A competency based development of knowledge and skills in Allergy and Immunology through clinical experience, bedside teaching, didactic conferences and readings to achieve competence, proficiency and the foundation for mastery. Clinical Information and Didactics - Residents will attend all scheduled clinics. Residents are expected at 8:30 after Morning Report/Grand Rounds. When not in clinic, residents should be available for consults.
| Monday | Tuesday | Wednesday | Thursday | Friday | AM | 8:00 am Allergy Rounds (676 N St. Clair, 14-024) 9:00 am Clinic - Galter 18 | 7:30 am Grand Rounds 8:30 am Clinic - Galter 18 | 7:30 am Morning Report 8:30 am Clinic - Galter 18 | 7:30 am Morning Report 8:30 am Clinic - Galter 18 | 7:30 am Morning Report 8:30 am Clinic - Galter 18 | PM | 1:00 pm Clinic – Galter 18 | 12:30 pm Allergy Conf (676 N St. Clair, 14-018A) 1:30 pm Clinic – Galter 18 | 1:00 pm Clinic – Galter 18 | 12:15 pm Allergy Rounds (676 N St. Clair, 14-024) 1:00 pm Clinic – Galter 18 | 1:00 pm Clinic - Galter 18 |
- Residents will be expected to attend all Allergy specific conferences scheduled above.
- A pre-test and post-test is required to receive credit for the rotation.
- Each resident will be required to prepare a 10 minute presentation during the rotation.
- Contact the HELP desk of 5-HELP and notify them that you will be on Allergy-Immunology. There will be paperwork to complete for non-NMH residents.
- New patient information sheets can be selected from patient instructions in Epic:
a) New patient information b) Corticosteroid information c) Pregnancy medication safety d) Idiopathic Anaphylaxis algorithm e) Dust mite encasing f) Ketotifen ordering information g) Pre-operative management (prednisone and hydrocortisone) h) Bone health advice *Patients on a varying dose of prednisone should have instructions inserted into Epic for them. *Write prednisone prescriptions as follows: Prednisone 5mg tablets Sig: as directed Dispense 100 (usually) No refills - Billing information should be discussed with the attending to ensure proper billing.
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Practice Based Learning and Improvement PGY1: Incorporate regular chart review and patient follow up to learn from your clinical care. Teach and mentor students. PGY2/3: Incorporate evidence based medicine into clinical decision making. Review the latest research pertaining to your your patients. Teach and mentor students and interns. Systems Based Practice PGY1: Work in a multi-disciplinary team to provide high quality coordinated care. Ensure accurate and timely documenation through the use of the electronic medical record. PGY2/3: Use knowledge and skills in quality improvement and patient safety to deliver safe and effective care. Apply team leadership skills in appropriate settings. Practice cost effective medicine with an awareness of health care economics and patient insurance status. Interpersonal Skills and Communication PGY1: Use effective listening skills with patients and health care providers. Elicit and provide information using effective nonverbal, explanatory, questioning, and writing skills. PGY2/3: Develop interpersonal and communication skills necessary to run an effective clincal team in the ambulatory. Role model and teach effective communication techniques. Professionalism PGY1: Carry out your professional responsibilities in a timely manner. Adhere to the ethical principles of a patient-centered practice. Be sensitive to a diverse patient population and health care staff. PGY2/3: Understand how biases influence clinical care, patient-physician interactions and health team interactions. Role model and provide feedback to students and interns the principles of humanism in medicine. Patient Care and Medical Knowledge A. Asthma PGY1 Evaluate a patient and classify asthma as mild, moderate or severe. Define potentially fatal or malignant potentially fatal asthma. Review the aspirin triad. Differentiate non-allergic vs allergic asthma. Recognize nocturnal symptoms, frequency of inhaler use, frequency of ER visits, hospitalizations, ICU admissions, intubations, steroid use as criteria to assess asthma severity. List allergic and non-allergic triggers of asthma . Review concomitant conditions such as GERD, COPD and sinusitis.
