Antinuclear Antibody Test Research Articles

Anti-DFS70 antibodies detected by immunoblot methods: A reliable tool to confirm the dense fine speckles ANA pattern

BackgroundAutoantibodies to the DFS70 (dense fine speckles 70) protein have been identified among the antinuclear antibodies (ANA) in patients with various disorders. However, the ANA test in indirect immunofluorescence (IIF) is not a reliable method to identify anti-DFS70 antibodies. We undertook this study to evaluate the diagnostic performance of two new immunoblot methods for the detection of anti-DFS70 antibodies and to investigate whether their different DFS70 antigen composition could affect diagnostic accuracy in detecting anti-DFS70 antibodies. Methods62 samples showing a DFS70 staining pattern by IIF were tested by dot blot (Alphadia) and line blot (Euroimmun) methods. The dot blot method employs a truncated sequence of the DFS70 antigen (residues 349-435), while the line blot uses the full-length protein (aa 1-530). The 62 samples were previously assayed by a chemoluminescent (CLIA) method also using a truncated antigen (aa 349-435): 27 were CLIA positive and 35 were CLIA negative. 120 sera from subjects with infectious diseases were used as controls. ResultBoth immunoblot methods were positive in the 27 IIF/CLIA positive samples; in addition, the Alphadia dot blot identified another seven DFS70 samples and the Euroimmun line blot was positive in five samples that were negative by CLIA. Among the 120 control samples, two false positives were recorded for the CLIA method, six for the Alphadia method and four for the Euroimmun method. Therefore, in this selected series of samples, sensitivity and specificity were 43.5% and 98.3% for the CLIA method, 54.8% and 95% for the dot blot and 51.6% and 96.6% for the line blot, respectively. ConclusionsBecause of great inconsistency in assessing the DFS70 pattern using the ANA-IIF test, specific assays should be used to confirm anti-DFS70 antibodies. The results of this study show that there is no difference in the overall diagnostic accuracy among methods that use the truncated or the full-length DFS70 antigenic sequence and that it is likely that antibodies directed against antigens other than DFS70 may be responsible for producing a DFS70-like ANA-IIF pattern.

Computer Aided Diagnosis for Anti-Nuclear Antibodies HEp-2 images: Progress and challenges

The Anti-Nuclear Antibodies (ANA) test using Human Epithelial (HEp-2) cells has been the gold standard to identify the presence of Connective Tissue Diseases (CTD) such us Systemic Lupus Erythomatus (SLE). As the ANA test is time consuming, labor intensive and subjective, there has been an on-going effort to develop image-based Computer Aided Diagnosis (CAD) systems. This paper discusses the current progress and challenges in this field and will highlight areas which require more attention.

Systemic lupus erytherymatosus: an interdisciplinary approach to the diagnosis

Diagnosis of systemic lupus erythematosus presents certain difficulties up to now. Due to the prognostic significance of the disease and the need to early pathogenetic treatment clinical cases of SLE are described. Questions of modern differential diagnosis are reviewed. If skin changes are presented a positive test for antinuclear antibodies helps to detect SLE timely. 4 clinical cases of women with systemic lupus erythematosus are presented. Diagnostics required comprehensive examination with histopathological and immunological studies: blood test antinuclear factor on HEp-2 cells with the definition of lupus anticoagulant in blood plasma, rheumatoid factor, anticardiolipin antibody IgG and IgM, double stranded DNA, antinuclear antibody IgG, auto antibodies to IgG AMA-M2 (immunoblott), cardiolipin antibodies and lupus anticoagulant.

Bilateral pulmonary embolism and ilio-femoral DVT associated with recent amputation of lower limb, long distance air travel and suspected thrombophilia.

