|Year : 2018 | Volume
| Issue : 3 | Page : 178-181
Enhancement of knowledge and skills in laboratory techniques for autoantibody evaluation: Utility of a single-day hands-on workshop
Durga Prasanna Misra1, Krushna Chandra Pani1, Sajjan N Shenoy2, Anupam Wakhlu3, Parasar Ghosh4, Pravin Hissaria5, Vikas Agarwal1
1 Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
2 Department of Clinical Immunology and Rheumatology, Kasturba Medical College and Hospital, Mangalore, Karnataka, India
3 Department of Rheumatology, King George's Medical University, Lucknow, Uttar Pradesh, India
4 Department of Rheumatology, Institute of Post Graduate Medical Education and Research, Kolkata, West Bengal, India
5 Department of Clinical Immunology, Royal Adelaide Hospital, Adelaide, Australia
|Date of Web Publication||21-Aug-2018|
Dr. Vikas Agarwal
Department of Clinical Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow - 226 014, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Background: Laboratory tests evaluating autoantibodies form a key part of rheumatology practice, yet this remains the least emphasized part of rheumatology training.
Methods: We conducted a single-day autoantibody workshop to train young rheumatologists in the principles of autoantibody testing as well as provide hands-on exposure to conduct these tests. We assessed the efficacy of this workshop by pretest and posttest questionnaires evaluating three domains – Antigen–antibody interactions and laboratory techniques other than immunofluorescence (Domain 1); immunofluorescence (Domain 2); and clinical relevance of autoantibodies (Domain 3). In addition, we also sought unstructured feedback from participants.
Results: There was a baseline knowledge deficit regarding autoantibody estimation and evaluation among the participants. Comparison of pre- and posttest questionnaires revealed that the 1-day workshop was effective in improving overall knowledge about autoantibody testing as well as in Domain 1 and 2 but not Domain 3. Hands-on exposure and basic level discussion of laboratory techniques were appreciated by attendees.
Conclusion: A single-day workshop is effective in enhancing knowledge of attendees about autoantibody testing. In-depth discussions about these laboratory techniques in rheumatology, the immune mechanisms involved and association with clinical scenarios require workshops of longer duration.
Keywords: Antineutrophil cytoplasmic antibody, antinuclear antibody, Autoantibody, medical education, workshop
|How to cite this article:|
Misra DP, Pani KC, Shenoy SN, Wakhlu A, Ghosh P, Hissaria P, Agarwal V. Enhancement of knowledge and skills in laboratory techniques for autoantibody evaluation: Utility of a single-day hands-on workshop. Indian J Rheumatol 2018;13:178-81
|How to cite this URL:|
Misra DP, Pani KC, Shenoy SN, Wakhlu A, Ghosh P, Hissaria P, Agarwal V. Enhancement of knowledge and skills in laboratory techniques for autoantibody evaluation: Utility of a single-day hands-on workshop. Indian J Rheumatol [serial online] 2018 [cited 2020 Feb 23];13:178-81. Available from: http://www.indianjrheumatol.com/text.asp?2018/13/3/178/228383
| Introduction|| |
Laboratory tests form a key component of the armamentarium of a rheumatologist during patient evaluation. Interpretation of multiple autoantibody tests such as rheumatoid factor and antinuclear antibodies (ANAs) forms an integral part of day-to-day rheumatology practice.,,,, Techniques such as nephelometry, immunofluorescence, and line immunoassay are routinely used in rheumatology patient care, whereas enzyme-linked immunosorbent assay (ELISA) is used for both routine patient care and research. Training and curriculum in the subspecialty of Clinical Immunology and Rheumatology in India is an evolving area, with few facilities for formal training available within the country.,, In general, trainees also have to manage the clinical care of a large number of patients; hence, the aspect of laboratory training and interpretation of autoantibody techniques is often given the least priority.
In the above context, it is important to have adequate exposure to the principles and interpretation of autoantibody tests for rheumatologists during their formal training., Even if skills related to interpretation of autoantibody tests may have been gained through repeated patient exposure, the processes involved in generating these test results remain largely ignored. Residents/fellows-in-training are generally not exposed to the methodology of laboratory techniques, including testing of autoantibodies. A better understanding of laboratory immunology techniques will not only serve to demystify them for the clinician but also enable a better understanding of borderline positive or negative results, which may still be clinically relevant. With this background, we decided to conduct a 1-day autoantibody workshop equally emphasizing on the theoretical aspects of autoantibody evaluation as well as providing hands-on exposure enabling candidates to perform immunofluorescence and line immunoassay techniques themselves, as part of the preconference proceedings of the annual conference of the Indian Rheumatology Association held at Lucknow in November 2017.
