Fellowship in Allergology by School of Medicine

D.Y.Patil university announces Fellowship in Allergology one year course under Prof Dr.Kiran Godse.Eligibility – MD / MS in dermatology Pediatrics Chest Medicine General Medicine or ENT

Index

Guidelines for competency based training program for Fellowship in Allergology.

Goals:

The goal of Fellowship training in Allergology is to prepare an all round specialist who has achieved the competency in the fields of Dermatology, Pulmonary Medicine, Paediatrics, and ENT, who can practice at secondary and tertiary level of health care delivery system. The person must be trained in Basic Allergology keeping with the objective of complete allergy control.
The person shall be abreast with the recent advances and development in the specialty of Allergology.
The person should be oriented to the principles of related research methodology and epidemiology and must acquire basic skills in teaching the specialty.

Programme Objectives:-

At the end of Postgraduate Fellowship in Allergology, the Fellow shall be able to –
1. Recognize the importance of Urticaria, Atopic Dermatitis, Contact Dermatitis,  Allergic rhinitis,asthma and other allergy disorders with the health needs of the community.
2. Practice in the field of Allergology ethically.
3. Demonstrate the understanding of the basic sciences relevant to Allergy disorders.
4. Develop comprehensive and evidence-based diagnosis and management skills for patients with allergic disorders.
5. Counsel patients and the broader community on prevention and rehabilitation of allergic diseases.
6. Communicate effectively with patients and their families, as well as other physicians and health care professionals.
7. Function as a member of a health care team.
8. Demonstrate competency in research methodology.
9. Develop good teaching skills.
10. Evaluate the Allergology literature critically and apply pertinent information to patient management.
11. Perform necessary technical skills specific for management of patients with allergic diseases.
12. Undertake accurate self-appraisal; develop a personal continuing education strategy, to help develop a lifelong mastery of the field of Allergology.

During the Allergology training program, the trainee must undertake a broad range of practical clinical experiences including acute and chronic allergic care, ambulatory care, and prevention and rehabilitation. The trainee must be involved in a program of formal educational activities, and have exposure to and involvement with current research activities. Gradually, the trainee must assume responsibility for clinical decision making and patient care, and be able to function as an independent clinical decision maker after completion of the programme.

Fellowship Eligibility and Selection method:

The Fellows selected for the course must possess recognized MD degree in dermatology or Pediatrics,or Medicine or chest medicine, and should have obtained permanent registration with Medical Council of India or any of the states of Medical Councils.
The Fellows will be selected strictly on the basis of their academic merit.
Course duration : 1 year with rotation in four departments of dermatology, pediatrics, Chest medicine and ENT.
Must see 500 patients of Allergy  in this duration
Maintain Log book
Paper publication

Specific Learning Objectives:

a) Theoretical knowledge :
1. Mastery of all theoretic aspects of the allergic and clinical immunologic evaluation including prevention, diagnosis and treatment, and systemic manifestations of allergic and clinical immunologic disease.

2. Problem solving and clinical decision making, including the ability to correlate, evaluate, and prioritize information acquired by clinical assessment; formulate an appropriate problem list; and develop and implement a diagnostic and therapeutic plan using appropriate knowledge derived from clinical appraisals of relevant literature.

b)Practical Skills :
1. For each clinical problem, the Fellow must be able to perform

A complete and accurate history and physical examination,

  • Formulate appropriate differential and provisional diagnoses
  • Develop an appropriate plan of investigation and
  • Be able to interpret the results

The graduate must also be able to develop a therapeutic plan, develop plans for primary, secondary and tertiary prevention, and be able to demonstrate appropriate clinical judgment considering such factors as the patient’s age and status of health, as well as the risks, benefits, and costs of diagnostic and therapeutic strategies.

2. The trainee must be able to understand the indications, contraindications, complications, and interpretation of diagnostic and provocation tests and must have experience in the technical performance of such tests.

3. The trainee must be able to understand the indications, contraindications, complications, and interpretation of allergen avoidance, pharmacotherapy, allergen-specific immunotherapy and other procedures for immunomodulation.

