Integration of Immunology in a Systems-Based Osteopathic Medical Curriculum
Abstract
1. Introduction
2. Methodology
3. Discussion
3.1. Foundational Knowledge in Immunology
3.2. Integration in Community Health, Patient Presentations Related to Wellness and Genetics
3.3. Integration in Musculoskeletal and Integumentary System
3.4. Integration in Circulatory and Hematologic System
3.5. Integration in the Respiratory System
3.6. Integration in the Endocrine System and Metabolism
3.7. Integration in Human Development, Reproduction, and Sexuality
3.8. Integration in the Nervous System and Mental Health
3.9. Integration in the Renal System
3.10. Integration in the Gastrointestinal System and Nutritional Health
3.11. Integration in Osteopathic Medicine
4. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
- Seffinger, M.A. Foundations of Osteopathic Medicine: Philosophy, Science, Clinical Applications, and Research; American Osteopathic Association: Chicago, IL, USA, 2018; issuing body. [Google Scholar]
- Bordoni, B. The Five Diaphragms in Osteopathic Manipulative Medicine: Neurological Relationships, Part 1. Cureus 2020, 12, e8697. [Google Scholar] [CrossRef]
- Esteves, J.E.; Zegarra-Parodi, R.; van Dun, P.; Cerritelli, F.; Vaucher, P. Models and theoretical frameworks for osteopathic care—A critical view and call for updates and research. Int. J. Osteopath Med. 2020, 35, 1–4. [Google Scholar] [CrossRef]
- Mein, E.A.; Richards, D.G.; McMillin, D.L.; McPartland, J.M.; Nelson, C.D. Physiological regulation through manual therapy. In Physical Medicine and Rehabilitation: State of the Art Reviews; Hanley and Belfus: Philadelphia, PA, USA, 2000; Volume 14. [Google Scholar]
- American Association of Colleges of Osteopathic Medicine (AACOM). U.S. Colleges of Osteopathic Medicine [Website]. 2024. Available online: https://www.aacom.org/become-a-doctor/prepare-for-medical-school/us-colleges-of-osteopathic-medicine#:~:text=Osteopathic%20Medical%20Schools&text=There%20are%20currently%2041%20accredited,medicine%20in%20the%20United%20States) (accessed on 16 July 2024).
- Reynolds, A.B.; Bhattacharjee, R.; Zhao, Y. Current Status of Immunology Education in U.S. Medical Schools. Immunohorizons 2022, 6, 864–871. [Google Scholar] [CrossRef] [PubMed]
- Bansal, A.S. Medical students’ views on the teaching of immunology. Acad. Med. 1997, 72, 662. [Google Scholar] [CrossRef] [PubMed]
- Lee, A.; Malau-Aduli, B. Medical students’ learning experiences and perceptions of immunology. Int. J. Med. Educ. 2013, 3, 1539. [Google Scholar]
- Haidaris, C.G.; Frelinger, J.G. Inoculating a New Generation: Immunology in Medical Education. Front. Immunol. 2019, 10, 2548. [Google Scholar] [CrossRef] [PubMed]
- Tomasi, A.G.; Belhorn, T.; Church, F.C. PRIME Immunology: Self-directed Introduction to Medical School Immunology. Med. Sci. Educ. 2021, 31, 1279–1282. [Google Scholar] [CrossRef] [PubMed]
- Siani, M.; Dubovi, I.; Borushko, A.; Haskel-Ittah, M. Teaching immunology in the 21st century: A scoping review of emerging challenges and strategies. Int. J. Sci. Educ. 2024. [Google Scholar] [CrossRef]
- Kulasegaram, K.M.; Martimianakis, M.A.; Mylopoulos, M.; Whitehead, C.R.; Woods, N.N. Cognition before curriculum: Rethinking the integration of basic science and clinical learning. Acad. Med. 2013, 88, 1578–1585. [Google Scholar] [CrossRef]
- Manglik, N.; Dudrey, E.F.; Baatar, D.; Piskurich, J.F. Immune response to bacteria: An integrated learning module to enhance preclinical students’ competency in immunology. MedEdPORTAL 2017, 13, 10585. [Google Scholar] [CrossRef]
- Bauzon, J.; Alver, A.; Ravikumar, V.; Devera, A.; Mikhael, T.; Nauman, R.; Simanton, E. The Impact of Educational Resources and Perceived Preparedness on Medical Education Performance. Med. Sci. Educ. 2021, 31, 1319–1326. [Google Scholar] [CrossRef]
- Griner, P.F.; Danoff, D. Sustaining change in medical education. J. Int. Assoc. Med. Sci. Educ. 2000, 283, 2429–2431. [Google Scholar] [CrossRef]
- Roberts, C.; Lawson, M.; Newble, D.; Self, A.; Chan, P. The introduction of large class problem-based learning into an undergraduate medical curriculum: An evaluation. Med. Teach. 2005, 27, 527–533. [Google Scholar] [CrossRef]
- Rapp, D.E. Integrating cultural competency into the undergraduate medical curriculum. Med. Educ. 2006, 40, 704–710. [Google Scholar] [CrossRef] [PubMed]
- Ramsey, P.G.; Miller, E.D. A single mission for academic medicine: Improving health. J. Int. Assoc. Med. Sci. Educ. 2009, 301, 1475–1476. [Google Scholar] [CrossRef] [PubMed]
- Booth, J.S.; Burges, G.; Justemen, L.; Knoop, F.C. Design and implementation of core knowledge objectives for medical microbiology and immunology. JIAMSE J. Int. Assoc. Med. Sci. Educ. 2009, 19, 100–138. [Google Scholar]
- National Board of Osteopathic Medical Examiners (NBOME). COMLEX-USA Master Blueprint (PDF). 2023. Available online: https://www.nbome.org/assessments/comlex-usa/master-blueprint/ (accessed on 24 May 2023).
- United States Medical Licensing Association. Step 1 Content Outline and Specifications. 2022. Available online: https://www.usmle.org/prepare-your-exam/step-1-materials/step-1-content-outline-and-specifications (accessed on 7 July 2023).
