Stanley J. Naides

Despite advances in lupus biomarker research, clinical translation has remained limited, leading to delayed diagnosis, imprecise disease monitoring and trial-and-error treatment approaches. This roadmap, developed by the Lupus Research Alliance’s Biomarker Roadmap Committee with input from patients and experts, identifies key priorities for translating research into clinical benefit. Three major clinical unmet needs are highlighted: improving diagnostic accuracy of SLE and neuropsychiatric SLE, developing sensitive longitudinal markers for disease activity (including LN), and predicting disease progression and treatment response. We review the current state of biomarker development across these domains and highlight barriers that hinder clinical validation, assay development and clinical adoption. We propose focused strategies to overcome these challenges, emphasizing analytically validated assays, diverse longitudinal cohorts, alignment with meaningful clinical outcomes and consortium-based efforts. The roadmap outlines a path to transform lupus diagnosis, monitoring and precision medicine, enabling research advances to improve patient care.

Objective: To investigate longitudinal trends in rheumatoid arthritis (RA) diagnosis and monitoring by physicians and advanced practice providers (APPs) as measured by laboratory testing. Methods: We conducted a retrospective review of RA‐associated diagnostic and monitoring tests ordered through Labcorp by 7,026 physicians and 2,188 APPs in primary care and rheumatology between 2012 and 2024. Diagnostic tests include conventional markers (rheumatoid factor and anti–cyclic citrullinated peptide) and emerging markers (14.3.3 eta protein, anti–citrullinated α‐enolase peptide 1, anti–carbamylated protein, and anti‐citrullinated vimentin antibodies). Panel tests combine these markers to enhance diagnostic accuracy. Monitoring tests include the Vectra tests. Results: From 2012 to 2024, rheumatology APPs who consistently ordered RA‐associated tests annually through Labcorp increased by 411.8%, whereas rheumatology physicians who consistently ordered RA‐associated tests through Labcorp grew by 58.5%. Compared with rheumatology physicians, rheumatology APPs ordered 37.9 fewer conventional markers ( P = 2.7 × 10 ⁻¹² ) and 2.4 more monitoring tests ( P = 0.019). Between 2012 and 2024, conventional marker volumes increased by 3.0% among rheumatology physicians, 98.9% among rheumatology APPs, 36.2% among primary care physicians, and 75.6% among primary care APPs. The yearly average volume of RA panel tests ordered by rheumatology APPs increased by 2,948.5% compared with increases of 218.4% by rheumatology physicians, 128.0% by primary care physicians, and 203.7% by primary care APPs. The difference in the proportion of positive diagnostic test results between rheumatology physicians and rheumatology APPs narrowed from 3.0% in 2015 to 0.5% in 2024. Conclusion: We observed a rise in APP contributions to RA‐diagnostic and RA‐monitoring test ordering, consistent with their growing presence within the rheumatology workforce.

Serum factors binding to cell nuclei were first described in the 1940s, and the antibodies responsible for the binding to self (autoantibodies) were discovered in the late 1950s. Routine standardized testing using a cell line (HEp-2) started in the 1980s and continues to evolve. In addition to the classic immunofluorescence assay (IFA), various immunochemical techniques have been developed for the measurement of antinuclear antibodies (ANAs). The complexity of ANA IFA pattern reading and the varying sensitivities, specificities, and overall clinical performance of the alternative methods have often generated controversies and sometimes even confusion among healthcare providers and laboratorians. A better understanding of the historical roots of ANA testing can aid in understanding these controversies and assist with selecting the best-performing methods. In this review, we present historic and contemporary ANA testing methods, highlighting the pros and cons of each. We also provide an overview of the current practice of ANA testing based on several recent large laboratory surveys. For optimal patient care, it is critical that clinicians and laboratorians using ANA testing understand the performance and limitations of the methods used by their institutions, as well as the meaning of the test results. Recently published surveys and standardization efforts initiated by several stakeholder scientific organizations will likely lead to new ANA diagnostic guidelines, to be followed by an improvement in testing practices, management, and outcomes for patients with autoimmune disorders.

