Is FA enough fo Immunology

[the god]

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Hey guys, is FA + UW enough for Immunology ?

 

[Chaoticsheath]

FA + notes from UW is more than enough. My score report said I didnt exceedingly well on questions pertaining to the immune system. just memorize whats in first aid. that Tbonesteak mnemonic is CLUTCH, but also def learn the immuno suppressive ILs, the maturation processes, and the immuno deficiencies

 

[Phloston]

FA + notes from UW is more than enough. My score report said I didnt exceedingly well on questions pertaining to the immune system. just memorize whats in first aid. that Tbonesteak mnemonic is CLUTCH, but also def learn the immuno suppressive ILs, the maturation processes, and the immuno deficiencies

What is the tbonesteak mnemonic?

 

[lstone13]

What is the tbonesteak mnemonic?

From what I can remember, without having it in front of me...

Hot T-Bone StEAk

Hot --> IL-1 - fever
T --> IL-2 - T-cell stimulation
B --> IL-3 - bone marrow stimulation
E --> IL-4 - IgE (and IgG) class switching
A --> IL-5 - IgA class switching

 

[Phloston]

From what I can remember, without having it in front of me...

Hot T-Bone StEAk

Hot --> IL-1 - fever
T --> IL-2 - T-cell stimulation
B --> IL-3 - bone marrow stimulation
E --> IL-4 - IgE (and IgG) class switching
A --> IL-5 - IgA class switching

Oh okay. Also:

IL-4 hyperactivation is seen in asthma due to increased Th2 cell activity --> increased IgE.

IL-5 also activates eosinophils.

Be able to differentiate those when it comes to asthma and type-I hypersensitivities.

In other words, when you're rushing, it's easy to just think IgE for type-I hypersensitivity and then select IL-4 for eosinophils; eosinophils are IL-5-induced, not IL-4, but IgE is IL-4, as you've said.

 

[Dallas]

If you have time I would definitely flip through a Immuno book, like levinsons or HY or something to understand concepts. If you understand concepts you can later memorize the details in FA.

Some stuff has been on NBME etc that is not in FA.

IL-2 for example activates NK cells and is actually used as a therapy for tumorlysis.

 

[Phloston]

If you have time I would definitely flip through a Immuno book, like levinsons or HY or something to understand concepts. If you understand concepts you can later memorize the details in FA.

Some stuff has been on NBME etc that is not in FA.

IL-2 for example activates NK cells and is actually used as a therapy for tumorlysis.

With respect to your last sentence, I believe that's actually in FA. Aldesleukin (IL-2) is known to treat metastatic melanoma.

To that effect, using IFN-alpha for metastatic melanoma is just a different approach to the same idea, because, with respect to treating tumors, it increases MHC-I/II expression.

 

[Dallas]

With respect to your last sentence, I believe that's actually in FA. Aldesleukin (IL-2) is known to treat metastatic melanoma.

To that effect, using IFN-alpha for metastatic melanoma is just a different approach to the same idea, because, with respect to treating tumors, it increases MHC-I/II expression.

Right but the question if I remember correctly was to the effect of a patient with renal CA comes in and is put on IL-2 therapy, 2 months later on follow up CA has regressed, what is the mechanism of IL-2 ?

A) cytotoxic effect of IL-2 on tumor
B) Activation of NK cells
C) whatevs
D) whatevs

See what I mean? Do they want you to answer A because of the cascade effect IL-2 has on activating and recruiting NK cells and T cells who exert cytotoxic effect on the tumor or do they want you to do a one step thinking and think activates NK cells which kill tumor.

FA says NK cells are activated by IL-2 and have antiapoptotic and tumor lytic characteristics. Plus UpToDate mentions IL-2 activating NK cells in tumor regression alot.
But at the same time the hot t bone steak mnemonic makes me think cytotoxic T cell activation, which has a cytotoxic effect on tumor cells.

Mucho confuso.

 

[Phloston]

Right but the question if I remember correctly was to the effect of a patient with renal CA comes in and is put on IL-2 therapy, 2 months later on follow up CA has regressed, what is the mechanism of IL-2 ?

A) cytotoxic effect of IL-2 on tumor
B) Activation of NK cells
C) whatevs
D) whatevs

See what I mean? Do they want you to answer A because of the cascade effect IL-2 has on activating and recruiting NK cells and T cells who exert cytotoxic effect on the tumor or do they want you to do a one step thinking and think activates NK cells which kill tumor.