- Matinho, D.; Pietrandrea, M.; Echeverria, C.; Helderman, R.; Masters, M.; Regan, D.; Shu, S.; Moreno, R.; McHugh, D. A Systematic Review of Integrated Learning Definitions, Frameworks, and Practices in Recent Health Professions Education Literature. Educ. Sci. 2022, 12, 165. [Google Scholar] [CrossRef]
- Brauer, D.G.; Ferguson, K.J. The integrated curriculum in medical education: AMEE Guide No. 96. Med. Teach. 2015, 37, 312–322. [Google Scholar] [CrossRef] [PubMed]
- Harden, R.M.; Davis, M.H.; Crosby, J.R. The new Dundee medical curriculum: A whole that is greater than the sum of the parts. Med. Educ. 1997, 31, 264–271. [Google Scholar] [CrossRef]
- Grant, J. Principles of curriculum design. In Understanding Medical Education: Evidence, Theory, and Practice, 3rd ed.; Swanwick, T., Forrest, K., O’Brien, B.C., Eds.; Wiley-Blackwell: Oxford, UK, 2019; pp. 71–88. [Google Scholar]
- Wijnen-Meijer, M.; Ten Cate, O.T.J.; Rademakers, J.J.D.J.M.; Van Der Schaaf, M.; Borleffs, J.C.C. The influence of a vertically integrated curriculum on the transition to postgraduate training. Med. Teach. 2009, 31, e528–e532. [Google Scholar] [CrossRef]
- Neufeld, V.R.; Woodward, C.A.; MacLeod, S.M. The McMaster M.D. program: A case study of renewal in medical education. Acad. Med. 1989, 64, 423–432. [Google Scholar] [CrossRef] [PubMed]
- Porter, E.; Amiel, E.; Bose, N.; Bottaro, A.; Carr, W.H.; Swanson-Mungerson, M.; Varga, S.M.; Jameson, J.M. American Association of Immunologists recommendations for an undergraduate course in immunology. Immunohorizons 2021, 5, 448–465. [Google Scholar] [CrossRef] [PubMed]
- Wilkerson, L.; Stevens, C.M.; Krasne, S. No content without context: Integrating basic, clinical, and social sciences in a pre-clerkship curriculum. Med. Teach. 2009, 31, 812–821. [Google Scholar] [CrossRef] [PubMed]
- Kennelly, P.J.; Bond, J.S.; Masters, B.S.; Dennis, E.A.; Brenner, C.; Raben, D.M. Desperately seeking Flexner: Time to reemphasize basic science in medical education. Acad. Med. 2013, 88, 1405–1406. [Google Scholar] [CrossRef]
- Weston, W.W. Do we pay enough attention to science in medical education? Can. Med. Educ. J. 2018, 9, e109–e114. [Google Scholar] [CrossRef] [PubMed]
- General Medical Council (GMC). Tomorrow’s Doctors; GMC: London, UK, 2009. [Google Scholar]
- Association of American Medical Colleges (AAMC). Report IV—Contemporary Issues in Medicine: Basic Science and Clinical Research; Medical School Objectives Project; AAMC: Washington, DC, USA, 2001. [Google Scholar]
- Bruner, J.S. The Process of Education; Harvard University Press: Cambridge, MA, UAS, 1960. [Google Scholar]
- Davis, M.H.; Harden, R.M. Planning and implementing an undergraduate medical curriculum: The lessons learned. Med. Teach. 2003, 25, 596–608. [Google Scholar] [CrossRef] [PubMed]
- Larkins, M.C.; Thombare, A. Point-of-Care Testing. [Updated 2023 May 29]. In StatPearls [Internet]; StatPearls Publishing: Treasure Island, FL, USA, 2024. Available online: https://www.ncbi.nlm.nih.gov/books/NBK592387/ (accessed on 16 July 2024).
- Berraondo, P.; Sanmamed, M.F.; Ochoa, M.C.; Etxeberria, I.; Aznar, M.A.; Pérez-Gracia, J.L.; Rodríguez-Ruiz, M.E.; Ponz-Sarvise, M.; Castañón, E.; Melero, I. Cytokines in clinical cancer immunotherapy. Br. J. Cancer 2019, 120, 6–15. [Google Scholar] [CrossRef]
- Justiz Vaillant, A.A.; Nessel, T.A.; Patel, P.; Zito, P.M. Immunotherapy. In StatPearls [Internet]; StatPearls Publishing: Treasure Island, FL, USA, 2024. [Google Scholar]
- World Health Organization. Immunization Coverage. Available online: https://www.who.int/newsroom/fact-sheets/detail/immunization-coverage (accessed on 16 July 2024).
- Centers for Disease Control and Prevention. Vaccine-Preventable Deaths. Available online: https://www.cdc.gov/vaccines/vpd/about/disease-dis.html (accessed on 16 July 2024).