We present a 36 years old Bangladeshi male, known smoker, while working in Bahrain, suffered from arterial thromboembolism on left lower extremity resulting in gangrene of left leg. He underwent above knee amputation of the affected limb. After 16 days stay in the hospital with an open amputated stump wound, he was sent back to Bangladesh by air. While in the airplane, he complained of chest discomfort about two hours before landing at Dhaka airport of Bangladesh. Following disembarkation he was admitted into local cardiac hospital where a diagnosis of left ventricular failure with unstable angina was made. Five days later he was transferred to ICU of Ibn Sina Hospital for better management. Patient had high serum D-dimer level and fibrin degradation products (FDP) level. negative antinuclear antibody (ANA) test, negative anti-cardiolipin antibody test, normal troponin I, Homocysteine, antithrombin III, protein S, & protein C levels. Initial X-ray chest showed left lower zone wedge shaped density. ECG showed sinus tachycardia. CT angiogram of chest showed bilateral pulmonary embolism (PE) and large left pleural effusion. Contrast CT abdomen showed bilateral iliac vein thrombus extending to lower inferior vena cava. Left pleural effusion was found to be grossly hemorrhagic. Patient was treated with low molecular weight heparin and warfarin. As thrombolysis was not feasible, he was advised to have thrombo-embolectomy. He refused surgical option and left hospital against medical advice. This case illustrates that multiple risk factors can be responsible for PE, and appropriate & timely interventions are always needed to prevent morbidity and or mortalityBangladesh Crit Care J March 2016; 4 (1): 46-50

Biosensor for total antinuclear antibody determination at the point-of-care

Antinuclear antibodies (ANA) are important in diagnosis and follow-up of patients with autoimmune conditions. The current increase in ANA requests is driven by broadening the use of ANA from a test for lupus to a test for diverse autoimmune diseases, but the standard method is protracted, cumbersome and prone to error. We describe an electrochemical method for quantifying total ANA for use as a point-of-care diagnostic aid. In this technology the target autoantigens are derived from a protein/nucleoprotein mixture prepared from an inexpensive source and adsorbed to a porous membrane with high protein binding capacity. Serum is slowly drawn through the membrane comprising the high density autoantigen mixture to induce rapid binding of patient autoantibodies. After rinsing, peroxidase-conjugated anti-IgG is drawn through the membrane followed by rinsing, insertion of an electrode assembly, and addition of the enzyme substrate. Substrate peroxidation is measured by microamperage-level current accompanying electrochemical reduction of the intermediate product. Values are comparable to a standard ANA test but require a total processing time of ~20min. This method has the promise to greatly expand ANA testing in clinical settings for initial patient assessment of autoimmune disease.

Antinuclear antibody testing: discordance between commercial laboratories.

Antinuclear antibody (ANA) test results frequently affect the course of patients' evaluations, diagnosis, and treatment, but different laboratory centers may yield conflicting results. This study investigated the degree of agreement between laboratory results in a group of subjects who had ANA testing performed at two commercial laboratories. This was a chart review study, in which all ANA tests ordered by the authors from one commercial laboratory over a 4-year period were queried. Corresponding patient charts were reviewed, and if ANA testing had also been performed at the second commercial laboratory, subjects were entered into the study. The primary measurement was agreement between paired ANA results, and we performed sensitivity analysis using varying criteria defining agreement (criteria A to criteria D [strictest to most lenient definition of agreement]). Other data captured included relevant data obtained through the course of evaluation (e.g., presenting complaints, exam findings, other laboratory data) and final diagnoses. Of 101 paired ANA tests, there was 18% agreement according to the strictest criteria and 42% according to the most lenient. Of the seven subjects with ANA-associated rheumatic disease, none of the paired tests were in agreement according to criteria A (two agreed according to criteria D). Our findings demonstrate poor agreement between paired ANA tests performed at two commercial laboratories. The low level of agreement may have far-reaching clinical implications. Specifically, this finding calls into question the reliability of ANA testing as it is currently performed and suggests that results may in part depend upon the laboratory center to which patients are referred.