FA says NK cells are activated by IL-2 and have antiapoptotic and tumor lytic characteristics. Plus UpToDate mentions IL-2 activating NK cells in tumor regression alot.
But at the same time the hot t bone steak mnemonic makes me think cytotoxic T cell activation, which has a cytotoxic effect on tumor cells.

Mucho confuso.

I would definitely go with the IL-2 function (choice A) because IL-2 is a notable Tx for metastatic melanoma and RCC. Although, yes, IL-2 probably helps facilitate NK-cell activity, the medications that are specifically known for working based on upregulating that latter mechanism are the interferons.

 

[Dallas]

http://forums.studentdoctor.net/showthread.php?t=936601

The supposed answer was Activation of NK cells, the discussion is at the bottom of that page.

 

[Belleza156]

Similar question was in uworld. Answer is activation of nk cells. I also saw it written verbatim in my micro/immuno rapid review book also. Do a search in the keyword search on uworld and ull find the explanation.

Sent from my PC36100 using SDN Mobile

 

[Dallas]

Similar question was in uworld. Answer is activation of nk cells. I also saw it written verbatim in my micro/immuno rapid review book also. Do a search in the keyword search on uworld and ull find the explanation.

Sent from my PC36100 using SDN Mobile

tried both 'NK' and 'IL-2' cant find it, care to post q ID?

 

[Phloston]

http://forums.studentdoctor.net/showthread.php?t=936601

The supposed answer was Activation of NK cells, the discussion is at the bottom of that page.

Why would you lead me to an NBME2 spoiler thread? I had to X out of it before I started reading anything.

Either way, I'm a bit surprised that NK cell activation would be the answer. If so, maybe they're trying to illustrate that it's not the IL-2 itself that has the cytotoxic effect, which would make sense. I'd have to see the way the question/answer choices are written, but I appreciate the heads-up, so I'll be vigilant from here on out regarding that topic.

 

[Dallas]

Ah sorry about that, didnt realize you were going to do NBME 2. My sincerest apologies.
Yeah Im thinking along those lines as well, perhaps the real question on the NBME had the word 'direct' before cytotoxic.

Who knows, who knows.

 

[thinker]

when they say Cytotoxic effect of substance X I would understand that they mean the direct effect of substance X being cytotoxic.. not via a cascade. Thus i would pick B.

 

[Dallas]

when they say Cytotoxic effect of substance X I would understand that they mean the direct effect of substance X being cytotoxic.. not via a cascade. Thus i would pick B.

Thats a nice way of understanding, you are probably going to miss quite a few points on the exam with this line of thinking since its my experience that they like to ask questions that require you to think of a multistep cascade effect without being too obvious. They also typically reword or describe the keyword for you to make the association in the correct answer.

They may also from time to time include a simpler straightforward answer that is disguised as the correct one but is in detail incorrect.
Just a heads up.
Sneaky test makers.

 

[illegallysmooth]

Thats a nice way of understanding, you are probably going to miss quite a few points on the exam with this line of thinking since its my experience that they like to ask questions that require you to think of a multistep cascade effect without being too obvious.

I really don't agree. The word "cytotoxic" implies a direct toxicity to cells - not that it upregulates or downregulates mechanisms X, Y or Z to result in cell death. You're correct in that the test requires understanding of multiple steps and cascades, but in this question one needs to recognize that answer choice A is referring to direct cytotoxicity, and answer B is the one referring to a "cascade" that results in cell death. IL-2 is not cytotoxic. It is toxic to cancer cells only by acting as a cellular messenger that employs NK cells which are cytotoxic.

 

[Dallas]

I really don't agree. The word "cytotoxic" implies a direct toxicity to cells - not that it upregulates or downregulates mechanisms X, Y or Z to result in cell death. You're correct in that the test requires understanding of multiple steps and cascades, but in this question one needs to recognize that answer choice A is referring to direct cytotoxicity, and answer B is the one referring to a "cascade" that results in cell death. IL-2 is not cytotoxic. It is toxic to cancer cells only by acting as a cellular messenger that employs NK cells which are cytotoxic.