- U.S. Board on Health Promotion and Disease Prevention. Vaccine Safety Forum: Summaries of Two Workshops; National Academies Press: Washington, DC, USA, 1997. [Google Scholar]
- Abdelwhab, E.M.; Veits, J.; Mettenleiter, T.C. Antigenic drift and antigenic shift in influenza A viruses. Viruses 2023, 15, 125. [Google Scholar]
- Gebre, M.S.; Brito, L.A.; Tostanoski, L.H.; Edwards, D.K.; Carfi, A.; Barouch, D.H. Novel approaches for vaccine development. Cell 2021, 184, 1589–1603. [Google Scholar] [CrossRef]
- Dubé, E.; Vivion, M.; MacDonald, N.E. Vaccine hesitancy, vaccine refusal and the anti-vaccine movement: Influence, impact and implications. Expert Rev. Vaccines 2013, 14, 99–117. [Google Scholar] [CrossRef]
- Larson, H.J.; Jarrett, C.; Eckersberger, E.; Smith DM, D.; Paterson, P. Understanding vaccine hesitancy around vaccines and vaccination from a global perspective: A systematic review of published literature, 2007–2012. Vaccine 2014, 32, 2150–2159. [Google Scholar] [CrossRef] [PubMed]
- Stormacq, C.; Van den Broucke, S.; Wosinski, J. Does Health Literacy Mediate the Relationship between Socioeconomic Status and Health Disparities? Integrative Review. Health Promot. Int. 2019, 34, e1–e17. [Google Scholar] [CrossRef] [PubMed]
- Willis, D.E.; Andersen, J.A.; Bryant-Moore, K.; Selig, J.P.; Long, C.R.; Felix, H.C.; Curran, G.M.; McElfish, P.A. COVID-19 Vaccine Hesitancy: Race/Ethnicity, Trust, and Fear. Clin. Transl. Sci. 2021, 14, 2200–2207. [Google Scholar] [CrossRef] [PubMed]
- Kim, B.; Hong, S.; Kim, S. Are They Still Determining? Analysis of Associations among Ethnicity, Gender, Socioeconomic Status, Neighborhood Factors, and COVID-19 Vaccination. Front. Commun. 2023, 8, 1040797. [Google Scholar] [CrossRef]
- Volkov, M. Autoantibodies and B Cells: The ABC of rheumatoid arthritis pathophysiology. Immunol. Rev. 2020, 294, 148–163. [Google Scholar] [CrossRef] [PubMed]
- Centers for Disease Control and Prevention. Rheumatoid Arthritis (RA). Available online: https://www.cdc.gov/arthritis/basics/rheumatoidarthritis.html#:~:text=Rheumatoid%20arthritis%2C%20or%20RA%2C%20is,usually%20many%20joints%20at%20once (accessed on 24 May 2023).
- Smolen, J.S.; Aletaha, D.; McInnes, I.B. Rheumatoid arthritis. Lancet 2016, 388, 2023–2038. [Google Scholar] [CrossRef] [PubMed]
- Sparks, J.A.; Chang, S.-C.; Deane, K.D.; Gan, R.W.; Demoruelle, M.K.; Feser, M.L.; Karlson, E.W. Associations of smoking and age with inflammatory joint signs among unaffected first-degree relatives of rheumatoid arthritis patients: Results from studies of the etiology of rheumatoid arthritis. Arthritis Rheumatol. 2019, 71, 652–660. [Google Scholar] [CrossRef] [PubMed]
- Okada, Y.; Wu, D.; Trynka, G.; Raj, T.; Terao, C.; Ikari, K.; Kochi, Y.; Ohmura, K.; Suzuki, A.; Yoshida, S.; et al. Genetics of Rheumatoid arthritis contributes to biology and drug discovery. Nature 2014, 506, 376–381. [Google Scholar] [CrossRef]
- McInnes, I.B.; Schett, G. The pathogenesis of rheumatoid arthritis. N. Engl. J. Med. 2011, 365, 2205–2219. [Google Scholar] [CrossRef]
- van Venrooij, W.J.; van Beers, J.J.B.C.; Pruijn, G.J.M. Anti-CCP antibodies: The past, the present and the future. Nat. Rev. Rheumatol. 2011, 7, 391–398. [Google Scholar] [CrossRef]
- Holers, V.M.; Demoruelle, M.K.; Kuhn, K.A.; Buckner, J.H. Rheumatoid arthritis and the mucosal origins hypothesis: Protection turns to destruction. Nat. Rev. Rheumatol. 2019, 15, 457–466. [Google Scholar] [CrossRef] [PubMed]
- Mayo Clinic Staff. Ankylosing Spondylitis. Available online: https://www.mayoclinic.org/diseases-conditions/ankylosing-spondylitis/symptomscauses/syc20354808#:~:text=Ankylosing%20spondylitis%2C%20also%20known%20as,be%20difficult%20to%20breathe%20deeply (accessed on 24 May 2023).
- Reveille, J.D. Genetics of spondyloarthritis—Beyond the MHC. Nat. Rev. Rheumatol. 2017, 13, 404–416. [Google Scholar] [CrossRef] [PubMed]
- Ciccia, F.; Guggino, G.; Rizzo, A.; Alessandro, R. Role of gut microbiota in the pathogenesis of rheumatic diseases. Best Pract. Res. Clin. Rheumatol. 2017, 31, 767–779. [Google Scholar]
- Baeten, D.; Sieper, J. Ankylosing spondylitis. Lancet 2018, 390, 73–84. [Google Scholar]
- Benjamin, J.L.; Hedin CR, H.; Koutsoumpas, A.; Ng, S.C.; McCarthy, N.E.; Prescott, N.J.; Hart, A.L. Smokers with active ankylosing spondylitis have elevated chemokine receptor6 levels in serum. PLoS ONE 2019, 14, e0215124. [Google Scholar]
- Salem, I.; Ramser, A.; Isham, N.; Ghannoum, M.A. The gut microbiome as a major regulator of the gut-skin axis. Front. Microbiol. 2018, 9, 1–13. [Google Scholar] [CrossRef]
- Hruby, R.J.; Hoffman, K.N.; Avian, A.A.; Hough, B. Osteopathic manipulative treatment for rheumatoid arthritis: A systematic review and meta-analysis. Altern. Ther. Health Med. 2018, 24, 18–24. [Google Scholar]