4. Patient education is an integrated part of Allergology and clinical immunology treatment, and the trainee must be able to formulate appropriate patient education programs.

5. The trainee must demonstrate consultation skills, which include the ability to present clear and pertinent assessments and recommendations in both written and verbal forms, participate constructively as part of a team of other physicians and other health professionals, ensure appropriate follow-up and reassessment of the patient’s progress, and ensure maintenance of appropriate records.

c) Research – He/she should know basic concepts of research methodology, plan research projects and should have basic knowledge of statistics. He/she should be well-versed with computer and internet.

d) Teaching – He/she should learn the basic methodology of teaching and develop competence in teaching medical / paramedical students.

CORE CURRICULUM:

1. Basic Sciences –

A. Anatomy and Cellular Elements of the Immune System
1. Lymphoid organs – anatomy and functions
2. Cells of relevance to the immune response, their unique identifying features, and positive and negative selection during ontogeny.

B. Immune Mechanisms
1. Innate and acquired immunity

2. The major histocompatibility complex – molecular structure and function

3. Antigens – processing and presentation

4. Allergens – structure, epitopes

5. Immunogenetics

6. T cell mediated immunity
a. T cell activation – T cell receptor, epitope recognition and accessory molecules in signal transduction
b.Cytokines and co-stimulatory molecules in T cell activation
c. T cell-mediated immune responses – participating cells

7. B cell-mediated immunity
a. B cell activation – T cell interaction and signal transduction
b. Immunoglobulin production and epitope recognition
c. Antibody isotype and maturation of the antibody response
d. Biologic processes initiated by antibody. IgM, IgG, and IgA mediated, e.g. opsonization, complement fixation, antibody dependent cell-mediated cytotoxicity.
e. IgE – structure, function, synthesis, regulation, receptors
f. IgE mediated immediate and late phase reaction
g. Immune complexes – physical properties, immunologic properties and mechanisms of clearance.
h. Immunodeficiencies

8. Other immune mechanisms
a. Natural killer cells
b. Lymphokine activated killer cells
c. Complement and complement deficiencies

9. Receptor ligand interactions in immune functioning – adhesion molecules, complement receptors, IgE receptors, Fc receptors. Signal transduction resulting from receptor ligand interaction. Genetic polymorphisms producing gain or loss of function.
a. Immunologic Memory

C. Immunomodulation in the Immune Response
1. Cytokines, chemokines, adhesion molecules and growth factors

2. Inflammation and its modulation
a. Mediators – preformed and newly generated
b. Effector cells in inflammation – allergic and other
c. Mast cells and basophils – structure, activation, preformed mediators, arachidonic acid metabolisms, prostaglandins, leukotrienes, PAF
d. Eosinophils – structure, activation, mediators

D. Mucosal Immunity
1. Non-immunologic – enzymes, acids, glycocalyx, normal flora, etc.

2. Immunologic – mucosa associated lymphoid tissue, antigen processing, antibody and cellular production, cell trafficking and homing

E. Transplantation Immunology
1. Mechanisms of allograft rejection

2. Graft versus host reactions (GVHR)

F. Tumor Immunology
1. Antigens of tumor cells – unique tumor specific antigens and tumor associated antigens.

2. Oncogenes, translocations and tumor suppressor genes

3. Mechanisms of immunosurveillance

G. Immunoregulatory Mechanisms
1. Tolerance mechanisms

2. Idiotypic networks

3. Apoptosis

Clinical Sciences

A. Allergic Disorders
GENERAL ASPECTS
• Epidemiology of allergic diseases – environment
• Prevalence and incidence of allergic diseases
• Risk factors for allergic diseases
• Genetics of allergic diseases
• Allergens – concept of protein families (profiline, lipocalines, PR proteins etc.),
natural sources, physicochemical properties and relevance to disease, cross reacting
allergens, haptens and small molecular compounds, recombinant allergens,
aerobiology

DIAGNOSTIC PROCEDURES
Please note:
The theoretical background is identical for every topic:
Principles of the test, indications, contraindications, interactions by drugs and diseases, sideeffects,
reproducibility, sensitivity, specificity and predictive value, cost-effectiveness.
1. Skin testing: perform
• Skin prick tests,
• Intradermal skin tests,
• Patch tests,
• Delayed type skin tests with recall antigens.