PGY2,3 Operate the PFT machine and interpret results including VCD Know indications for skin testing and be able to perform and interpret skin testing results Initiate therapy with beta agonist and steroid inhalers Name indications for PO steroid therapy and appreciate the limitations of pharmacologic agents in the management of asthma Define cough-equivalent asthma Compare various inhaled steroid and beta-agonist preparations Instruct patients on the use of MDI’s, disks and dry powder inhalers Review indications for and mechanism of action of oral leukotriene inhibitors Initiate therapy for asthma Name non-pharmacologic strategies in asthma management. Discuss indications for a change in asthma therapy Define ABPA and when to investigate a patient for this condition Describe ABPA serologies and when to obtain them List treatment regimens for ABPA and complications of untreated ABPA Review indications for CXR and PFT’s in a patient with asthma Recognize patients who need evaluation for osteoporosis Discuss management of asthma in pregnant patients
B. Rhinitis PGY1 List manifestations of rhinitis including nasal discharge and post-nasal drip Identify significance and location of pruritus Review triggers of rhinitis including tobacco smoke and cleaning solutions Contrast seasonal, perennial and mixed rhinitis Define vasomotor rhinitis. Demonstrate knowledge of various nasal steroid and antihistamine preparations Differentiate allergic from non-allergic nasal disease Initiate therapy in a patient with rhinitis
PGY2,3 Recognize when a change of therapy is indicated and what options are available Review reasons for treatment failure in a patient with rhinitis Instruct patient in the use of nasal sprays Recognize and review management of nasal polyps Classify patients in whom immunotherapy may be indicated Discuss the mechanism of action of immunotherapy Identify patients with non-organic disease
C. Rhinosinusitis PGY1 PGY2,3 Review indications for sinus imaging and compare the various techniques Define allergic fungal sinusitis List indications for sinus surgery
D. Anaphylaxis Syndromes PGY1 Identify the structure of IgE and how exposure to allergen results in an allergic reaction on the molecular/cellular level Review the definition of a cytokine and discuss the actions of IL1, IL2, IL4 and IL5. Recognize clinical features and treatment of anaphylaxis.
PGY2,3 Describe Idiopathic anaphylaxis, its workup and treatment. Discuss the role of skin testing for foods in the evaluation of patients with anaphylaxis. Classify idiopathic Anaphylaxis into categories of angioedema, generalized, questionable and variant Review causes of angioedema and management strategies List common triggers of anaphylaxis
F. Dermatologic conditions PGY1 PGY2,3 G. Immunodeficiency syndromes PGY1 PGY2,3 1) Budesonide/formoterol combination therapy as both maintenance and reliever medication in asthma
O'Byrne PM, Bisgaard H, Godard PP, Pistolesi M, Palmqvist M, Zhu Y, Ekstrom T, Bateman ED. Budesonide/formoterol combination therapy as both maintenance and reliever medication in asthma. Am J Respir Crit Care Med. 2005 Jan 15;171(2):129-36. Epub 2004 Oct 22. A single treatment for asthma? The paper nicely proves an improvement in asthma control with the use of a combination budesonide/fomoterol inhaler used as both maintenance and rescue therapy. The postulation is that, by using the combination as rescue, the patient will also be self-titrating inhaled corticosteroids to match worsening asthma control. This cannot be extrapolated to fluticasone/salmeterol (Advair) as the long-acting beta-agonist in that medication has too slow an onset to provide acute symptom relief. The combination studied should be available in the US in mid-2007. 2) Beta-Agonist Study (BAGS) – Safety of beta-agonist use
Drazen JM, Israel E, Boushey HA, Chinchilli VM, Fahy JV, Fish JE, et al. Comparison of regularly scheduled with as-needed use of albuterol in mild asthma. N Engl J Med 1996; 335: 841-7. At the time of this study, the asthma community debated the possible danger of beta-agonist overuse. Some felt that regular beta-agonist use caused worsening asthma control and, in fact, were at least partly to blame for increasing asthma mortality. This study refutes that well in a muti-center, double-blind, randomized study looking at 2 groups: one taking albuterol scheduled and one taking the medication as needed. Patients were not blinded, of course. The results showed no benefit or harm. Increased beta-agonist use is still a marker for worsening asthma control and a need for increased maintenance therapy, but it is not the cause of these things. 3) Allergic Bronchopulmonary Aspergillosis (ABPA) Review
Greenberger PA. Allergic bronchopulmonary aspergillosis. J Allergy Clin Immunol 2002;110:685-92. The ABPA article presented is a nice review by one of the leaders in the field, and a local Northwestern Faculty member, Dr. Paul Greenberger. There are few in this country that are as knowledgeable about the subject or carry as many patients with the diagnosis as Dr. Greenberger. 4) Aspirin Desensitization Review
Stevenson DD, Simon RA. Selection of patients for aspirin desensitization treatment. J Allergy Clin Immunology 2006;118:801-804. The review on Aspirin desensitization comes from the Scripps Clinic, which is regarded as one of the national centers on the subject. This is a concise and excellent overview of the subject. 5) Landmark Article on Venom Immunotherapy
