Curriculum standards
Knowledge guides
LG13: Foundations of immunology, diagnostics, and therapeutics
Epidemiology, pathophysiology, and clinical sciences
Advanced Trainees will have in-depth knowledge of the topics listed under each clinical sciences heading.
For the statistical and epidemiological concepts listed, trainees should be able to describe the underlying rationale, the indications for using one test or method over another, and the calculations required to generate descriptive statistics.
Investigations, procedures, and clinical assessment tools
Advanced Trainees will know the scientific foundation of each investigation and procedure, including relevant anatomy and physiology. They will be able to interpret the reported results of each investigation or procedure.
Advanced Trainees will know how to explain the investigation or procedure to patients, families, and carers, and be able to explain procedural risk and obtain informed consent where applicable.
Important specific issues
Advanced Trainees will identify important specialty-specific issues and the impact of these on diagnosis, management and outcomes.
Allergy and hypersensitivity
- Gell and Coombs classification system: hypersensitivity responses – type I:
- cells of the allergic reaction, such as:
- basophils
- eosinophils
- mast cells
- cytokines / chemokines relevant in allergic responses
- generation and regulation of type 2 helper T (Th2) responses
- immunoglobulin E (IgE)-mediated acute-phase and late-phase reactions
- IgE and receptor interactions
- cells of the allergic reaction, such as:
- Gell and Coombs classification system: hypersensitivity responses – types II–IV:
- antibody-mediated cytotoxicity responses
- cell mediated immunity – types IV a, b, c, d
- immune complexes, immunologic properties, and mechanisms of clearance
- Putative mechanism of desensitisation:
- immunoglobulin G4 (IgG4)
- regulatory T cell (Tregs)
Cellular components of the immune system
- Atypical lymphocytes, innate lymphoid cells, and natural killer cells
- Basophils, eosinophils, and mast cells
- Distribution, ontogeny, and subtypes of T and B cells
- Lymphocytes
- Phagocytes
Cell signalling
- Cytokine signalling via nuclear factor kappa-light-chain-enhancer (Nf-kB) versus interferon-based signalling
- Principles of cytokine signalling via Janus kinase (JAK) and signal transducer and activator of transcription (STAT)
- Proximal signalling after T cell receptor or B cell receptor ligation – SMAC organisation and constituents
- Toll-like receptors signalling via myeloid differentiation primary response gene 88 (MyD88) and Nf-kB
Effector mechanisms
- Acute phase response
- Antibody function
- Complement
- Cytotoxicity
- Fibrosis
- Mast cell mediators
- Polymorphonuclear cell recruitment and action
Evolution and development
- Principles of immune organ development
- Selective pressure on immune system during evolution
Human immunodeficiency virus (HIV)
- HIV diversity
- HIV life cycle
- Pathogenesis of HIV-induced immunodeficiency
- Principles of antiretroviral therapy and opportunistic infection prophylaxis
Immune response to infections
- Extracellular bacteria
- Fungi, such as various locations, including:
- cutaneous
- lung
- sinuses
- Helminth and other parasites such as scabies
- Intracellular bacteria such as mycobacteria
- Protozoa
- Viruses
Immunology memory
- B cell differentiation in germinal centres, including affinity maturation
- Memory B cells
- Plasma cells:
- long-lived
- short-lived
- T cell memory subsets:
- Tfh
- Th1
- Th2
- Th17
Signal one - antigen receptors
- Antigen-presentation to T cells – distinctions between MHC class I & II
- B cell activation:
- antigen presentation to B cells
- class switch recombination, including cytokine signals, and molecular mechanisms of somatic hypermutation
- Classification of nucleic acid receptors, such as RIG-I-like and toll-like receptors
- Danger-associated molecular patterns (DAMPs) and pathogen-associated molecular patterns (PAMPs)
- Lectins, leucine rich repeats, and toll-like receptors
- Molecular mechanisms of V(D)J recombination
- Pathogen recognition receptors (PRP)
Signal two - accessory signals
- Adhesion molecules
- B7 family
- Complement
- Cytokine receptor families