2. Nasal examinations: perform
• Anterior nasal examination (speculum),
• Nasal endoscopy examination (optional),
• Rhinomanometry (optional)

3. Pulmonary tests: perform
• Peak expiratory flow measurements
• spirometry
• whole-body plethysmography (optional)
• bronchoalveolar lavage (optional)
• Induced sputum

4. Provocation tests: perform
• Conjunctival allergen provocation test,
• Nasal non-specific provocation test,
• Nasal allergen provocation test,
• Bronchial non-specific provocation test,
• Bronchial allergen provocation test,
• Food challenges,
• Drug challenges,
• Occupational allergen exposure test,
• Exercise provocation tests,
• Physical provocation tests (cold, heat, pressure).

LABORATORY MEASUREMENTS
1. Techniques: understanding of the principles and methodology of these techniques, particularly as they relate to measurement of immunoglobulin levels, immunoglobulin classes and subclasses, specific antibodies, lymphocyte phenotyping, cellular response to mitogens, antigens and allogenic cells, immune complexes, cryoprecipitable proteins, total serum complement activity, complement components, and histocompatibility typing.
Serologic: ELISA, radioimmunoassay, in vitro diagnostic tests (e.g., RAST, histamine release), radial immunodiffusion, nephelometry, immunoblots, high performance liquid chromatography, isoelectric focussing, immunoelectrophoresis, electroimmuno-diffusion, and protein electrophoresis.
b. Cellular: flow cytometry, assays of chemotaxis, phagocytosis, cytolysis, lymphocyte proliferation, immunoglobulin production
c. Immunofluorescence and immune histochemistry
d. Northern, Southern, Western blots; polymerase chain reactions; crossover breakpoint analysis; ligase chain reactions; in situ hybridization
e. Hybridomas and monoclonal antibodies
f. Other relevant tests

2. Test-performance characteristics: principles of sensitivity, specificity, and predictive value as well as cost-effectiveness

THERAPEUTIC MODALITIES
a. Allergen avoidance (reduction)
• Theoretical: Rational for intervention, indications, and cost-effectiveness
• Practical: Perform allergen avoidance interventions
b. Allergen-specific immunotherapy
• Theoretical: Principles of the treatment, different induction regimens, allergen extracts, indications, contraindications, interactions by drugs and diseases, side-effects, preventive capacity, long-term capacity, and cost-effectiveness
• Practical: Perform induction and maintenance treatments (both patients allergic to inhalant allergens and Hymenoptera venoms)
c. Pharmacotherapy with antihistamines, theophylline, α & β agonists, sympathomimetics, calcium channel blockers, cromones, anticholinergics, corticosteroids, leukotriene antagonists, immunosuppressors, mucolytics, antibiotics, local dermatological therapy, and newly introduced drugs.
• Theoretical: Principles of the treatment with drugs, indications, contraindications, interactions by other drugs and diseases, step up and step down treatment, side-effects, therapeutic capacity, and cost-effectiveness
• Practical: Be responsible for the pharmacological treatment of patients including handling of adverse effects
d. Allergenic extract preparation
• Theoretical: Principles of the preparation of allergen extracts

RESEARCH PRINCIPLES
1. Ethics, e.g. Declaration of Helsinki
2. Experimental design and good clinical practice
3. Data analysis and biostatistics
4. Epidemiology
5. Grant writing
SPECIFIC DISEASES
Please note:
The theoretical background is identical for every disease:
Physiology, pathology, diagnosis, differential diagnosis, and treatment including mechanisms
of action, dosing, adverse effects, and costs of therapy.