Hunt KJ, Valentine MD, Sobotka AK et al. A controlled trial of immunotherapy in insect hypersensitivity. N Engl J Med 1978;299:157-161 The venom immunotherapy article is an older one, but it still directs much of venom immunotherapy. Prior to this study, immunotherapy for hymenoptera (bees, wasps, etc.) venom allergies was done with whole-body insect extracts. This paper demonstrates a dramatic clinical superiority of venom immunotherapy when compared to either placebo or whole body extracts. 6) C-Kit Mutations on Mast Cells
Akin C, Metcalfe D The biology of Kit in disease and the application of pharmacogenetics. J Allergy Clin Immunol 2004:114;13-19. Mastocytosis is a rare disease with a varied presentation, including urticaria, edema, diarrhea, hypotension, heptosplenomegaly, organic brain syndrome, and sarcomas. This article reviews some details on the c-kit mutations, as well as the pathobiology of their relationship to human disease. The proto-oncogene c-kit, located on chromosome 4, encodes for a tyrosine kinase transmembrane receptor for stem cell factor. 7) Tyrosine Kinase-targeted Therapy in Hypereosinophilic Syndrome
Cools J, DeAngelo DJ, Gotlib J, et al. A tyrosine kinase created by fusion of the PDGFRA and FIP1L1 genes as a therapeutic target of imatinib in idiopathic hypereosinophilic syndrome. N Engl J Med. 2003;348:1201-14. Hypereosinophilic syndrome (HES), also a rare disorder, can cause various types of end-organ damage. This article presents a small series of patients treated with imatinib for HES. It not only offers promising results, but the paper also reviews the genetics or platelet-derived growth factor receptor. 8) Novel Modification on Immunotherapy with a TLR-9 Agonist: Mixed results
Creticos P. S., Schroeder J. T., Hamilton R. G. Immunotherapy with a Ragweed–Toll-Like Receptor 9 Agonist Vaccine for Allergic Rhinitis. N Engl J Med 2006; 355:1445-1455. The paper on a novel approach to immunotherapy failed to prove statistical significance for the primary endpoints, but it did prove beneficial on enough of the secondary endpoints to provoke thought. The authors conjugated traditional ragweed immunotherapy extracts containing Amb a 1 (the central ragweed allergen) to a CpG-containing DNA sequence (referred to as AIC). The CpG-containing sequence is a known Toll-Like Receptor 9 (TLR 9) agonist. The thinking was that, since TLR 9 ligation inhibits Th2 cells, its addition to tradition ragweed immunotherapy would increase the vaccine’s efficacy. The primary endpoint, albumin extravasation in nasal lavage fluid after allergen challenge, showed no statistically significant difference from placebo. There were differences in secondary endpoints such as sneeze counts, symptom scores, and Amb a 1-specific IgE. There were several issues with this study, including the lack of comparison to tradition IT and the choice of placebo type. In the end, those reading this paper should not conclude that AIC is ready for mass use. Instead, it suggests that further investigation may be warranted, and that novel approaches to immunotherapy may enhance allergic rhinitis treatments. 9) Pollen Immunotherapy to Prevent Asthma: The PAT Study
Moller C, Dreborg S, Ferdousi HA, Halken S, Host A, Jacobsen L, Koivikko A, Koller DY, Niggemann B, Norberg LA, Urbanek R, Valovirta E, Wahn U. Pollen immunotherapy reduces the development of asthma in children with seasonal rhinoconjunctivitis (the PAT-study). J Allergy Clin Immunol. 2002 Feb;109(2):251-6. The PAT study paper demonstrates a statistically significant difference in children treated with immunotherapy from those that were not in terms of developing asthma. This is especially intriguing as other studies looking to prevent asthma with corticosteroid use (PEAK, IMPACT) found no benefit. 10) Omalizumab (Anti-IgE) Phase III Trial
Busse W, Corren J, Lanier BQ, McAlary M, Fowler-Taylor A, Cioppa GD, van As A, Gupta N. Omalizumab, anti-IgE recombinant humanized monoclonal antibody, for the treatment of severe allergic asthma. J Allergy Clin Immunol. 2001 Aug;108(2):184-90. The omalizumab trial paper describes 525 subjects enrolled in a double-blind, placebo-controlled trial and demonstrates a significant decrease in asthma exacerbations. In addition, the subjects treated were able to decrease their steroid dosage to a greater extent. In addition, symptom scores, measured FEV1, and morning peak expiratory flow were improved on omalizumab. Of note, the FEV1 change was only modestly different in the 2 groups. Though the omalizumab group had a decreased free IgE when compared to placebo, there was no difference in the two groups in terms of total serum IgE. This paper does not describe the small increase in malignancies seen in the omalizumab-treated group, though most consider this difference not significant as most of neoplasms seen would have taken far too long to grow to have been caused by the medication. There have been increased concerns of late in regards to anaphylactic reactions to omalizumab, resulting in longer suggested wait times in the clinic after injection. 11) The following syllabus will be handed out for additional reading and references: Northwestern University Allergy-Immunology Syllabus: Residents and Students, Allergy and Asthma Proc 2004;25:S1- S63. Collection by Dr. Michael Radtke with assistance by Dr. Paul Greenberger For a full list of references, click on: Allergy Reading List- with direct links to articles via Galter Library. Back to Curriculum | 
