Section:Immunology

Duration: 1 month

Goals & Objectives

For residents in AP/CP or CP only, this rotation is designed to provide experience in many aspects of modern immunology, from the serological to the combined immunological/morphological. For residents in AP only, the serological portion of the rotation is not required, although it is recommended. All residents should learn how to develop a useful testing strategy for reaching diagnoses.

A central goal is to learn how to synthesize information gained from immunological, ultrastructural, and flow analyses, in order to maximize the strength of the diagnosis. Learning to identify potential pitfalls, both of a technical nature and in the interpretive process itself, is a critical objective of the rotation. Residents should learn quality control procedures that underlie the validity of the tests employed. Finally, residents should increasingly be able to communicate with the attending physicians with respect to the laboratory investigation of their patients.
Duties & Responsiblities:

Resident responsibilities in the Clinical Immunology/Flow Cytometry/Electron Microscopy rotation are: the resident will write the interpreta-tion for all tests that require an attending signature on a report. This includes acquiring whatever information (history, other laboratory data, etc.) is needed for the test evaluation. The current responsibilities include signing out with the appropriate attending the following assays:

Resident responsibilities in the Tissue Immunology Lab

1. The resident will review all immunofluorescence cases, which includes biopsy and autopsy tissues: kidney, lung, skin, nerve, brain, and indirect immunofluorescence tests for tissue specific serum anti-bodies to glomerular basement membranes, basement membrane zone of skin, anti-nerve antibodies. The resident will write a description of the findings and a diagnosis, and then will sign out the case with Dr. Tatum or Dr. Shanley. Appropriate information should be obtained before sign--out, such as reviewing the kidney histology in Nephropathology Lab, and finding appropriate history. After sign-out the resident will photo-graph relevant positive and negative findings, and will present them to the renal pathology conferences in coordination with Drs. Tatum and Shanley.
2. The resident will review all tissue immunoperoxidase solid tumor markers for quality assurance and diagnosis, and then will sign these cases out with Dr. Tatum or Dr. Landas with suggestions for follow-up testing if indicated. Any technical problems with the assay will be evaluated and recom-mendations for corrective action will be written in the log book.
3. All cases for immunofluorescence testing from outside hospitals will require the preparation of a surgical pathology report, including a brief gross description, microscopic analysis, interpreta-tion and diagnosis and SNOMED coding.
4. Estrogen and progesterone receptor assays will be reviewed, written up, and signed out with the attending.

General responsibilities

1. During the rotation the resident must present at least one Immunology/Flow Cytometry/Electron Microscopy Conference with the subject to be determined by consultation with attendings. The most appropriate time to present this case would be during the weekly Clinical Pathology Service Review.
2. Cases for the Rheumatology Conference will be reviewed and worked-up for presentation in coordination with Dr. Tatum.
3. Review all unusual requests for send-outs with the technical staff.
4. Understand the following basic procedures and their interpretations: _ Immunofluorescence/Immunochemistry _ Non-leukemic T and B cell enumeration includ-ing subpopulations _ Other Flow cytometry
5. Understand the following serologic procedures and their interpretations (required for all AP/CP or CP only residents; recommended for AP only resident): _ Monospot _ VDRL and MHATP _ ASO _ Rheumatoid factor _ Cold aggluti-nins _ Cryptococcal antigens _ Thyroid antibodies _ Radial immunodiffusion _ Immunofixation _ Cryoglobulin _ "ELISA" techniques - e.g. Varicella _ Hepatitis testing by ELISA _ HIV Testing and protocol

Evaluation:

Clinincal Immunology

• Immunofixation:

The residents will demonstrate competance in the interpretation of immunofixation by taking a practical quiz of approximatly ten immunofixation gels. The gels will consist of classic diagnostic gel, artifacts that can be confused with paraproteins, and examples of non-neoplastic conditions. The quiz will also include questions about how the gels should be signed out, and what further testing is indicated by the gell patterns to arrive at a correct diagnosis.

• Antinuclear Antibody Analysis:

The residents will demonstrate competance in the interpretation of anti-nuclear antibody analysis by taking a practical quiz of approximatly ten indirect immunofluorescence images of Hep2 cells. The images will consist of classic diagnostic patterns, artifacts that can be confused with antinuclear antibodies. The quiz will also include questions about how the analysis should be signed out, and what further testing is indicated to arrive at a correct diagnosis. These quizes will include other testing by the Immunology laboratory including immunodiffusion for Extractable Nuclear Antigens (ENA), Anti-Double Stranded DNA antibodies, and complement levels.



