italy
| | - Brunetta Porcelli
- UOC Laboratorio Patologia Clinica, Policlinico S. Maria alle Scotte, AOU Senese, Siena, Italy
| | - Lucia Terzuoli
- UOC Laboratorio Patologia Clinica, Policlinico S. Maria alle Scotte, AOU Senese, Siena, Italy
| | - Maria Concetta Sorrentino
- Dipartimento di Medicina di Laboratorio e Biotecnologie avanzate, Laboratorio di Patologia Clinica, Microbiologia e Virologia, Palermo, Italy
| | - Marilina Tampoia
- Laboratorio di Autoimmunologia, UOC di Patologia Clinica Universitaria, Bari, Italy
| | | | - Danilo Villalta
- SSD di Allergologia e Immunologia clinica, Presidio Ospedaliero S. Maria degli Angeli, Pordenone, Italy
| | - Mariaelisabetta Conte
- SSD di Allergologia e Immunologia clinica, Presidio Ospedaliero S. Maria degli Angeli, Pordenone, Italy
| | - Giuseppina Barberio
- U.O.C. Medicina di Laboratorio Azienda ULSS n2 Marca trevigiana, Treviso, Italy
| | - Nicoletta Gallo
- Dipartimento di Medicina di Laboratorio, Azienda Universitaria di Padova, Padova, Italy
| | | | - Nicola Bizzaro
- Laboratorio di Patologia Clinica, Ospedale San Antonio, Tolmezzo, Italy
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