CLINICAL IMMUNOLOGY – OHSU

Teaching Staff:

Tony Bakke, Ph.D.,D(ABMLI), Scientific Director of Special Immunology and Flow Cytometry Laboratory

Additional faculty in hematopathology:
Rita Braziel,M.D. Chief, Hematopathology Service
Guang Fan,M.D.,Ph.D. Medical Director, Flow Cytometry Service, Heme. Fellowship Director
Katalin Kelemen, M.D., Ph.D., Medical Director of Hematology
Ken Gatter,M.D. Hematopathologist, Vice Chair for Anatomic Pathology
Nicky Leeborg, M.D., Hematopathologist
Marc Loriaux, M.D. Ph.D., Hematopathologist

Duration:

Required two week rotation coupled with 10 weeks of hematopathology.

Goals and Objectives:

    The overall goal for the immunology portion of the rotation is to train residents to function as effective laboratory consultants to their clinical colleagues in the interpretation of immunologic assays of analytes using antibodies and antigens, including flow cytometry. The basic immunology rotation is designed to provide opportunities to learn the fundamental knowledge and skills in diagnosis of infection, allergy, autoimmunity, transplant immunology, tumor immunology and immunodeficiency.

At the end of the rotation the resident will have demonstrated competency in the following skills:

  • Patient care:
    1. Understand the indications of flow cytometric analysis. Be able to triage and select appropriate antibody combinations for specific samples submitted for flow cytometric analysis based clinical history and morphological evaluation of cytological preparation.
    2. Be familiar with the normal distribution, lineage specificity and their diagnostic significance of cell markers (CD1a, CD2, CD3, CD4, CD5, CD7, CD10, CD11c, CD13, CD14, CD16, CD15, CD19, CD20, CD22, CD23, CD25, CD34, CD38, CD41, CD51, CD55, CD56, CD57, CD64, CD71, CD103, CD117, CD138, glycophorin A, TdT, MPO, and TCR).
    3. Understand the significance of lymphocyte quantitation in diagnosis of immune deficiency. The resident should be able to offer consultative advice on immunodeficiency cases to referring physicians, and be able to construct a consultative report.
    4. Viral Serology Testing--

      • Be able to explain the methodology and reasons for ordering any follow-up or confirmatory tests offered at other labs, namely, HEP Be tests, HEP B core IgM, HIV Western Blot, Hepatitis C RIBA, Hepatitis C RNA by PCR.
      • Be able to determine the approximate stage of infection from the results of a panel of tests for Hepatitis A, B, C, D, or E.

    5. Autoimmune Serology--

      • Review clinical indications and interpretations for all tests.
      • Discuss quality control problems with these tests.
    6. Allergy Serology--

      • Review clinical indications and interpretations for all tests.
    7. Tumor Marker Testing--

      • Be able to explain the type of tumor detected and additional markers which might be beneficial in various disease states.
    8. Miscellaneous Immunoassay--

      • Review patient test results for IMx testing over a several day period test results.
      • Follow up on at least one patient by reviewing other lab results, reviewing the chart, and consulting with the patient's physician; then present findings to Immunology Staff.
  • Medical Knowledge:

    1. Understand the molecular mechanism for paroxysmal nocturnal hemoglobinuria (PNH) and immunophenotypic studies in diagnosis of PNH.
    2. Understand the immunophenotype of normal hematopoietic populations in the peripheral blood, bone marrow, thymus, spleen, and lymph node, the immunophenotypical changes of lymphoid and myeloid precursors during the maturation and differentiation.
    3. Be able to identify aberrant T-cell antigen expression and its significance.
    4. Be able to identify the NK cell population and understand the clinical significance of NK-cell proliferation.
    5. For immunodeficiencies understand the symptoms and laboratory findings for the following diseases:

      • DiGeorge syndrome
      • X-linked infantile hypogrammaglobulinemia
      • X-linked lymphoprofliferative disorder
      • Common variable immunodeficiency
      • Severe combine immunodeficiency syndrome
      • Ataxia-telangectasia
      • Graft-versus-host disease
      • Leukocyte adhesion deficiency
      • HIV disease

    6. For Viral Serology Testing:

      • Review lab procedures for Hepatitis A, B, C, and HIV 1/2, HIV p24, and HTLV-I tests.
      • Read and understand the Abbott Diagnostics Hepatitis Learning Guide.
      • Review Hepatitis and HIV patient test results over a several day period to find unusual test results.
      • Follow up on at least one patient by reviewing other lab results, reviewing the chart, and consulting with the patient's physician; then present findings to Immunology Staff.
    7. For Autoimmune Serology:

      • Review procedures for anti-DNA test and Extratible Nuclear Antigen (ENA) test.
      • Review results for these tests and also review typical results for ANA and ANCA tests in the study guide.
    8. For Allergy Serology:

      • Review procedures for the Unicap RAST and immunoprecipitin tests.
      • Discuss quality control problems with these tests.
    9. For Tumor Marker Testing:

      • Be familiar with the tumor markers which can be analyzed by immunoassay including: PSA, CEA, AFP, HCG, B2 Microglobulin.
    10. Miscellaneous Immunoassay--
      • Review basic immunoassay principles and be able to explain the critical components of a conventional radioimmunoassay procedure including: standards, labeled antigen, specific antibody, patient sample, and list and explain 3 separation techniques.
      • Be able to explain the principle of operation of the IMx analyzer.
      • Observe one "run" of testing, including patient and control samples, on the IMx or Immulite Analyzer with technologist supervision.
  • Practice based learning and improvement:

    1. Indications and interpretation of special immunology tests, including surface marker immunophenotyping, autoantibody testing, infectious antibody testing, allergy antibody testing, including IgE and IgG, tumor marker serology and immunoassays for drug monitoring.
    2. Be familiar with the basic procedures listed below:

      • Specimen requirements for immunophenotyping / processing.
      • Density centrifugation methods for peripheral blood and bone marrow; effects of Ficoll-Hypaque density centrifugation on the sample.
      • Red cell lysis.
      • Preparation of cell suspensions for flow from solid tissue biopsies.
      • Trypan blue dye exclusion test for viability determination.
      • Preparation of imprints and cytopreps and morphologic screening of Dif-Quik-stained cyto-preps of cell suspensions.
      • Antibody staining methods for flow cytometry, including differences between the use of directly labeled primary antibodies, unlabeled primary antibodies, the use of different fluorochromes, and single color versus multicolor analyses.
      • The difference in procedures in detection of surface vs. cytoplasmic markers.
    3. Understand the principles of operation of flow cytometers. Be able to interpret the dot plots or histograms of the flow cytometry, including identification of different cell populations ased their light scatter properties and their intensity of CD45 expression.
    4. Understand the concepts of gate, event, population, cell size, percentage of cells gated, percentage of total. Be able to evaluate whether populations of interest are appropriately gated and whether the phenotype for the populations of interpret is appropriately displayed in the printouts of the dot plots or histograms.
    5. Be able to identify appropriateness of antibody reactivity using internal control populations in blood, bone marrow and lymphoid tissue.
    6. Understand the limitations of sub-optimal or inadequate specimens.
    7. Correlation of other laboratory findings with flow cytometry results and clinical disease.
    8. Be able to compare current and previous pathology results to understand treatment effects on disease processes.
  • Interpersonal and communication skills:

    Communication of test results to clinicians.

    Communication with clinicians to obtain history for interpretation of test results and/or appropriateness of tests ordered.

    Communication with Laboratory technologists about test methods, additional test requests, etc.

    Presentation of cases at weekly call rounds as needed.

    Communication with attending pathologists about patient material.

    Effectively communicate immunophenotypic and immunoassay findings to clinicians.

    Write immunodeficiency reports that provide appropriate descriptions and synthesize findings into a comprehensive diagnosis.