Combination therapy of cyclosporine and prednisolone in a dog with systemic lupus erythematosus

Abstract : An 11-year-old, spayed female poodle presented with fever and shifting lameness. Physical examinationrevealed hyperthermia (40.6 o C), and proteinuria was detected upon urinalysis. Increased neutrophils (83%) and decreasedviscosity were revealed upon synovial fluid analysis. Serum antinuclear antibody was positive at 1 : 80. Based on thesefindings, the dog was diagnosed with systemic lupus erythematosus. Immunosuppressive therapy was initiated withprednisolone and cyclosporine, and the condition was markedly improved after the treatments. This case report describesthe clinical and laboratory findings, imaging characteristics and successful outcomes after prednisolone plus cyclosporinetherapy in a canine systemic lupus erythematosus case.Keywords : antinuclear antibody, cyclosporine, glomerulonephritis, polyarthritis, systemic lupus erythematosus Systemic lupus erythematosus (SLE) is a multisystemicautoimmune disorder in which immunity is directed againstvarious tissues or tissue components [1]. The most commonclinical features include shifting lameness from polyarthritis,ulceration of extremities caused by vasculitis, icteric and palemucous membranes resulting from immune-mediated hemol-ysis, and peripheral edema or pleural effusion due to hypoal-buminemia secondary to glomerulonephritis. Additionally,dermatologic lesions may be present, including crusting, alope-cia, erythema, ulceration, and hyperkeratosis [8].Major signs of SLE are skin lesions, non-erosive polyarthri-tis, hemolytic anemia, glomerulonephritis, polymyositis, leuko-penia, and thrombocytopenia [1]. Minor signs are fever, centralnervous system symptoms, oral ulcerations, lymphadenopa-thy, pericarditis, and pleuritis [2]. The antinuclear antibody(ANA) test and lupus erythematosus (LE) cell preparations areused clinically for the diagnosis of SLE, but until recently, theANA test is considered the most sensitive [3, 14]. Immunosup-pression is vital to treating this abnormal immune response,and patients can be treated with high dose of prednisolone (1–2 mg/kg, per oral [PO], q12h) and cytotoxic drugs, such asazathioprine, cyclosporine, and cyclophosphamide [4, 5]. Thiscase report describes successful treatment using prednisoloneand cyclosporine in a dog with SLE.An 11-year-old, 6.1 kg, spayed female poodle dog pre-sented with fever, lethargy, anorexia, and shifting lameness.The dog had a history of reluctance to stand up and walk,which was intermittent and partially responsive to non-steroi-dal anti-inflammatory drugs. Physical examination was unre-markable except for hyperthermia (40.6

Choosing Wisely in Daily Practice: An Intervention Study on Antinuclear Antibody Testing by Rheumatologists.

To assess the effect of a simple intervention on antinuclear antibody (ANA) test overuse by rheumatologists. This was an explorative, pragmatic, before-and-after, controlled implementation study among rheumatologists working at 3 rheumatology departments in secondary and tertiary care centers in The Netherlands. The intervention was given in all study centers separately and combined education with feedback. Six outcome measures describe the intervention effects: the ANA/new patient ratio (APR), difference with the target APR, percentage of positive ANA tests, percentage of repeated ANA testing, percentage of ANA-associated diseases, and APR variation between rheumatologists. Outcomes were compared between the pre- and postintervention period (both 12 months) using (multilevel) logistic regression or F testing. Results are reported together for centers 1 and 2, and separately for center 3, because ANA tests could not be linked to an individual rheumatologist in center 3. The APR decreased from 0.37 to 0.11 after the intervention in centers 1 and 2 (odds ratio [OR] 0.19, 95% confidence interval [95% CI] 0.17-0.22, P < 0.001) and from 0.45 to 0.30 in center 3 (OR 0.53, 95% CI 0.45-0.62, P < 0.001). The percentage of repeated ANA requests in all centers and the APR variation for centers 1 and 2 decreased significantly. Only in center 3 did the percentage of ANA-associated diseases increase significantly. A simple intervention resulted in a relevant and significant decrease in the numbers of ANA tests requested by rheumatologists, together with an improvement on 3 other outcome measures.