1. Upper airway diseases
a. Rhinitis
• Practical: Assessment of nasal secretions; understanding of indications for and methodology of nasal challenges; assessment of ciliary function; rhinoscopy; nasal examination; assessment of radiographic examination including computerized enhancement, environmental assessment
b. Sinusitis
• Practical: Rhinoscopy; nasal examination; assessment of radiographic examination including computerized enhancement
c. Nasal polyposis
• Practical: Assessment of ciliary function; rhinoscopy; nasal examination; assessment of radiographic examination including computerized enhancement
d. Otitis media (bacterial and serous)
• Practical: Ear examination; assessment of radiographic examination including computerized enhancement, and tympanometry
e. Laryngeal disorders
• Practical: Laryngoscopy

2. Eye diseases
a. Conjunctivitis
• Practical: Inspection of the conjunctiva
b. Iritis, iridocyclitis
• Practical: Eye examination in cooperation with an ophthalmologist
c. Keratoconjunctivitis sicca*
• Practical: Eye examination in cooperation with an ophthalmologist

3. Skin diseases
a. Urticaria and angioedema
• Practical: Cutaneous examination, immediate hypersensitivity skin tests, tests for physical urticaria, autologous serum skin test, skin biopsy and immunohistology.
b. Atopic dermatitis
• Practical: Cutaneous examination, immediate hypersensitivity skin tests, atopy patch test and food challenge.
c. Contact dermatitis
• Practical: Cutaneous examination, (photo) patch testing, intradermal skin tests and application test
d. Mastocystosis
• Practical: Cutaneous examination, skin biopsy, tryptase and histamine metabolites. Often treated in cooperation with other specialists.
e. Drug rashes
• Practical: Cutaneous examination, patch testing, drug skin testing and in vitro tests.
f. Hypersensitivity reactions (e.g., hypersensitivity vasculitis and other immunologic skin disease)
• Practical: Cutaneous examination, patch testing, immediate hypersensitivity skin tests, skin biopsies

4. Lower respiratory tract disease
a. Asthma (allergic, exercise-induced, sulfite-related, aspirin-induced, occupational, menstrual cycle related, infection-related, and intrinsic)
• Practical: Chest examination, pulmonary function testing, bronchial challenges, sputum analysis, and interpretation of bronchoscopy and bronchial lavage and of radiographs
b. Allergic bronchopulmonary aspergillosis
• Practical: Chest examination, precipitating antibodies test performance characteristics, pulmonary function testing, bronchial challenges, sputum analysis, and interpretation of bronchoscopy and bronchial lavage and of radiographs
c. Hypersensitivity pneumonitis
• Practical: Chest examination, precipitating antibodies test performance characteristics, pulmonary function testing, bronchial challenges, sputum analysis, and interpretation of bronchoscopy and bronchial lavage and of radiographs
d. Chronic obstructive pulmonary disease
•Practical: Mostly treated by other specialists
e. Cystic fibrosis
• Practical: Mostly treated by other specialists
f. Immotile cilia syndrome
• Practical: Mostly treated by other specialists
g. Sarcoidosis
• Practical: Mostly treated by other specialists
h. Chronic cough syndrome
• Practical: Treated in cooperation with other specialists

5. Drug hypersensitivity
• Practical: Drug skin testing and in vitro tests, patch test, challenge tests (oral, intravenous, intramuscular, subcutaneous), desensitizing protocols

6. Adverse reactions to ingestants
a. Food allergies and intolerance
• Practical: Food allergen skin testing, food allergen challenge tests (open and placebo-controlled, double-blind), combined food challenge and exercise tests, prescription of adequate diets
b. Food-additive reactions
• Practical: Food-additive challenge tests (open and placebo-controlled, double-blind)
c. Gluten sensitivity
• Practical: Diagnostic test for gluten enteropathy
d. Gastrointestinal eosinophilic diseases
• Practical: Food allergen skin testing, food allergen challenge tests (open and placebo-controlled, double-blind)

7. Anaphylaxis
a. Anaphylaxis (allergen-induced, related to blood products, exercise-induced, menstrual-related, idiopathic, drug-related, and radiocontrast media-induced)
• Practical: Emergency treatment, testing for responsible allergen, e.g. peanuts, penicillin, latex, etc., challenge tests, prophylaxis

8. Insect hypersensitivity
a. Stinging insect reactions
• Practical: Venom skin testing, instruction in emergency treatment, allergen-specific immunotherapy
b. Other hypersensitivity reactions
• Practical: Instruction in emergency treatment, symptomatic treatment