- Cutler, M.J.; Holland, B.S.; Stupski, B.A.; Gamber, R.G. The effect of osteopathic manipulative treatment on disease severity in patients with rheumatoid arthritis: A pilot study. J. Am. Osteopath. Assoc. 2017, 117, e5–e6. [Google Scholar]
- Orrock, P.J.; Myers, S.P. Osteopathic intervention in chronic non-specific low back pain: A systematic review. BMC Musculoskelet. Disord. 2013, 14, 129. [Google Scholar] [CrossRef]
- Cataland, S.R.; Holers, V.M.; Geyer, S.; Yang, S.; Wu, H.M.; Soundar, E. Biomarkers of ADAMTS13 activity in thrombotic microangiopathies. Medicine 2018, 97, e12172. [Google Scholar]
- Page, E.E.; Kremer Hovinga, J.A.; Terrell, D.R.; Vesely, S.K.; George, J.N.; Hovinga, K.R. Thrombotic thrombocytopenic purpura: Diagnostic criteria, clinical features, and long-term outcomes from 1995 through 2015. Blood Adv. 2017, 1, 590–600. [Google Scholar] [CrossRef] [PubMed]
- Fowkes FG, R.; Rudan, D.; Rudan, I.; Aboyans, V.; Denenberg, J.O.; McDermott, M.M.; Criqui, M.H. Comparison of global estimates of prevalence and risk factors for peripheral artery disease in 2000 and 2010: A systematic review and analysis. Lancet 2017, 382, 1329–1340. [Google Scholar] [CrossRef]
- Bennett, M.R.; Sinha, S.; Owens, G.K. Vascular smooth muscle cells in atherosclerosis. Circ. Res. 2016, 118, 692–702. [Google Scholar] [CrossRef] [PubMed]
- Watkins, D.A.; Johnson, C.O.; Colquhoun, S.M.; Karthikeyan, G.; Beaton, A.; Bukhman, G.; Zuhlke, L.J. Global, regional, and national burden of rheumatic heart disease, 1990–2015. N. Engl. J. Med. 2017, 377, 713–722. [Google Scholar] [CrossRef] [PubMed]
- Rose, N.R.; Mackay, I.R. The Autoimmune Diseases, 5th ed.; Academic Press: Cambridge, MA, USA, 2014. [Google Scholar]
- Doulatov, S.; Notta, F.; Laurenti, E.; Dick, J.E. Hematopoiesis: A human perspective. Cell Stem Cell 2012, 10, 120–136. [Google Scholar] [CrossRef] [PubMed]
- Kelloway, L.; Record, E.; St Clair, N.; Wade, L.; Bedard, M.; Bezanson, J. The effects of osteopathic manipulative treatment on vascular endothelial function. J. Am. Osteopath. Assoc. 2017, 117, e6. [Google Scholar]
- Hodge, L.M.; King, H.H.; Williams, A.G. Effects of osteopathic manipulative treatment on circulation and immunological parameters in nursing home residents: A pilot study. J. Am. Osteopath. Assoc. 2005, 105, 400–408. [Google Scholar]
- Kesner, V.G.; Oh, S.J.; Dimachkie, M.M.; Barohn, R.J. Lambert-Eaton Myasthenic Syndrome. Neurol. Clin. 2018, 36, 379–394. [Google Scholar] [CrossRef]
- Sève, P.; Pacheco, Y.; Durupt, F.; Jamilloux, Y.; Gerfaud-Valentin, M.; Isaac, S.; Boussel, L.; Calender, A.; Androdias, G.; Valeyre, D.; et al. Sarcoidosis: A Clinical Overview from Symptoms to Diagnosis. Cells 2021, 10, 766. [Google Scholar] [CrossRef]
- Reggiani, F.; L’Imperio, V.; Calatroni, M.; Pagni, F.; Sinico, R.A. Goodpasture syndrome and anti-glomerular basement membrane disease. Clin. Exp. Rheumatol. 2023, 41, 964–974. [Google Scholar] [CrossRef]
- Kumar, V.; Abbas, A.K.; Aster, J.C. Robbins and Cotran Pathologic Basis of Disease, 10th ed.; Elsevier: Amsterdam, The Netherlands, 2021. [Google Scholar]
- Gillespie, K.M. Type 1 diabetes: Pathogenesis and prevention. CMAJ 2006, 175, 165–170. [Google Scholar] [CrossRef] [PubMed]
- Radetti, G. Clinical aspects of Hashimoto’s thyroiditis. Endocr. Dev. 2014, 26, 158–170. [Google Scholar] [CrossRef] [PubMed]
- Subekti, I.; Pramono, L.A. Current Diagnosis and Management of Graves’ Disease. Acta Med. Indones 2018, 50, 177–182. [Google Scholar] [PubMed]
- Bowman, J.M. RhD hemolytic disease of the newborn. N. Engl. J. Med. 1998, 339, 1775–1777. [Google Scholar] [CrossRef] [PubMed]
- Sammaritano, L.R. Antiphospholipid syndrome. Best Pr. Res Clin Rheumatol. 2019, 34, 101463. [Google Scholar] [CrossRef] [PubMed]
- Kirtschig, G. Lichen Sclerosus-Presentation, Diagnosis and Management. Dtsch. Arztebl. Int. 2016, 113, 337–343. [Google Scholar] [CrossRef]
- Goldman, L.; Schafer, A.I. Goldman-Cecil Medicine, 27th ed.; Elsevier: Amsterdam, The Netherlands, 2024. [Google Scholar]
- Fusco, G.; Chen, S.W.; Williamson, P.T.F.; Cascella, R.; Perni, M.; Jarvis, J.A.; Cecchi, C.; Vendruscolo, M.; Chiti, F.; Cremades, N.; et al. Structural basis of membrane disruption and cellular toxicity by α-synuclein oligomers. Science 2017, 358, 1440–1443. [Google Scholar] [CrossRef] [PubMed]
- Chikly, B.J. Manual techniques addressing the lymphatic system: Origins and development. J Am Osteopath Assoc. 2005, 105, 457–464. [Google Scholar] [PubMed]
- Kuchera, M.L.; Kuchera, W.A. Osteopathic Consideration in Systemic Dysfunction, 2nd ed.; Greyden Press: Columbus, OH, USA, 1994. [Google Scholar]
- Bath, M.; Nguyen, A.; Bordoni, B. Physiology, Chapman’s Points. In StatPearls [Internet]; StatPearls Publishing: Treasure Island, FL, USA, 2024. Available online: https://www.ncbi.nlm.nih.gov/books/NBK558953/ (accessed on 16 July 2024).