Dense fine speckled indirect immunofluorescence pattern in an Australian population

The dense fine speckled (DFS) pattern is an antinuclear antibody (ANA) pattern that has recently become of interest. This particular pattern has not been associated with systemic autoimmune rheumatic disorders (SARD) but has been associated with other inflammatory conditions such as interstitial nephritis, autoimmune thyroid disease and atopic eczema as well as being found in healthy individuals. We have been reporting this pattern in our laboratory for the past 3 years. The objective of this study was to determine the frequency of the DFS pattern as detected on indirect immunofluorescence (IIF) in an Australian population and to assess association of this pattern with other laboratory autoimmune markers. ANA tests performed by IIF from July 2012 until June 2014 were reviewed and the frequency of DFS pattern was determined. All DFS positive samples that had undergone concurrent testing for antibodies to extractable nuclear antigens (ENA), anti-dsDNA antibodies, rheumatoid factor (RF), anti-citrullinated protein antibodies (CCP) and anti- phospholipid antibodies were compared. Over the 2 year period, 181,819 patients had ANA tests performed and 51,905 were ANA positive. The DFS pattern was found in 5.7% of ANA positive patients. Within this group of patients, only 1.8% were positive for antibodies to ENA and only 0.7% had anti-dsDNA antibodies level greater than 9IU/mL. RF and anti-CCP antibodies were positive in 6.3% and 4.1% of DFS positive samples, respectively. There were only two samples positive for anti-phospholipid antibodies when the DFS pattern was present. The presence of the DFS pattern as detected by IIF is infrequently associated with autoimmune markers of SARD which is consistent with international studies.

Abstract 116: Antinuclear Antibody levels Study in Postural Orthostatic Tachycardia Syndrome

Background: Postural orthostatic tachycardia syndrome (POTS) is an autonomic disturbance characterized by the clinical symptoms of orthostatic intolerance, mainly light headedness, fatigue, sweating, tremor, anxiety, palpitation, exercise intolerance and near syncope on upright posture. These are relieved on lying down. Patients also have a heart rate &gt;120 beats/min (bpm) on standing or increase their heart rate by 30 bpm from a resting heart rate after standing for 10 min. An antinuclear antibody (ANA) test measures the amount and pattern of antibodies in blood that work against own body (autoimmune reaction). If there are more antibodies in the blood than normal, the test is positive. The aim of this study is to demonstrate ANA levels in POTS. Methods: 151 patients were selected randomly from our clinic with POTS. Patients ANA levels were reviewed from electronic medical records and performed data analysis. Results: Out of 151 patients, 129 patients are females (85%, n=129, age 32±10.98), 22 patients are males (15%, n=22, age 27.90±12.11). 110/151(73%) patients had negative ANA, 41(27%) patients had positive ANA. Conclusion: Our research results demonstrated that ANA levels are positive in one fourth of Postural Orthostatic Tachycardia Syndrome (POTS) patients.

Using the American College of Rheumatology (ACR) and Systemic Lupus International Collaborating Clinics (SLICC) criteria to determine the diagnosis of systemic lupus erythematosus (SLE) in patients with subacute cutaneous lupus erythematosus (SCLE)