Availability of relevant biological samples supports both basic science research and patient-centered clinical studies. Establishing a biorepository faces challenges at multiple levels. These tasks include defining mission definition and scope; selection of subjects and sample types; recruitment strategies; timing of collection in the patient’s journey; sample logistics and processing; determining what clinical data to collect; ensuring sample integrity on transport, processing, and storage; defining governance structures and oversight responsibilities; clarifying sample provenance and ownership; establishing procedures for sample and data access; selecting testing to be performed routinely versus upon request, and management of results; data security; funding sources; and regulatory compliance. Establishing and maintaining a biorepository therefore requires careful planning, diligent and sustained execution, technical and financial resources, stakeholder support, and flexible and resilient management to respond to changing environments and needs. Key words Biobank Biospecimen Pregnancy Neonatal Fetus Processing Compliance Human subjects Data bank Outcomes

Lyme disease in pregnancy is understudied. The few available reports of Borrelia infection during pregnancy collecting clinical outcomes, with or without confirmed fetal infection both in utero and neonatal, are limited to case reports and small series. Population-based studies are not available. We propose a prospective study of Borrelia infection during pregnancy based in obstetrical practices in both endemic and nonendemic areas, with long term follow-up of pregnancy outcomes and development assessment of offspring infected or exposed to Borrelia in utero using current serological, microscopic, culture, and molecular techniques. In addition to detection of Borrelia burgdorferi sensu stricto, additional Borrelia species and other pathogens known to be transmitted by ticks will be tested. Serial biospecimens including maternal and cord blood, maternal peripheral blood mononuclear cells and urine, and, when clinically indicated, amniotic fluid, chorionic villi, intrauterine cord blood, will be collected with clinical data, imaging, and for infections treatment medications. Offspring will be followed until age 5 years with annual developmental assessments to assess pregnancy outcomes. The study will require parallel development of a biorepository with strategies for management, data security and data sharing. A public-private partnership will be required to support the study. Key words Lyme disease Borrelia Pregnancy Fetus Neonate Outcomes Development

We thank Dr. Russell for raising the issue of reporting the false positivity rate of antinuclear antibody (ANA) indirect immunofluorescent assay (IFA) testing.¹ It is difficult, however, for a laboratory to state a false positive rate, per se, as the determination of “falseness” is dependent on clinical evaluation that is typically not available to most laboratories.

The 14-3-3η (eta) protein was evaluated as a biomarker in a cohort of patients with juvenile idiopathic arthritis (JIA), as well as disease- and healthy-controls, to determine its potential clinical utility. In this case-control study, levels of 14-3-3η protein were evaluated in archival specimens from patients with JIA, systemic lupus erythematosus (SLE), and rheumatoid arthritis (RA), as well as healthy pediatric controls. Just over 200 patients were evaluated, using specimens banked between 1990 and 2011. Comparisons were made to complete blood cell count (CBC), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), rheumatoid factor (RF), anti-cyclic citrullinated peptide (anti-CCP) antibodies, and anti-nuclear antibody (ANA) positivity. 14-3-3η at levels 0.2 ng/mL or higher was considered positive. Fisher’s exact tests, odds ratios, 95% confidence intervals, and p-values were reported. 14-3-3η positivity was seen in all included JIA subtypes. The rate of positivity was the highest in RF-positive (pos) polyarticular JIA. In the disease and healthy controls, lower rates of positivity were observed. The frequency of 14-3-3η positivity among RF-positive and RF-negative (neg) polyarticular JIA patients, especially at values ≥0.5 ng/mL (associated with poor outcomes in adults), was also highest. Several JIA patients with 14-3-3η positivity developed RF and anti-CCP positivity later in their disease. Significant levels of 14-3-3η can be found in approximately 30% of RF-pos and RF-neg patients with polyarticular JIA. This protein may represent a new biomarker for polyarticular JIA, particularly RF-neg polyarticular JIA.

Introduction The time‐dependent nature of factor VIII (FVIII) inhibitors is well described, and the standard FVIII Bethesda assay used to measure inhibitors incorporates a 2‐hour incubation. Despite case reports and reviews describing the immediate‐acting nature of factor IX (FIX) inhibitors, many coagulation laboratories continue to use a traditional prolonged incubation for FIX Bethesda assays. To our knowledge, a comprehensive evaluation of the FIX Bethesda assay without incubation has not been reported. Aim The goal of this study was to evaluate the performance of a rapid FIX Bethesda (ie no incubation) compared with the standard Bethesda assay (2‐hour incubation). Methods The analysis used a Bethesda assay configured for either immediate testing or a 2‐hour incubation. Samples from 14 haemophilia B patients with inhibitors and 9 non‐human controls were tested. Results The two assays yielded similar performance overall. The average per cent difference in inhibitor titre between the rapid and standard FIX Bethesda assay was −3% (range −15% to +13%; P = .175) for patient samples and −2% (range −17% to +14%; P = .376) for controls. Conclusion The rapid Bethesda assay showed good agreement with the standard Bethesda assay for determination of inhibitor levels in patients with severe haemophilia B. The rapid assay allows for faster assessment of inhibitors in patients with severe haemophilia B and has the potential to improve the ability of the coagulation laboratory to perform testing from a logistical viewpoint. Further studies involving larger numbers of patients would be important to confirm our findings.