• Hepatitis/HIV Serology:

The residents will demonstrate competance in the interpretation of hepatitis serology analysis by taking a practical quiz of approximatly ten cases with various examples of Hepatitis A,B,C and HIV at various stages of the diseases. The case will consist of classic diagnostic patterns, and artifacts that can be confused with hepatitis. The quiz will also include questions about how the analysis should be signed out, and what further testing is indicated to arrive at a correct diagnosis. These quizes will include other testing such as liver biopsy and molecular diagnostic testing for quantitative analysis of circulating viral genome copies. The quiz will also cover current standards of confidentiality regulations and practice.



• Immunodeficiency Syndromes

The residents will demonstrate competance in the interpretation of immunodeficiency analysis by taking a practical quiz of approximatly ten cases with various examples of congenital and acquired immunodeficiency sydromes at various stages of the diseases. The case will consist of classic diagnostic diseases and selected unusual syndrome. The quiz will also include questions about how the analysis should be signed out, and what further testing is indicated to arrive at a correct diagnosis. These quizes will include other testing such as lymphocyte mitogen stimulation and molecular diagnostic testing for specific diagnostic molecular markers. The quiz will also cover current standards of confidentiality regulations and practice.



• Transplantation

The residents will demonstrate competance in the interpretation of histocampatibility analysis by taking a practical quiz of approximatly ten cases with examples including:

• Analysis of family phenotypic analysis
• Prediction of familial haplotypes
• Analysis of pre-tranplant phenotypic and serological analysis
  
  The resident will also demonstrate competance in immunology by writing short summaries of the transplants that occur while on the service, with emphasis on the clinically relevant findings including donor selection. The resident demonstrate competance in transplantation consultation by presenting data to the transplant physiacian at the weekly working tranplant conference. The resident will review any biopsies of transplants and prepare a short written analysis of the clinical situation. This would be similar to an investigation of a possible transfusion reaction. The results of the biopsy findings will be correlated with the findings of the pre-transplant laboratory data, and discussed with the transplant laboratory personnel. The resident will perform at least one HLA phenotypic analysis under the supervision of the laboratory staff, and review and initial all reports generated by the laboratory before signout with the laboratory director.
  
  
• Flow Cytometry

Competence of the interpretation of lymphocyte subsets in non-neoplatic disease will be demonstrated by the analysis of selected cases a immunodeficiency sydromes, as part of the immunodeficiency quizs. The resident will perform at least one lymphocyte analysis under the supervision of the flow cytometry staff and present the results to the attending. The resident will demonstrate competance in ploidy/cell cycle analysis by taking a quiz of ploidy analysis, and review the flow cytometric patterns with the pathologist at signout. (See below, IHC tumour markers)



• Anatomic Tissue Immunopathology
• Immunofluorescence: The resident will demonstrate competence in the technique and interpretation of direct immunofluorescence by performing at least one kidney and skin IF probably on autopsy material. The resident will also take a quiz of photographic images of skin and kidney IF materials of classic cases, and artifacts that can lead to serious misdiagnoses. The resident will also write short descriptions of the kidney IF of cases that occur during the rotation and present the results at kidney signout for correlation with the light and EM findings.
• Tumor Immunohistochemistry: The resident will demonstrate competence in tumor IHC by reviewing the IHC orders each day, looking at the H+E slides, and acquiring enough history to develop an accurate and cost-effective diagnostic algorhythym that provides a definitive diagnosis. The resident will also demonstrate competence in the trouble-shooting of IHC testing by writing a short analysis of QA problems that arise in the IHC testing, and and how the problem was resolved, and steps taken to prevent the recurrance of the particular problems. These problems include, underfixation, overfixation, improper use of different fixatives, processing inconsistencies, autolysis, deterioration of IHC reagents, deterioration of or use of inappropriate controls, and robotic machine errors. In addition there will be a quiz documenting these competencies.
• Tumor Prognositc Marker Analysis: The resident will review all breast cancer cases and write up a brief report with the semi-quantitative analysis of Estrogen/Progesterone receptors, Her2 amplification analysis, and the determination of ploidy status and S-phase determination by flow cytometry. These reports then be signed out with the attending. The resident will also demonstrate competence by taking and image quiz of flow cytomety ploidy and s-phase analysis. There will also be glass slide quiz of selected breast cancer case that contain classic examples of typical results and artifacts that can result in misinterpretation of marker data.
• Rheumatological pathology: The resident will demonstrate competence in Rheumatological pathology by working up the consults that occur during the rotation, including presenting the results at the Rheumatology Pathology conference. This will include correlation with the ANA, ANCA, complement analysis, and other serolological markers of connective tissue diseases. There will also be an image quiz with examples of connective tissue diseases including skin, kidney, lung, nerve, and muscle biopsies.

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