Approximately 50% of patients with subacute cutaneous lupus erythematosus (SCLE) meet criteria for systemic lupus erythematosus (SLE). The Systemic Lupus International Collaborating Clinics (SLICC) developed new SLE criteria to improve the American College of Rheumatology (ACR) criteria but the SLICC criteria have not been evaluated in patients with SCLE. We sought to determine how patients with SCLE/SLE meet the ACR and SLICC criteria to compare the 2 sets of criteria. This was a retrospective analysis of 107 patients with SCLE enrolled in a database at the University of Pennsylvania. Patients with SCLE/SLE were more likely than those with only SCLE to have oral ulcers, positive anti-double-stranded DNA antibodies, and positive antinuclear antibody test findings using both sets of criteria. Patients with SCLE/SLE were also more likely to have low complement using the SLICC criteria. There was a statistically insignificant increase in individuals meeting the SLICC criteria. Not all patients received comprehensive laboratory testing. Most patients with SCLE who formally meet criteria for SLE do so based on the laboratory and mucocutaneous criteria. Neither the ACR nor SLICC criteria distinguish patients with SCLE and major internal disease from patients with SCLE without major internal disease.

The comparison of antinuclear antibody positivity and thiol/disulfide levels / Antinükleer antikor pozitifliği ve tiyol/disülfid düzeylerinin karşılaştırılması

Abstract Objective: There is also a growing body of evidence showing that an abnormal thiol disulphide homeostasis state is involved in the pathogenesis of certain diseases. In the present study, it was aimed to investigate the relationship among ANA positivity and dynamic thiol/ disulphide homeostasis in serum samples Methods: Serum samples were collected from ANA-positive and ANA-negative individuals. The indirect immunofluorescence antinuclear antibody test (HEp 20-10, EUROIMMUN, Germany) was used. The serum thiol/disulfide levels were measured with the fully automated new method. Results: No statistically significant difference was detected between thiol/disülfide levels in individuals who were negative and those who were positive for ANA (p&gt;0.05). Besides, among the ANA patterns was not found statistically significant difference for thiol/disulfide levels (p&gt;0.05). However, serum native thiol, total thiol and disülfide levels were decreased with aging. The native thiol, total thiol levels and native thiol/disulfide, total thiol/disulfide, native thiol/total thiol ratio was found statistically significant difference among the different age groups (p&lt;0.05). Conclusion: Determination of thiol/disulfide homeostasis can not provide valuable information on normal or abnormal biochemical processes in ANA-positive individuals. However, determination of thiol/disulfide homeostasis which could be a contributing factor to the pathogenesis of some age-related diseases.

Short-term assessment of BCR repertoires of SLE patients after high dose glucocorticoid therapy with high-throughput sequencing.

We analyze and assess BCR repertoires of SLE patients before and after high dose glucocorticoid therapy to address two fundamental questions: (1) After the treatment, how the BCR repertoire of SLE patient change on the clone level? (2) How to screen putative autoantibody clone set from BCR repertoire of SLE patients? The PBMCs of two SLE patients (P1 and P2) at different time points were collected, and DNA of these samples were extracted. High-throughput sequencing technology was applied in detection of BCR repertoire. Finally, we used bioinformatic methodology to analyse sequence data. We found that these two patients lost some IGHV3 family genes usage after treatment compared with before treatment. For pairing of IGHV–IGHJ gene, no significant change was shown for each patient. In addition, analyses of the composition of H-CDR3 showed overall AA compositions of H-CDR3 at three time points in each SLE patients were very similar, and the results of H-CDR3 AA usage that had the same length (14 AA) and the same position were similar. Antinuclear antibody tests of SLE patients showed that level of some antinuclear antibodies reduced after treatment; however, there was no sign that the percentage of autoantibody clones in BCR repertoires would reduce. High dose glucocorticoid treatment in short term will have little impact on composition of BCR repertoire of SLE patient. Treatment can reduce the amount of autoantibody in the protein level, but may not reduce the percentage of autoantibody clones in BCR repertoire in the clonal level.Electronic supplementary materialThe online version of this article (doi:10.1186/s40064-016-1709-4) contains supplementary material, which is available to authorized users.

Relation of Nailfold Capillaries and Autoantibodies to Mortality in Patients With Raynaud Phenomenon.

