Dr Cush thank you for your reply it is very nice to interact with you I follow your weekly reviews religiously and appreciate them. 1) Ana may be neg in non lupus ctd but when positive it helps. So if no clinical lupus, still order Ana if ctd is suspected. 2)I don’t think Ana that comes and goes is useless. I’ve diagnosed ctd including lupus in currently Ana neg past Ana pos or vice versa pts. So if it is neg it may be pos in future or may have been pos in past. That changes my approach if cro is also elevated especially. 3)I dontctegularly diagnose or treat lupus with a neg Ana. I don’t believe in ruling out lupus if clinical signs are present Ana neg due to #2 above.4) I think rules can be bent or may prove less rigid my 18 years in Rheumatology has taught me this . Maybe another 18 years will teach me the opposite. I will live and learn, again very nice talking with you Ulker.