Foundational Knowledge in Immunology | ||
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Topics | Core Concepts | Clinical Correlations |
Cells and organs of the immune system | Development and maturation of white blood cells. Bone marrow, thymus, spleen, lymph nodes, MALTs. Development of T and B cells. | Leukocytosis, leukopenia, hepatosplenomegaly, aplastic anemia, developmental stasis in hematological malignancy, genetic immune deficiency. |
Innate immune system | Physical barriers to infection. Physiological barriers to infection. Cells of the innate immune response (neutrophils, macrophages, dendritic cells, NK cells) and their functions in recognition of microbes, cytokine production, and destruction of microbes. The phagocytic barrier to infection. Recognition of microbes by phagocytic cells. Major components of the inflammatory response. Local and systemic effects of the inflammatory response. Key inflammatory cytokines and their roles. Functional role of cell adhesion molecules (selectins, integrins). Chemotactic factors involved in inflammatory cell recruitment. The complement system: pathways, components, and their functions. | Inflammation, neutrophilia, septic shock, disseminated intravascular coagulation (DIC), deep vein thrombosis (DVT), anaphylaxis, myeloperoxidase deficiency, chronic granulomatous disease (CGD), Chediak-Higashi syndrome, severe congenital neutropenia, complement deficiencies, leukocyte adhesion deficiency types I and II, paroxysmal nocturnal hemoglobinuria (PNH), atypical hemolytic uremic syndrome, hereditary angioedema without urticaria. |
Adaptive immune system | Specificity, diversity, specialization, self-activation, memory. Cells involved in the adaptive immune response (T cells, B cells, antigen-presenting cells). Clonal selection of T and B cells. Phases of adaptive immune response –recognition, activation, effector, contraction, and memory. Basic effector functions of T and B cells in an immune response. | Central and peripheral tolerance, naturally and artificially acquired active and passive immunity, autoimmune polyendocrinopathy-candidiasis-ectodermal dystrophy (APECED), severe combined immunodeficiency (SCID). |
Antigens and Antibodies | Antigen, antigenic determinant, epitope, and hapten. Fundamental difference between B cell and T cell epitopes. Basic structure of the immunoglobulin molecule, including the major Ig fragments (Fab, Fc) and regions (hinge, variable, hypervariable). Structures and functions of the major classes and subclasses of immunoglobulins. | Vasculitis, arthritis, hemolytic disease of the newborn (erythroblastosis fetalis), hyper IgM syndrome, hyper IgE syndrome, selective IgA deficiency, common variable immunodeficiency (CVID). |
Antigen Receptor Diversity MHC, Antigen Processing and Presentation | Molecular genetic mechanisms of generation of antibody diversity. Isotype switching and its functional significance. Somatic hypermutation and its functional significance. Crosstalk between innate and adaptive immunity. Essential characteristics of humoral and cellular immunity. T and B cell activation and the role of antigen-presenting cells. Functions of MHC molecules in antigen presentation and cell-cell interactions in the immune system. Major structural features of the MHC gene products. Tissue distribution of class I and class II MHC. | Multiple myeloma, chronic lymphocytic leukemia (CLL), hemochromatosis, ankylosing spondylitis, reactive arthritis, IBD, acute anterior uveitis, Addison disease, myasthenia gravis, Grave disease, psoriasis, severe allopurinol (gout treatment) hypersensitivity, hypersensitivity to abacavir (HIV antiviral agent), severe hypersensitivity to carbamazepine, celiac disease, hay fever, Goodpasture syndrome, lupus, Type 1 diabetes. |
B and T lymphocyte activation Regulation of Immune Response Cellular Immunity Immunity to Microbe and Vaccines | Activation of T cells (e.g., the interactions between APCs and T cells leading to T cell activation). Functional role of the T cell accessory protein CD4 and CD8 in recognition of antigen and T cell activation. Mechanism of superantigen activation of T cells. Mechanism of antigen-induced B lymphocyte activation. Compare and contrast the effects of T-independent and T- dependent antigens on B cell activation. Lymphocyte Tolerance and Selection. Regulation of Lymphocyte Activation Response Cytokines. Effector T cell populations and their activation requirements. The process by which effector CTLs recognize target cells. Role of Fas and Fas ligand in CTL-mediated lysis of target cells. CTL-mediated cell lysis, the role of perforin. Role of NK cells in mediating lysis of virally infected target cells. Functional differences between innate and adaptive immune responses. Roles of CD4+ and CD8+ T cells in the adaptive immune response to viral infection. Role of CD4+ T cells in activation of macrophages. CTL-mediated cell lysis, the role of perforin. Immune response to extracellular bacterial infections. Immune response to intracellular bacterial infections. Delayed type hypersensitivity as it relates to host responses against intracellular bacteria. Mechanisms of immune evasion by pathogens. Types of vaccines (inactivated, attenuated, recombinant vaccines, DNA vaccines). Primary versus secondary immune responses to vaccines and microbes. Mode of action of adjuvants and examples of adjuvant materials. | Bare lymphocyte syndrome-I, bare lymphocyte syndrome-II, HSV-I recurrence, necrotizing fasciitis, toxic shock syndrome, T-B+NK+ SCID, T cell signaling defects, DiGeorge syndrome (q22 deletion syndrome), acquired immune deficiency syndrome (AIDS), Chai and Lataie disease, Bruton’s tyrosine kinase (BTK) deficiency or X-linked agammaglobulinemia (XLA), Wiskott–Aldrich syndrome (WAS), immune dysregulation, polyendocrinopathy, enteropathy, X-linked (IPEX) syndrome Fas or FasL deficiency aka autoimmune lymphoproliferative syndrome (ALPS), Perforin deficiency aka familial hemophagocytic lymphohistiocytosis, Arthus reaction. |