In incipient Raynaud phenomenon, nailfold capillaroscopy and autoantibody tests are obtained to screen for an emerging connective tissue disease. Whether the presence of abnormal nailfold capillaries and autoantibodies are related to mortality in patients with incipient Raynaud phenomenon is not known. In 2958 consecutive patients (78% women, median age 45 years) with incipient Raynaud phenomenon without previously known connective tissue disease, nailfold capillaroscopy and laboratory tests for antinuclear antibodies (ANA) and ANA subsets were obtained at initial presentation. During a median follow-up period of 9.3 years, 227 women (9.9% of female patients) and 129 men (20% of male patients) with Raynaud phenomenon died. In comparison with a demographically matched standard population, survival was poorer in patients with Raynaud phenomenon (log-rank test P<0.0001). In patients with Raynaud phenomenon, mortality was higher in men than in women (P<0.0001, Cox proportional hazards model). In women, the presence of abnormal nailfold capillaries, ANA, and anti-Scl-70 antibodies were related to an increase in all-cause mortality. The conjoint presence of abnormal nailfold capillaries and autoantibodies was associated with the highest mortality rates. In men, abnormal nailfold capillaries, and ANA and ANA subsets, as well, were not related to survival. In both sexes, patients' age and serum creatinine were associated with mortality. In Raynaud phenomenon, male sex, age, and serum creatinine are related to mortality. Abnormal nailfold capillaries and autoantibodies are associated with an increase in all-cause mortality in female patients, but not in male patients with Raynaud phenomenon.

Distribution of the patterns in patients with positive antinuclear antibody and anti-extractable nuclear antigen

Background: Early diagnosis of autoimmune disorders is critical in order to prevent complications, morbidity and mortality. Antinuclear antibody (ANA) tests are commonly used in support of the diagnosis of autoimmune diseases. In the present study, we aimed to compare and evaluate the ANA patterns which were determined via an IFA method for the detection of the presence of autoantibody against extractable nuclear antigens (ENA). Material and Methods: Antinuclear antibodies were tested for a total of 5453 patients admitted to various clinics of Ondokuz Mayis University Medical Faculty. A 1:100 dilution of each serum sample was used, and the presence of ANA and staining pattern was evaluated with ANA-IFA. A total of 616 ANA-positive samples were also tested for anti-ENA using the same method. Results: ANA tests were detected as positive in 843 samples (15.5%). Amongst patients, 624 (74%) were female, and 219 (26%) were male. Anti-ENA antibodies were positive for 192 (31.2%) of 616 which are positive for ANA and of which anti-ENA was sought. Of those, the most common-ANA patterns were detected as speckled in 144 (75.0%) samples, nucleolar in 20 (10.4%), and homogeneous in 13 (6.8%) samples. The most common anti-ENA antibodies were found to be anti-SS-A in 50 samples (26.0%), RO-52 in 39 (20.3%), and anti-scl-70 in 34 (17.7%) samples. Conclusion: Findings of the present study suggested that anti-ENA antibodies do not follow a specific ANA pattern an ANA pattern isn’t related to a specific anti-ENA antibody type. However, the presence of various ANA patterns may sometimes be associated with a specific disease or a syndrome. Detection of antinuclear antibodies, determination of the ANA patterns and, assessment of different ENA antibody types and interpretation of the results altogether will help the clinician significantly in the diagnosis of autoimmune diseases.

