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Contents : Arthritis & Rheumatism (Arthritis Care & Research) Vol. 47 No. 4 August 15 2002 pp 434 444 DOI 10.1002/art.10561 2002 American College of Rheumatology SPECIAL ARTICLE Evidence-Based Guidelines for the Use of Immunologic Tests: Antinuclear Antibody Testing DANIEL H. SOLOMON 1 ARTHUR J. KAVANAUGH 2 PETER H. SCHUR 1 AND THE AMERICAN COLLEGE OF RHEUMATOLOGY AD HOC COMMITTEE ON IMMUNOLOGIC TESTING GUIDELINES Introduction This article is part of a series on immunologic testing guidelines. The series introduction published in this issue outlines the full methodology for obtaining data grading the literature combining the information from multiple sources and developing recommendations. Brie y MEDLINE and Healthstar were searched using a variety of search terms and all relevant available literature was reviewed. All articles were critically reviewed using published standards for studies of diagnostic tests. Test use was categorized as primarily diagnostic or prognostic (which also included monitoring). Information was extracted from each article to allow for calculation of a weighted average for sensitivity and speci city likelihood ratios (LRs) were then derived from these values (positive LR sensitivity / 1-speci city negative LR 1-sensitivity / speci city). Recommendations for use of tests were based on the LRs where a test was considered to be very useful for a given disease if the weighted average positive LR was 5 or negative LR was 0.2. A test was considered useful if the weighted average positive LR was 2 and 5 or negative LR was 0.2 and 0.5. A test Members of the American College of Rheumatology Ad Hoc Committee on Immunologic Testing Guidelines are as follows: 1Daniel H. Solomon MD MPH Peter Schur MD: Brigham and Women s Hospital Boston Massachusetts 2 Arthur F. Kavanaugh MD (chair): University of California at San Diego John D. Reveille MD: University of Texas Health Science Center Houston Texas Yvonne R. S. Sherrer MD: Center for Rheumatology Immunology & Arthritis Fort Lauderdale Florida Robert Lahita MD PhD: St. Vincent s Medical Center New York New York. The American College of Rheumatology is an independent professional medical and scienti c society that does not guarantee warrant or endorse any commercial product or service. Address correspondence to Daniel H. Solomon MD MPH Division of Pharmacoepidemiology Division of Rheumatology Immunology and Allergy Brigham and Women s Hospital 221 Longwood Avenue Suite 341 Boston MA 02115. E-mail: dhsolomon@partners.org. Submitted for publication September 6 2001 accepted in revised form March 10 2002. 434 was considered not useful if the positive LR was 2 or the negative LR was 0.5. De nition Antinuclear antibodies (ANA) directed against a variety of nuclear antigens have been detected in the serum of patients with many rheumatic and nonrheumatic diseases as well as in patients with no de nable clinical syndrome. These antibodies can be detected using a variety of substrates and staining techniques as described below and are directed against many different nuclear antigens. Background Hargraves described the lupus erythematosus (LE) cell in the blood of patients with systemic lupus erythematosus (SLE) in 1948 (1). Although the LE cell preparation was the rst test that facilitated the laboratory diagnosis of SLE it soon became evident that some patients with clinical SLE had negative LE cell tests and some people had positive LE cell tests but did not have SLE. In an attempt to improve the sensitivity and speci city of tests for the diagnosis of SLE techniques were developed to characterize the LE cell factor(s) which were soon recognized to be a family of antibodies to nuclear constituents. A number of immunochemical techniques were utilized to detect and characterize these antinuclear antibodies (ANA). These methods include immuno uorescence microscopy (i.e. ANA/ANF tests that use rodent liver or kidney human cell lines and other substrates) immunodiffusion (i.e. Ouchterlony and counterimmunoelectrophoresis) hemagglutination complement xation solid-phase immunoassays (i.e. enzymelinked immunosorbent ELISA or immunoblotting) and radioimmunoassays. Tests have used whole cells (i.e. ANA) partially puri ed nuclear antigens (i.e. immunodiffusion) or highly puri ed or recombinant nuclear antigens (i.e. ELISA assays). Methods. ANA results vary widely depending on the substrate and immunohistochemical methods used for detection. The technique most widely described in the current literature is immuno uorescent microscopy performed on rodent kidney or liver cells or human epithelial 2 (HEp-2) cells. The HEp-2 cell line is derived ANA Testing Guidelines from a human epithelial cell tumor. Because the cells are identical they provide a standardized substrate for detecting ANA. ANAs perfor

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