| Methods|| |
We conducted a single-day workshop for registered trainee and established rheumatologists. Rheumatologists experienced in running diagnostic and research laboratories performing autoantibody techniques from the country and abroad served as resource persons. The objectives of the workshop were to impart understanding of the basic principles of laboratory techniques (agglutination, indirect immunofluorescence, ELISA, and line immunoassay) used in testing autoantibodies in clinical practice as well as the appropriate analysis and interpretation of such results. Didactic lectures on antigen–antibody interactions, principles of various laboratory assays and clinical relevance of autoantibodies, and laboratory techniques (30% of total time) were supplemented by hands-on demonstration, performance, and interpretation of immunofluorescence (ANA and anti-neutrophil cytoplasmic antibodies [ANCAs]) and line immunoassay (antibodies to extractable nuclear antigens) techniques (70% of total time). A 5-min video demonstrating the procedure of immunofluorescence was shown to the participants, and they were provided a manual on autoantibody techniques.
Before the lectures, attendees were asked to fill a pretest questionnaire to assess their baseline knowledge regarding autoantibody estimation [Supplementary File 1][Additional file 1] . The same questionnaire was repeated at the end of the workshop to evaluate for any changes in scores, reflecting knowledge, or skills gained. This questionnaire comprising 25 questions assessed three domains (8 questions on antigen–antibody interactions and laboratory techniques other than immunofluorescence [Domain 1], 8 on immunofluorescence [Domain 2] and 9 on the clinical relevance of autoantibodies [Domain 3]). Additional unstructured feedback was sought regarding the experience of the participants and suggestions for improvement in the future workshops. Nonparametric tests were used to present the scores (median with interquartile range) and the paired scores were compared using Wilcoxon matched pairs signed-rank test performed using GraphPad Prism (version 6.00 on Mac OSX, manufactured by GraphPad Software at La Jolla, California, USA).
| Results|| |
The workshop had 18 participants, majority of whom were trainee rheumatologists. Seventeen participants completed the questionnaire; however, we had to exclude two from analysis as they had not been filled both before and after. The remaining fifteen sets of scores were compared for total scores as well as for each of the three domains separately. The overall median baseline score was 13/25, suggesting a knowledge deficit in this area. When assessed for each domain separately, Domains 2 and 3 had median scores in excess of 50%, whereas Domain 1 had median score <50%. The posttest questionnaire revealed a significant increase in the total score as well as in Domains 1 and 2, but not Domain 3 [Table 1].
|Table 1: Comparison of scores of pre- and posttest questionnaire - total- and domain-wise scores|
Click here to view
The feedback received from the participants was uniformly positive. Particularly, some participants appreciated the hands-on nature of the workshop with interactive discussions with faculty and affirmed that they would be more confident in interpreting autoantibody reports henceforth. Suggestions for enhancement included greater discussion of clinical scenarios as well as inclusion of other laboratory techniques such as flow cytometry. However, some participants did appreciate the need to discuss basics alone and avoid more advanced discussions in a single-day workshop. The suggestions of the participants regarding enhancement of the content of the workshop are presented in [Table 2].
| Discussion|| |
Overall, we observed that the attendees had only an average baseline knowledge of subjects discussed in the workshop. The design of the workshop possibly attracted more trainees as compared to trained rheumatologists, who may have a more in-depth knowledge for these tests. The relative lack of knowledge could be reflective of lack of training in curriculum, lack of time or initiative, or the lack of a dedicated laboratory in their training facilities. However, the intervention of conducting a single-day autoantibody workshop with emphasis on hands-on laboratory work was useful in enhancing the knowledge of participants about laboratory techniques commonly used in autoantibody estimation. Significant improvement was not observed in the knowledge domain regarding diseases, associations, and understanding of the clinical relevance of autoantibodies, as it was not the major objective of this time-constrained 1-day autoantibody workshop. The main emphasis of this autoantibody workshop was on understanding basic principles of antigen–antibody interaction and laboratory techniques.
The results of the pretest questionnaire reflect a need to conduct more such workshops and training courses on techniques of autoantibody estimation. Such skills are not routinely imparted during fellowship training in Clinical Immunology and Rheumatology, wherein much of the trainees' attention is occupied with burgeoning patient care and challenging clinical rheumatology cases. Furthermore, designing curriculum for this subspecialty is a work under evolution. Fellows attending such autoantibody workshops during or soon after completing their training will be able to acquire basic laboratory skills which shall help them interpret rheumatology laboratory reports in a more scientific manner, especially those in the borderline positive or negative category. Furthermore, they would be better placed should they desire to set up their own laboratories to perform common tests such as nephelometry, ELISA, and immunofluorescence. Rheumatologists can add value to the subjective reporting, as is required in immunofluorescence if they are appropriately skilled in the techniques.