Diseases of the immune system | Immunopathologic mechanisms of hypersensitivity, allergies, and asthma: Gell and Coomb’s classification of hypersensitivity. Pathophysiologic mechanisms associated with Type I (IgE)-mediated injury. Primary effector mediators released by mast cells. Pathologic changes in tissues during anaphylactic reactions –acute phase reaction and late phase reaction. Effect of mediators on target organs with clinical expression of allergic reactions. Therapeutic modulation of type I hypersensitivity. Clinical expression of anaphylactic reactions and diagnosis via skin tests, RAST, immunoassays, etc. Allergic asthma Bronchial wall changes that occur in asthma Treatment considerations of various forms of asthma Type II and type III hypersensitivity reactions Compare immunopathology of Goodpasture’s syndrome and Lupus Drug-induced type I and II hypersensitivity Erythroblastosis fetalis Mechanism and histopathology of Arthus reaction Type IV cell-mediated hypersensitivities Basis for and examples of contact hypersensitivity Tuberculin reaction Autoimmunity: Organ-specific autoimmune diseases Systemic autoimmune diseases Autoimmune diseases mediated by autoantibodies Autoimmune diseases mediated by T cells Basic therapeutic intervention used to treat autoimmune diseases | Hypersensitivities, allergies and asthma, hay fever, autoimmune hemolytic anemia, systemic anaphylaxis, Goodpasture syndrome, lupus, drug-induced type I and II hypersensitivity, erythroblastosis fetalis, serum sickness, Arthus reaction, contact dermatitis, multiple sclerosis, type-I diabetes, transplant rejection, tuberculin reaction, myasthenia gravis, thrombocytopenic purpura, pemphigus vulgaris, pernicious anemia, rheumatic fever, post-streptococcal glomerulonephritis, hypersensitivity pneumonitis. |
Transplantation Immunology | Immunologic basis of graft rejection Principle of first set and second set rejection Autograft, isograft, allograft and xenograft Role of CD4 and CD8 T cells in graft rejection Non-self MHC molecules as the major molecular targets in graft rejection Hyperacute, acute, and chronic rejection and the immunological reactions involved Tests used to measure tissue histocompatibility Areas of clinical organ transplantation Approaches to prolonging graft survival (immunosuppressive drugs, mAbs, immune modulators) Mechanism of inhibition of T cell activation used by several drugs The special immunological complexities that can be associated with bone marrow transplantation | Transplant rejection reactions (hyperacute rejection, acute cellular rejection, acute humoral rejection, chronic rejection), Graft-Versus-Host Reaction (GVHR), GVHD. |
Immunodeficiencies | Congenital versus acquired immunodeficiency Presentation and pathophysiology associated with severe combined immunodeficiencies A condition associated with DiGeorge Syndrome B cell defects, including X-linked agammaglobulinemia, Hyper-IgM Syndrome, Common variable immunodeficiency, and selective IgA deficiency Phagocytic defects, including chronic granulomatous disease, leukocyte adhesion deficiencies, and Chediak-Higashi syndrome Acquired immunodeficiencies and their causes (AIDS, drug-induced, radiation-induced) Immunological abnormalities associated with HIV infection | Bruton’s tyrosine kinase (BTK) deficiency or X-linked agammaglobulinemia (XLA), Wiskott–Aldrich syndrome (WAS), immune dysregulation, polyendocrinopathy, enteropathy, X-linked (IPEX) syndrome, SCID, DiGeorge syndrome. |
Applied Immunology: Immunotherapeutics | Antibody therapy Use of immunosuppressive drugs Use of bone marrow transplantation Use of IVIG Potential therapeutic roles of cytokines or antibodies specific for cytokines and/or their receptors | Immunosuppression treatments in tissue transplants, inflammatory conditions, autoimmune diseases. |
Immunodiagnostics | ELISA, Western blotting, flow cytometry, immunofluorescence staining, RIA, etc. | General principles and applications of each test in clinical diagnosis and management, point-of-care testing (POCT). |
Community Health, Patient Presentations Related to Wellness and Genetics | |
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Topics/Core Concepts | Clinical Correlations |
Epidemiology | Public health risks: Infection outbreaks, epidemics, endemics, pandemics, bioterrorism. |
Vaccination and immunization programs | Inactivated vaccines: Live-attenuated vaccines, mRNA vaccines, Subunit, recombinant, polysaccharide, and conjugate vaccines, toxoid vaccines, viral vector vaccines, CDC vaccine schedules, antitoxins, antigen-allergy desensitization, immunosuppressive therapy in managing autoimmune disorders and cancer, the influence of immunology knowledge on healthcare, the impact of vaccines on health, economics, and social perspectives. |
Herd immunity | Protection of infants, immunocompromised, and elderly patients, transmission rate, and outbreak control |
Immunogenetics | HLA-typing, hereditary immunodeficiencies, diagnostics, blood transfusion reactions, genetic predisposition, resistance to infections, prospects of immunological education and research in developing countries. |
Personalized medicine and precision health | Combination therapy in cancer based on immunological profiles reduced healthcare-associated pathogen resistance, reduced polypharmacy, and adverse drug reactions. |
Immunological responses to occupational/ environmental factors | Smoking, pollution, radiation, and sunscreen, contaminations, industrial chemicals/irritants on chronic pulmonary, integument, organ diseases, foreign body reactions, pet/animal-related reactions, and other environmental allergic reactions. |
Community-based interventions for promoting immunological health and wellness | Social determinants of health: Education level, nutrition, exercise, etc. Education: Sanitation efforts, chronic disease outcomes, cancer outcomes, genetic testing and counseling, STD testing and counseling. Nutrition: Impact of food quality on metabolic diseases, diabetes, and cardiovascular diseases, inflammation related to cultural/ethnic food preferences. |