Band-like Acral Osteolysis in Limited Cutaneous Scleroderma

Abstract: Acral osteolysis is a well-recognized manifestation of scleroderma. Scleroderma is characterized by abnormal deposition of collagen and other extra cellular matrix macromolecules leading to vascular damage, inflammation and tissue fibrosis. Acral osteolysis in scleroderma occurs due to digital ischemia resulting from the vasculopathy. Treatment is directed towards providing symptomatic relief and prevention of complications. Here we present a case of band-like acral osteolysis seen in a patient of limited cutaneous scleroderma. Keywords: Osteolysis; Acral osteolysis; Scleroderma; Systemic sclerosis Introduction:Scleroderma is a multisystem connective tissue disorder that is characterised by abnormal deposition of collagen and other connective tissue macromolecules in the skin and multiple internal organs leading to inflammation and fibrosis. The exact etiology is unknown. Various genetic, infectious, and environmental factors have been implicated in the pathogenesis of scleroderma leading to vascular injury, fibrosis, and immune activation. The pathological pathways include vasculopathy and abnormalities in both humoral and cellular immunity. Osteolysis is a well-recognized manifestation of scleroderma. Here we report a case of band-like acral osteolysis seen in a patient of scleroderma. Clinical Presentation: A 25 years old female presented with a history of progressive tightening of the skin over her fingers and face for 3 years associated with phasic changes in skin colour (white, blue and red) typical of Raynaud’s phenomenon. On physical examination, the skin over her face appear stretched out, tight and shiny. The skin over the distal part of most her fingers also appear tight and stretched out. The tips of most of her fingers appear shortened (Figure 1). A test for antinuclear antibodies was positive with a titre of 1: 1280. Her Anticentromere antibodies were positive. A radiograph of both hands showed symmetrical band-like osteolysis of the diaphysis of distal phalanges suggestive of acral osteolysis (Figure 2). Echocardiography revealed a normal study. Further test were done that ruled out other organ systems involvement. Discussion: Acral osteolysis in scleroderma is thought to result from impaired blood flow due to vasculopathy resulting in digital ischemia and subsequent damage to the terminal phalanges [1]. It may also be a result of pressure changes due to the induration and tightening of the skin. Acral osteolysis can also be seen in various other pathological conditions such as diabetes mellitus, tabes dorsalis, leprosy, psoriasis, rheumatoid arthritis, exposure to vinyl chloride, following trauma or in association with hyperparathyroidism [2]. Treatment options are limited and is focused on providing symptomatic relief and preventing complications. Patients should avoid prolonged cold exposure and avoid digital or skin trauma. Calcium channel blockers and alpha receptor blockers may reduce the ischemia by promoting vasodilatation. Phosphodiesterase-5 inhibitors such as sildenafil may also help provide symptomatic relieve. The disease is, however, progressive in nature and currently there are no approved therapy aimed at retarding the vascular damage, fibrosis and altered immunological response. Current experimental therapies are based on immune-suppression and immune-modulation and include drugs like methotrexate, mycophenolate mofetil, D-penicillamine and rituximab. Tocilizumab, an interleukin-6 (IL-6) receptor antagonist was recently granted breakthrough therapy designation status for systemic sclerosis by the United States Food and Drug Administration (USFDA) [3]. Various other possible immune-inflammatory therapies are currently under study, including modulators of the profibrotic pathways [4]. The safety and possible toxicity of these agents remain a cause for concern.