    Ask appropriate questions of attendings and clinicians to improve understanding of clinical significance of pathologic findings.

  • Professionalism:

    Be available in special immunology/flow cytometry laboratory and sign-out area as required

    Demonstrate self-motivation in pursuit of rotation requirements

    Demonstrate courteous and collegial behavior with peers and laboratory staff

    Follow up on all studies on assigned cases until the case is completely signed-out.

    Read independently on cases and search primary sources.

  • Systems based practice:

    1. Be able to evaluate and trouble-shoot problem cases and situations identified by the laboratory staff or others, conferring with the attending pathologist when necessary.
    2. Understand principles of laboratory quality control and quality assurance. Learn how to prepare the laboratory for inspection.
    3. Be familiar with Laboratory Information System (Ultra) and entry/retrieval of laboratory results, including hematology information system.
    4. Be familiar with Hospital Information System (Epic or LCR) for retrieval of clinical information on patients.
    5. Be familiar with anatomic pathology information system (Tamtron), including retrieval of pathology reports, ordering special stains, etc.
    6. Understand cost-effective laboratory utilization in the evaluation of immunologic disorders.



Duties:

  1. Arrange and attend bench instruction with the technologists in each of the component laboratories.
  2. Triage and select appropriate markers for flow cytometric analysis based cytological evaluation and clinical indication for the case.
  3. Daily review with Dr. Bakke of dot plots or histograms on cases of lymphocyte quantitation, CD34 stem cell enumeration, CD4 cell enumeration, PNH, reticulated platelets, and immunodeficiency.
  4. Prepare reports of the cases submitted for flow cytometric analysis including obtaining clinical information on patients. The name of the resident should be documented in the report. All reports will be reviewed and signed by attending.
  5. Order or gather additional studies when needed.
  6. Review procedures and have a thorough understanding of the principles of standard methods and instrumentation used in all sections of the Immunology laboratory sufficient to direct the laboratory's performance of assays with these methods and instruments and to interpret test results. Essential elements of this understanding include:

    1. effect of patient physiological status on test results;
    2. patient medication affecting test results;
    3. influence of specimen type on collection, handling, and analysis;
    4. specimen identification and tracking;
    5. safety in handling specimens;
    6. specimen stability (e.g., storage, transport requirements);
    7. expected precision and accuracy of results;
    8. quality control evaluation;
    9. pitfalls, interferences and test limitations;
    10. cost effectiveness of methods and trade off vs. quality;

  7. Interact with technical staff and provide consultation in troubleshooting as needed.
  8. Carry out additional assignments related to laboratory administration, quality control and quality improvement.
  9. Complete reading assignments and discuss these with the director.
  10. Call Responsibility:

    Residents on service will be the "day call person" for flow cytometry service. The resident will be the primary person for lab staff regarding problem cases and situations. After hours call will be handled by the hematopathologist on call.


Evaluation:

Residents meet on a regular basis with the Director of the rotation and with the lead technologists for supervision. Evaluations are based on daily interaction with residents over multi-headed microscope and other "sign-out" activities. In this way, residents receive daily feedback on their interpretations of case material. Residents are assisted by attending staff in preparation of conferences, and receive feedback on their presentations. Residents will be evaluated on the basis of the following core competencies:

  1. Patient Care - does the resident understand the impact of immunology testing on clinical diagnosis and patient management?
  2. Medical Knowledge - does the resident demonstrate an appropriate understanding of how immunology testing is performed and interpreted?
  3. Interpersonal and Communication Skills - does the resident interact well with support staff, faculty and clinicians?
  4. Practice-Based Learning and Environment - does the resident make appropriate use of available resources in working on cases requiring immunology testing?
  5. Professionalism - does the resident participate actively and demonstrate a commitment to meeting the goals of the rotation?
  6. Systems-Based Practice - does the resident understand how to carry out immunologic assays in a cost-effective manner?