title: The ANA-reflex test as a model for improving clinical appropriateness in autoimmune diagnostics.
abstract: Reflex tests are widely used in clinical laboratories, for example, to diagnose thyroid disorders or in the follow-up of prostate cancer. Reflex tests for antinuclear antibodies (ANA) have recently gained attention as a way to improve appropriateness in the immunological diagnosis of autoimmune rheumatic diseases and avoid waste of resources. However, the ANA-reflex test is not as simple as other consolidated reflex tests (the TSH-reflex tests or the PSA-reflex tests) because of the intrinsic complexity of the ANA test performed by the indirect immunofluorescence method on cellular substrates. The wide heterogeneity of the ANA patterns, which need correct interpretation, and the subsequent choice of the most appropriate confirmatory test (ANA subserology), which depend on the pattern feature and on clinical information, hinder any informatics automation, and require the pathologist's intervention. In this review, the Study Group on Autoimmune Diseases of the Italian Society of Clinical Pathology and Laboratory Medicine provides some indications on the configuration of the ANA-reflex test, using two different approaches depending on whether clinical information is available or not. We further give some suggestions on how to report results of the ANA-reflex test.
authors.affiliation: Laboratory of Immunopathology and Allergology, University Hospital Udine, P.le S. Maria della Misericordia 15, 33100, Udine, Italy. tonutti.elio@aoud.sanita.fvg.it.
authors.forename: Elio
authors.initials: E
authors.lastname: Tonutti
authors.affiliation: Laboratory of Clinical Pathology, San Antonio Hospital, Tolmezzo, Italy.
authors.forename: Nicola
authors.initials: N
authors.lastname: Bizzaro
authors.affiliation: Rheumatology Section, Department of Medical, Surgical and Neuro Sciences, University of Siena, Siena, Italy.
authors.forename: Gabriella
authors.initials: G
authors.lastname: Morozzi
authors.affiliation: Microbiology and Virology, San Carlo Borromeo Hospital, Milan, Italy.
authors.forename: Antonella
authors.initials: A
authors.lastname: Radice
authors.affiliation: Laboratory of Clinical Pathology, University Hospital San Giovanni di Dio and Ruggi D'Aragona, Salerno, Italy.
authors.forename: Luigi
authors.initials: L
authors.lastname: Cinquanta
authors.affiliation: Clinical Allergology and Immunology, S. Maria degli Angeli Hospital, Pordenone, Italy.
authors.forename: Danilo
authors.initials: D
authors.lastname: Villalta
authors.affiliation: Laboratory of Clinical Pathology, S. Maria degli Angeli Hospital, Pordenone, Italy.
authors.forename: Renato
authors.initials: R
authors.lastname: Tozzoli
authors.affiliation: Clinical Pathology I, University Hospital Policlinico Consorziale, Bari, Italy.
authors.forename: Marilina
authors.initials: M
authors.lastname: Tampoia
authors.affiliation: Department of Medical Biotechnology, University of Siena, Siena, Italy.
authors.forename: Brunetta
authors.initials: B
authors.lastname: Porcelli
authors.affiliation: Laboratory of Immunopathology and Allergology, University Hospital Udine, P.le S. Maria della Misericordia 15, 33100, Udine, Italy.
authors.forename: Martina
authors.initials: M
authors.lastname: Fabris
authors.affiliation: Analysis Laboratory, Buccheri La Ferla Hospital, Palermo, Italy.
authors.forename: Ignazio
authors.initials: I
authors.lastname: Brusca
authors.affiliation: Clinical Chemistry Analysis Laboratory, Papa Giovanni Hospital XXIII, Bergamo, Italy.
authors.forename: Maria Grazia
authors.initials: MG
authors.lastname: Alessio
authors.affiliation: Laboratory Medicine, Department of Clinical Pathology, Treviso Hospital, Treviso, Italy.
authors.forename: Giuseppina
authors.initials: G
authors.lastname: Barberio
authors.affiliation: Clinical Chemistry and Microbiology Analysis, ISMETT, Palermo, Italy.
authors.forename: Maria Concetta
authors.initials: MC
authors.lastname: Sorrentino
authors.affiliation: Analysis Laboratory, Santorso, Italy.
authors.forename: Antonio
authors.initials: A
authors.lastname: Antico
authors.affiliation: Microbiology and Virology, S. Chiara Hospital, Trento, Italy.
authors.forename: Danila
authors.initials: D
authors.lastname: Bassetti
authors.affiliation: Postgraduate School of Clinical Pathology and Biochemistry, University of Padua, Padua, Italy.
authors.forename: Desré Ethel
authors.initials: DE
authors.lastname: Fontana
authors.affiliation: Laboratory of Autoimmune Diseases, P.O. Spirito Santo, Pescara, Italy.
authors.forename: Tiziana
authors.initials: T
authors.lastname: Imbastaro
authors.affiliation: Laboratory of Immunopathology and Allergology, University Hospital Udine, P.le S. Maria della Misericordia 15, 33100, Udine, Italy.
authors.forename: Daniela
authors.initials: D
authors.lastname: Visentini
authors.affiliation: DIMI, University of Genova, Genoa, Italy.
authors.forename: Giampaola
authors.initials: G
authors.lastname: Pesce
authors.affiliation: DIMI, University of Genova, Genoa, Italy.
authors.forename: Marcello
authors.initials: M
authors.lastname: Bagnasco
keywords: ANA; Antinuclear antibodies; Immunofluorescence; Intracellular specific antigens; Pattern; Reflex test