Insufficient Teaching of Laboratory Medicine in US Medical Schools

For most of us who attended medical school more than 10 years ago, there was a course called ‘‘pathology’’ in the curriculum. The focus of the pathology course in most schools was almost exclusively anatomic pathology. The anatomic pathology of the myocardial infarction and the scar that evolves from it was shown to us with little information on troponin testing, despite the increasing difficulties in the interpretation of troponin test results. The change in the microscopic appearance of the myocardium showed the pathogenesis of myocardial infarction and, on that basis, was certainly important to discuss. The laboratory medicine/clinical pathology that was taught was very ‘‘anatomic pathology like.’’ Clinical pathology that was largely associated with the microscope was commonly included, such as peripheral blood smears, Gram stains and stains for other microorganisms, and the antinuclear antibody test. There were also other tests described with visual rather than numerical results, such as the gels from serum protein electrophoresis, and the aggregation of blood cells in the determination of blood type and Rh status. However, this approach to medical student teaching of laboratory medicine completely omitted the teaching of tests that generated only numbers and no visual pattern. Major areas of the clinical laboratory test menu including coagulation, endocrinology, and toxicology, which have limited gross and microscopic descriptions, were minimally considered in the pathology course and in the pathology textbooks. Over the past 10 to 15 years, a new approach to teaching basic science, including pathology, has appeared in many medical school curricula. The organor system-based approach includes pathology, but even in these basic science courses not called ‘‘pathology,’’ the pathology topics still remain dominantly anatomic. These are referred to as ‘‘student-centered curriculum,’’ in the form of problem-based learning and/or case-based learning. In these curricula, pathology/laboratory medicine learning objectives are woven into the first 2 years of medical school, and learning objectives are developed from cases that have pathology and laboratory data. An increasing percentage of medical schools are all student centered, partly student centered, or currently going through curricular revision to become more student centered. Education of medical students in the United States by experts on the selection of clinical laboratory tests and interpretation of the test results remains at risk for being very limited in the student-centered curriculum as well. Changes in the medical school curriculum have been occurring at a time when the test menu has been dramatically increasing in size, complexity, and cost. Highly complex genetic testing began to emerge in the clinical laboratory shortly after the year 2000, and medical students are poorly taught when to order such complex testing and how to interpret the genetic test results. Unfortunately, today medical students graduate and enjoy support by anatomic pathologists and radiologists to interpret test results, but they are faced with the impossible challenge of ordering the correct tests, and only the correct tests, from the thousands of expensive assays on the clinical laboratory test menu, with little or no education on the topic prior to graduation. In most institutions, no one is available to ‘‘automatically’’ help the treating physician with clinical laboratory tests as they are assisted in anatomic pathology and radiology, where cases are reviewed as a matter of course, without a special request. It is clear to me after 30 years in the field that less than 1% of the laboratory-related questions

Acute Chorea Onset after Hot Food Consumption in a Patient with Moyamoya Disease.

Acute Chorea Onset after Hot Food Consumption in a Patient with Moyamoya Disease.

Cyclic thrombocytopenia associated with menorrhagia

We studied a 17-year-old female P0 + 0 who presented with menorrhagia and cyclic thrombocytopenia (CTP). Cyclic changes were observed in platelet count in phase with menstruation with a nadir of 4–30 × 109/L and a rise of above 600 × 109/L noted over the 4 months period of the observation. Thrombocytopenia was associated with menorrhagia, gum bleeding and epistaxis, followed about 14 days later by normal or elevated platelet counts. Presenting packed cell volume (PCV), platelet count, and white blood cell (WBC) count were, 0.25 L/L, 4 × 109/L, and 6.8 × 109/L respectively, WBC and PCV all remain stable all through the period of study; antinuclear antibody, direct and indirect antiglobulin test was negative while flow cytometry for Gp IIb/IIIa and Ib were not done. Bone marrow examinations performed at the time of reduced platelet counts showed increased megakaryopoiesis. The patient was monitored and observed with only hematinics prescribed over the follow-up period, and menstrual suppression with combined oral contraceptives. CTP should always be suspected when a diagnosis of idiopathic thrombocytopenic purpura is entertained especially when there is a history of menorrhagia, thrombocytopenia, and rebound thrombocytosis.

Inappropriate use of commercial Antinuclear Antibody Testing in a community-based US hospital: a retrospective study

Healthcare providers use antinuclear antibodies (ANAs) to screen and diagnose patients with autoimmune diseases. In the recent years, commercial multiplex ANA kits have emerged as a convenient and fast diagnostic method. Diagnostic testing should follow sequenced algorithms: initial screen followed by specific antibody analysis. Second-level testing as an initial screen for autoimmune disease is inappropriate. We reviewed 68 patients with ANA comprehensive panels over a 6-month period from May 2015 to October 2015. We assessed appropriateness and estimated incurred losses from inappropriate testing. We found 92.6% (63 out of 68) of the ANA comprehensive panel results to be negative. Incurred losses from inappropriate ANA comprehensive panel testing were $66,000. Physicians should become familiar with ANA-sequenced diagnostic algorithms to avoid unnecessary higher level testing.