Musculoskeletal and Integumentary System | |
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Topics/Core Concepts | Clinical Correlations |
Autoimmunity and immunopathology of the musculoskeletal and integumentary system | Rheumatoid arthritis, juvenile rheumatoid arthritis, reactive arthritis, scleroderma, systemic lupus erythematosus, Sjogren syndrome, ankylosing spondylitis, acute and chronic inflammatory dermatoses (dermatomyositis, myositis, etc.), blistering diseases (dermatitis herpetiformis), bullous diseases (pemphigus, bullous pemphigoid), panniculitis, vitiligo, hidradenitis suppurativa. |
Inflammatory and non-inflammatory diseases | Inflammatory diseases of joints, adhesive capsulitis, bursitis, tendonitis, osteosis, polymyalgia rheumatica, JIA, osteoarthritis, fibromyalgia, vasculitis, gout, CPPD, FMF. |
Skin allergies | Food medication-related, aeroallergens, autoimmune disease, immunodeficiency, infection, IgE-driven mast cell degranulation and histamine release, use of antihistamines in allergy control, angioedema. |
Immunologic skin lesions | Psoriasis, lichen planus disease, scleroderma, tick bites, lice infestation (pediculosis), urticaria, dermatitis (allergic, contact, atopic), eczema, fungal infections, candidiasis, tinea capitis, tinea corporis, viral infections (varicella, herpes, enteroviruses, pityriasis rosea, bacterial and other opportunists, acne and related conditions (rosacea, acne vulgaris, acneiform skin lesions), systemic diseases, disseminated gonorrhea, secondary syphilis, lupus, Kawasaki disease, hair and nail related conditions, folliculitis. |
Laboratory test findings | Allergen sensitivity test with wheal formation, fungal and bacterial cultures, skin and muscle biopsy, eosinophilia, serological markers (rheumatoid factor, anti-cyclic citrullinated peptide antibodies), inflammatory markers (C-reactive protein, erythrocyte sedimentation rate), incorporation of immunological assays (immunofluorescence, enzyme-linked immunosorbent assay) for the detection of specific autoantibodies and immune complexes. |
Pharmacology of immunomodulators | DMARDs, corticosteroids, TNF-alpha and other interleukin inhibitors, biologics, antihistamines. |
Circulatory and Hematologic System | |
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Topics/Core Concepts | Clinical Correlations |
Autoimmune diseases and red blood cell disorders | Immune-complex deposition, rheumatic valvular heart disease, autoimmune hemolytic anemia, autoimmune platelet disorders (idiopathic immune thrombocytopenia (ITP) and thrombotic thrombocytopenic purpura (TTP), autoimmune clotting factor disorders (acquired hemophilias), antiphospholipid syndrome, autoimmune cytopenia, warm and cold agglutinations. |
Transfusion medicine and hematopoietic stem cell transplantation | Blood type reactions, ABO and Rh groups, graft-versus-host disease (GVHD), immune reconstitution syndrome, acute and chronic rejections. |
Immune deficiencies and infectious origins | Agammaglobulinemia, autoimmune cytopenia, myocarditis, pericarditis, infective endocarditis, peripheral arterial disease (PAD), infection-related diseases, circulatory inflammation and diseases, atherosclerosis, arteriosclerosis (foam cells, macrophages), peripheral vascular disease/blood vessel disorders, shock (septic, anaphylactic), human immunodeficiency virus infection and AIDS. |
Neoplastic disorders and other hematological malignancies | Leukemias, lymphomas, lymphatic system disorders, lymphadenopathy, lymphedema, plasma cell dyscrasias, amyloidosis, multiple myeloma. |
Laboratory test findings | Peripheral blood smears, human immunodeficiency virus testing (antibody, antigen, viral load), clinical HIV viral load test, CD4 count, interpretation of complete blood count, neutropenia, neutrophilia, serology. |
Respiratory System | |
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Topics/Core Concepts | Clinical Correlations |
Pulmonary defenses | Nasopharynx: Nasal hairs, turbinates, mucociliary apparatus. Oropharynx: Saliva, cough, bacteria interference, complement production. Trachea/Bronchi: Cough/epiglottic reflexes, mucociliary apparatus, dendritic cells, bronchus-associated lymphoid tissues (BALT), IgG/IgM/IgA, airway surface liquid (lysozyme, lactoferrin, secretory leukocyte proteinase inhibitor, antimicrobial peptides). Terminal airways/alveoli: Lining fluid (surfactant, fibronectin, immunoglobin, complement, free fatty acid, iron-binding proteins), alveolar macrophages, interstitial macrophages, neutrophils, dendritic cells, BALT. |
Autoimmune diseases | Sarcoidosis, small cell lung cancer, bronchial asthma, allergic rhinitis, hay fever, pulmonary fibrosis, granulomatosis with polyangiitis, eosinophilic granulomatosis with polyangiitis, microscopic polyangiitis, Goodpasture syndrome. |
Paraneoplastic syndromes | Lambert-Eaton myasthenic disease, paraneoplastic cerebellar degeneration, paraneoplastic encephalomyelitis, paraneoplastic sensory neuropathy, paraneoplastic dermatomyositis. |
Infection-related diseases | Tuberculous granuloma, aspergillosis, pneumonia (viral, bacterial, fungal). |
Hypersensitivity reactions | Extrinsic allergic alveolitis, chronic hypersensitivity pneumonitis, pulmonary Langerhans cell histiocytosis, berylliosis, pneumococcosis. |
Endocrine System and Metabolism | |
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Topics/Core Concepts | Clinical Correlations |
Autoimmune diseases | Hashimoto thyroiditis, Grave disease, Addison disease, type 1 diabetes, Cushing disease, euthyroid sick syndrome, autoimmune adrenalitis, primary adrenal insufficiency, autoimmune hypothyroidism, silent lymphocytic thyroiditis, Riedel thyroiditis, postpartum thyroiditis, atrophic thyroiditis, De Quervain thyroiditis, hypoparathyroidism. |
Immunological regulations | Role of pro-inflammatory cytokines- IL-1, IL-6, TNF-alpha, etc. Promotion of hypothalamic-pituitary-adrenal (HPA) axis, fever, secretion of catecholamines. Inhibition of hypothalamic-pituitary-thyroid (HPT) axis, hypothalamic-pituitary-gonadal (HPG) axis. |