B. Immunodeficiency diseases

1. Complement deficiencies
a. Hereditary and acquired angioedema
• Practical: Interpretation of quantitative and functional C-1-esterase inhibitor tests, complement C3, C4, C1q, investigation of mutations
b. Complement-component deficiencies
• Practical: Interpretation of complement test results

2. Primary immunodeficiencies
a. Severe combined immunodeficiency, DiGeorge syndrome, adenosine deaminase deficiency, ataxia telangiectasia, Wiskott-Aldrich syndrome, Netherton syndrome, congenital X-linked agammaglobulinemia, selective IgA deficiency, IgG subclass deficiencies, hyper-IgE syndrome, hyper-IgM syndrome, common variable immunodeficiency*
• Practical: Assessment for thymic shadow, assessment of recurrent serious infections, immunoglobulin level interpretation, functional antibody interpretations, lymphocyte subpopulation and function, and delayed skin test performance and interpretation.

3. Acquired immunodeficiencies
a. Acquired immunodeficiency syndrome, chromosomal defects, metabolic defects,
immunosuppression, viral infections, parasitism, malnutrition, malignancies, autoimmune diseases, burns, splenectomy, and radiation*
• Practical: Interpretation of human immunodeficiency virus tests (ELISA and Western blot), PCR testing, lymphocyte subpopulation and function

4. Phagocytic cell disorders
a. Chronic granulomatous disease of childhood, myeloperoxidase, deficiency, leukocyte-adhesion disorder (types 1 & 2), Chediak-Higashi syndromes, hypereosinophilic syndromes, and mastocytosis*
• Practical: Assessment of leukocyte function, chemiluminescence test interpretation, surface glycoprotein tests (e.g. CD1 1 a, b, c, and CD18) phenotype interpretation, chemotaxis assay interpretation, and absolute neutrophil count interpretation, superoxide generation, NBT testing.
C. Immunoregulatory Disorders
1. Autoimmunity
a. Organ and non-organ autoimmune diseases such as: systemic lupus erythematosus, other collagen-vascular diseases (connective tissue disease), immune endocrino-pathies, inflammatory gastrointestinal diseases, immunologic neuropathies and neuromuscular diseases, immuno-hematologic diseases, and immunologic eye diseases, etc.*
• Practical: Interpretation of physical findings; interpretation of autoantibody test results (including but not limited to) antinuclear antibody, anti-DNA, anti-Rho, and anti-La, antiintrinsic
factor, anti-parietal cell antibody, anti-receptor antibodies, anti-myelin antibody, anti-neutrophil antibody, and anti-phospholipid antibodies

2. Vasculitis
a. Small vessel disease, medium vessel disease, large vessel disease, pulmonary and renal immune disease, and cryoproteins*
• Practical: Interpretation of physical findings, interpretation of biopsy specimens of skin, kidney, and lung (immunofluorescence), interpretation of circulating immune complex levels, interpretation of cryoglobulins and autoantibodies.

3. Transplantation and GVHRs
a. Pharmacologic modulation and Immunomodulation of GVH reactions following transplant*
• Practical: Diagnosis and treatment normally undertaken by other specialists

4. Immune-related malignancies
a. Plasma cell dyscrasia, multiple myeloma and gammopathies*
• Practical: Interpretation of serum protein electrophoresis, interpretation of immunoelectrophoresis, interpretation of serum immunoglobulin levels, and interpretation of lymphocyte subset data. Treatment normally undertaken by other specialists.

5. Immune reproductive defects
a. Infertility (male and female), abortion (chronic), Rh incompatibility, ABO incompatibility, secondary reproductive defects*
• Practical: Interpretation of anti RH/AB antibody levels and interpretationof appropriate autoantibodies.

6. Immunomodulation
a. Immunosuppressants
b. Immune reconstitution
c. Gammaglobulin and monoclonal antibodies
d. Cytokine receptors and receptor antagonists
e. Vaccines
f. Plasmapheresis and cytopheresis
g. Recombinant molecules