The one domain that was not influenced by the workshop was that of the clinical relevance of autoantibodies. Rheumatologists are exposed to reports of autoantibody tests in their routine clinical practice on a daily basis. Hence, it is not surprising that there was a higher prevalence of knowledge at baseline in this aspect. Therefore, the scope to improve was lesser than in other domains, which could partially explain the results of our survey. Regarding inclusion of other rheumatology laboratory techniques such as flow cytometry in a workshop, this must be tempered with the feedback received that the discussion should remain at a certain basic level. We are of the opinion that advanced level discussions may be out of the scope of a single-day workshop intended for fellows-in-training and may better form part of a more extended workshop on autoantibody techniques. Indeed, these may put off certain participants and deter us from the objective of demystifying the laboratory to clinicians practicing rheumatology. Nevertheless, the feedback received regarding the need to discuss more clinical scenarios calls for an extended workshop (maybe a few rather than a single day) or multi-tiered workshop, starting from basic laboratory techniques, and finally culminating in advanced laboratory techniques and discussions regarding associations and interpretation of autoantibodies, in particular clinical scenarios.
The hands-on nature of the workshop was a key success, enabling clinicians to conduct and later interpret the reports of their own tests. We hope this encourages participants to venture and set up rheumatology laboratory services in different parts of the country at a more accessible cost to the public that are currently available.
Our analysis had certain limitations. It would have been better had the number of participants been greater in number; however, it was necessary to limit the number of participants due to the hands-on nature of the workshop, necessitating arrangement of requisite numbers of reagents, and slides to run the tests as well as the number of fluorescent microscopes available, as well as the time constraints of a single-day workshop. Furthermore, a follow-up questionnaire to be filled by the participants at 3 months and returned back to us shall more accurately assess the impact of such a workshop in real life. We plan to include such a follow-up questionnaire at the time we conduct our next workshop.
The autoantibody workshop reaffirmed a need to train young rheumatologists in India in laboratory techniques applicable to the specialty. A single-day workshop is effective in enhancing knowledge about autoantibody techniques (including immunofluorescence) but needs further work to enhance knowledge on the clinical relevance of autoantibodies. Participants in the future workshops could be better benefited by incorporating more clinical scenarios which exemplify challenges in autoantibody interpretation in routine rheumatology practice. Initiatives in this direction by the training institutes and by the regional and national rheumatology associations would be a welcome step, which may further improve autoantibody test ordering and interpretation by the clinicians and hence result in cost-effective and improved patient care.
We would like to acknowledge Mr. Rajeshwar Dayal, Mr. Sanjay Dwivedi, Mr. Mohammad Rizwan, and Mr. Abhishek Pandey, technical officers, Department of Clinical Immunology, SGPGIMS, Lucknow, for their help in demonstrating laboratory techniques to participants. We would like to thank Euroimmun for providing slides, reagents, and fluorescence microscopes for the workshop.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Tebo AE, Detrick B, Hamilton RG, Khanolkar A, O'Gorman MR, Schmitz JL, et al.
Clinical laboratory immunology: An indispensable player in laboratory medicine. Am J Clin Pathol 2014;142:437-44.
Saikia B, Rawat A, Vignesh P. Autoantibodies and their judicious use in pediatric rheumatology practice. Indian J Pediatr 2016;83:53-62.
Pisetsky DS. Antinuclear antibody testing-misunderstood or misbegotten? Nat Rev Rheumatol 2017;13:495-502.
Stoll DA. Special requirements for residency training in diagnostic laboratory immunology. J Allergy Clin Immunol 1991;87:117-9.
Correll CK, Spector LG, Zhang L, Binstadt BA, Vehe RK. Use of rheumatology laboratory studies among primary pediatricians. Clin Pediatr (Phila) 2016;55:1279-88.
Rosa Neto NS, Carvalho JF. The use of inflammatory laboratory tests in rheumatology. Rev Bras Reumatol 2009;49:413-30.
Gupta ED. Common laboratory tests for rheumatological disorders: How do they help the diagnosis? Malays Fam Physician Official J Acad Fam Physicians Malays 2009;4:48-50.
Misra DP, Agarwal V, Negi VS. Rheumatology in India: A Bird's eye view on organization, epidemiology, training programs and publications. J Korean Med Sci 2016;31:1013-9.
Handa R. Rheumatology in india – Quo vadis? Nat Rev Rheumatol 2015;11:183-8.
Ravindran V. Shortage of teaching faculty in rheumatology-Pragmatism necessary. Indian J Rheumatol 2014;9:159-60. [Full text]
Misra R. Rheumatology training in India: Problems and solutions. Indian J Rheumatol 2014;9:192-5. [Full text]
[Table 1], [Table 2]