- Tumour necrosis factor receptor (TNFR) superfamily
Structure and organisation of the immune system
- Basic development, location, and structure of primary and secondary lymphoid organs:
- bone marrow
- colonic patches
- lymph nodes and lymphatic system
- mucosa-associated lymphoid tissue (MALT), including tonsils
- Peyer’s patches
- spleen
- thymus
- Cutaneous and mucosal immune systems
- Emerging understanding of the vermiform appendix in gut immune homeostasis
- Innate and adaptive immunity
- Lymphocyte circulation in the body – anatomy and signals, including cellular adhesion and chemokines
- Organisation of secondary lymphoid organs:
- primary and secondary follicles
- principles of lymphocyte traffic
- T-zones
- Physiology of the upper and lower airways, skin, and gastrointestinal (GI) tract
Tolerance
- Central tolerance in the thymus and bone marrow:
- anergy
- clonal deletion
- receptor editing
- Dominant tolerance by regulatory T cells – FoxP3+ T-cells
- Two-signal models of peripheral tolerance
Transplantation immunology
- Allograft rejection
- Graft-versus-host reactions
- Maintenance of tolerance
Tumour immunology
- Immune surveillance
- Oncogenes
- Translocations
- Tumour-specific and tumour-associated antigens
- Tumour suppressor genes
- Checkpoint inhibitor
Intravenous immunoglobulin (IVIG)
- Indications for:
- IVIG and subcutaneous immunoglobulin (SCIg) replacement therapy for primary immunodeficiency and systemic autoimmune and inflammatory disease
- SCIg and IVIG therapy for immunomodulation:
- collection and manufacturing process for immunoglobulin preparations, and impact on efficacy and safety
- dose calculation and monitoring, dose escalation, and loading, including compliance with formal guidelines, such as:
- BloodSTAR
- National Blood Authority (NBA)
- New Zealand Blood Service (NZBS)
- efficacy monitoring of immunoglobulin infusions by clinical parameters, such as infections through symptoms and immunoglobulin G levels
- expectations of disease reversal or control with patients, their family, and/or carers
- IVIG’s potential adverse effects
- major components of IVIG and alternative preparations of immunoglobulin
- practicalities of administration, monitoring, and prescribing IVIG and SCIg therapy
- prescribe and arrange supply of IVIG and SCIg according to current guidelines and limitations of issuing authorities, such as NBA, Australian Red Cross blood transfusion service, and NZBS recommendations
- timing of prophylactic immunisations relative to immunomodulatory therapies, such as IVIG
Procedures
- Desensitisation procedures, when using established protocols
- De-labelling of patients
Action / Management plans
- Familiarity with and appropriately use standardised action and management plans for anaphylaxis and/or allergic reactions, and hereditary angioedema, as per the Australasian Society of Clinical Immunology and Allergy
Environmental changes and sustainability
- Be aware of potentially relevant health impacts of climate change, such as:
- alterations in pollen distribution
- expanding geographic areas for insect-borne diseases
- increasing storm activity
- Consider sustainability and environmental impact of current and emerging immunological diagnostics and therapeutics
Immunological therapeutics
- Access, availability, costs, and potential benefits versus risks of gene therapy for inborn errors of immunity (IEIs)
- Educating patients and families on the potential benefits, risks, and safety plans of therapies
- Managing intravenous access, including potential complications associated with intravascular access devices
- Mechanisms of action, indications (including emerging), contraindications, methods of delivery, pharmacology, and therapeutic rationale for immunological therapies such as:
- allergen-specific immunotherapy
- cytokines
- immunisations, including the role of adjuvants in modifying the immune response
- immunoglobulin replacement
- immunosuppressive and immunomodulatory drugs
- plasmapheresis
- recombinant protein-based therapies
- soluble receptors
- therapeutic monoclonal antibodies
- Preventing predictable adverse events of immunosuppressive therapy, including opportunistic infections and glucocorticoid-induced osteoporosis