Autoimmune flare-ups due to heat/UV exposure | Systemic lupus erythematosus (SLE) or Lupus, psoriasis, arthritis. |
Heat-sensitive conditions | Multiple sclerosis, thyroid disorders. |
Human Development, Reproduction, and Sexuality | |
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Topics/Core Concepts | Clinical Correlations |
Innate immune disorders | Intrauterine infections. |
Cellular and antibody deficiencies | Post-exposure antigen testing. |
Rh isoimmunization/incompatibility | Clinical Rh screening, hemolytic disease of the neonate (HDN), maternal IgA against necrotizing enterocolitis in preterm infants. |
Immunity development | Development of child immunity during the COVID-19 pandemic, early exposure to germs, and lasting benefits. |
Non-neoplastic disorders | Lichen sclerosis. |
Autoimmune conditions | Antiphospholipid syndrome (APS), autoimmune oophoritis, SLE. |
Nervous System and Mental Health | |
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Topics/Core Concepts | Clinical Correlations |
Autoimmune diseases: Antibody-mediated attack on central and peripheral nervous structures Paraneoplastic antibody production | Guillain-Barre syndrome, multiple sclerosis, optic neuritis, transverse myelitis, neuromyelitis optica, spasticity, paraneoplastic encephalitis, acute disseminated encephalomyelitis, Bell’s palsy, myasthenia gravis, Lambert-Eaton myasthenic syndrome. |
Infectious Diseases: Opportunistic CNS infection and malignancy CSF fluid analysis Molecular mimicry | HEENT infections (viral, bacterial, fungal, systemic, central nervous system), sinusitis, encephalitis, meningitis, toxoplasmosis, cryptococcal meningitis, and progressive multifocal leukoencephalopathy, Campylobacter jejuni infection. |
Renal System | |
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Topics/Core Concepts | Clinical Correlations |
Autoimmune diseases | Sjogren disease, Goodpasture syndrome, Alport syndrome, IgA nephropathy, idiopathic nephrotic syndrome, post-streptococcal glomerulonephritis, pelvic inflammatory disease, renal vasculitis (ANCA-associated), renal ischemia. |
Infection-related diseases | Post-streptococcal glomerulonephritis, pelvic inflammatory disease (PID). |
Genital lesions | Inflammatory and neoplastic causes, local or systemic, male or female excoriations and infestations. |
Bacterial toxin-related diseases | Hemolytic uremic syndrome, toxic shock syndrome. |
Gastrointestinal System and Nutritional Health | |
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Topics/Core Concepts | Clinical Correlations |
Autoimmune diseases | Pernicious anemia, intrinsic factor, celiac disease, ulcerative colitis, Crohn’s disease, MALT lymphoma. |
Infection-related diseases | Secretory diarrhea, viral hepatitis, MALT lymphoma due to Helicobacter pylori. |
Food allergies | Allergic eosinophilic esophagitis, food protein-induced proctocolitis, food protein-induced enteropathy, food protein-induced enterocolitis. |
Malabsorption conditions | Acute and chronic diarrhea, celiac disease, Crohn’s disease, Whipple disease, tropical sprue. |
Immune or enzyme deficiency | Lactase, disaccharidase, steatorrhea, irritable bowel syndrome (IBS), short-bowel syndrome, Crohn’s disease |
Integration of Immunology in Osteopathic Medicine | |
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Topics/Core Concepts | Correlation with Osteopathic Principles and Practices |
Five osteopathic models of treatment | Metabolic Energy Respiratory-Circulatory Model. |
Lymphatics drainage techniques | Myofascial release (MFR), suboccipital release, Miller thoracic Pump, pedal pump (Dalrymple technique), thoracic inlet release, doming of the diaphragm, thoracoabdominal MFR, pectoral traction, rib raising, cervical chain drainage, hepatic pump, spleen pump, ischiorectal fossa release, pelvic diaphragm MFR, bladder MFR, sternal/pericardial ligaments MFR, jugular vein drainage, MOPSE protocol. |
Soft tissue techniques | Lateral stretching, contralateral kneading, longitudinal kneading, cervical longitudinal traction, contralateral traction, condylar decompression, rolling, tapotement, effleurage, suboccipital inhibition, cervical paraspinal soft tissue technique, frontal sinus effleurage, maxillary sinus effleurage, trigeminal nerve decompression, auricular drainage, Galbreath technique. |
Four junctions | Occipitoatlantal Junction, cervicothoracic junction, thoracolumbar junction (respiratory diaphragm), lumbosacral junction (pelvic diaphragm). |
Chapman’s reflex points | Neurolymphatic, gangliform, contracted, edematous, ridge-like, ropy, shotty, fibro spongy, pinhead to almond-sized palpatory viscerosomatic tissue reflex points. |
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© 2024 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).
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Shabbir, Z.; Mazdeyasnan, L.; Iqbal, N.; Kadavakollu, S.; Qureshi, M.; Lamichhane-Khadka, R. Integration of Immunology in a Systems-Based Osteopathic Medical Curriculum. Int. Med. Educ. 2024, 3, 257-283. https://doi.org/10.3390/ime3030021
Shabbir Z, Mazdeyasnan L, Iqbal N, Kadavakollu S, Qureshi M, Lamichhane-Khadka R. Integration of Immunology in a Systems-Based Osteopathic Medical Curriculum. International Medical Education. 2024; 3(3):257-283. https://doi.org/10.3390/ime3030021
Chicago/Turabian StyleShabbir, Zian, Layla Mazdeyasnan, Naila Iqbal, Samuel Kadavakollu, Mahboob Qureshi, and Reena Lamichhane-Khadka. 2024. "Integration of Immunology in a Systems-Based Osteopathic Medical Curriculum" International Medical Education 3, no. 3: 257-283. https://doi.org/10.3390/ime3030021
APA StyleShabbir, Z., Mazdeyasnan, L., Iqbal, N., Kadavakollu, S., Qureshi, M., & Lamichhane-Khadka, R. (2024). Integration of Immunology in a Systems-Based Osteopathic Medical Curriculum. International Medical Education, 3(3), 257-283. https://doi.org/10.3390/ime3030021