Implied and implied, how do you reckon? You cant imagine a difficult question where they have omitted the word 'direct' before cytotoxic to refer to the cascadal cytotoxic effect IL-2 has by activating both NK cell AND CD8+ T cells who in turn exert a cytotoxic effect on tumor cells?

I'd say it is pretty high yield to understand the mechanisms of IL-2 in regards to both NK and CD8+ T cells. Implied or not.

We can argue this until the sun goes down, I still think it is ****ty of the test makers not to put 'direct cytotoxic effect of il-2' in the answer choice instead of having us test takers be mind readers in addition to having reasoning skills and a medical knowledge base.

 

[illegallysmooth]

Implied and implied, how do you reckon? You cant imagine a difficult question where they have omitted the word 'direct' before cytotoxic to refer to the cascadal cytotoxic effect IL-2 has by activating both NK cell AND CD8+ T cells who in turn exert a cytotoxic effect on tumor cells?

I'd say it is pretty high yield to understand the mechanisms of IL-2 in regards to both NK and CD8+ T cells. Implied or not.

We can argue this until the sun goes down, I still think it is ****ty of the test makers not to put 'direct cytotoxic effect of il-2' in the answer choice instead of having us test takers be mind readers in addition to having reasoning skills and a medical knowledge base.

If you understand those mechanisms, why would you not pick answer choice B??

You don't have to be a mind reader. You just have to read all of the answer choices and understand the mechanism. If you have a culture of cancer cells and add IL-2, do the cells die? If not, then it's not cytotoxic. If you understand the mechanism by which IL-2 is helpful in chemotherapy, then answer B is obviously correct.

 

[Dallas]

If you understand those mechanisms, why would you not pick answer choice B??

You don't have to be a mind reader. You just have to read all of the answer choices and understand the mechanism. If you have a culture of cancer cells and add IL-2, do the cells die? If not, then it's not cytotoxic. If you understand the mechanism by which IL-2 is helpful in chemotherapy, then answer B is obviously correct.

Because A is more broader encompassing both CD8 and NK cells.
NK cells is more narrow and although technically correct, one of the earliest things I was taught in reviewing for step 1 was that its a matter of the most correct answer choice.

Either way, I've noticed as my knowledge base grows I become more doubtful to which answer is correct, I can often convince myself that multiple answers are correct by different means. Ignorance truly is bliss.

 

[illegallysmooth]

Either way, I've noticed as my knowledge base grows I become more doubtful to which answer is correct, I can often convince myself that multiple answers are correct by different means. Ignorance truly is bliss.

I hear ya on that. We get so focused on knowing everything and getting as many points as possible that sometimes it's easy to overthink. I found myself asking "Do they want me to know that X does Y, or are there trying to test if I know that Y will feedback into Z which affects X?" and crap like that.

 

[Dallas]

I hear ya on that. We get so focused on knowing everything and getting as many points as possible that sometimes it's easy to overthink. I found myself asking "Do they want me to know that X does Y, or are there trying to test if I know that Y will feedback into Z which affects X?" and crap like that.

Yeah, the 80% got this question correct vs the 22% got this question correct can be almost identical. The only difference is that the 80% is so easy you start second guessing yourself, is that one of those 22% question where they are trying to trick me.

Ive grown to become a sad sad cynical man 🙁

 

[Phloston]

Just thought I should point out that I've encountered a Kaplan QBank question with LAK cells as one of the answer choices.

LAK cell = NK cell that's been activated by IL-2 (i.e. an NK cell with enhanced cytotoxicity).

I actually find Kaplan QBank to be excellent so far.

 

[Dallas]

Just thought I should point out that I've encountered a Kaplan QBank question with LAK cells as one of the answer choices.

LAK cell = NK cell that's been activated by IL-2 (i.e. an NK cell with enhanced cytotoxicity).

I actually find Kaplan QBank to be excellent so far.

Is it possible to expand on what it said about LAK cells? Context etc.

 

[Dallas]

Oh okay. Also:

IL-4 hyperactivation is seen in asthma due to increased Th2 cell activity --> increased IgE.

IL-5 also activates eosinophils.

Be able to differentiate those when it comes to asthma and type-I hypersensitivities.

In other words, when you're rushing, it's easy to just think IgE for type-I hypersensitivity and then select IL-4 for eosinophils; eosinophils are IL-5-induced, not IL-4, but IgE is IL-4, as you've said.

Didnt see this post earlier, im blind.

Yeah, this is really good information people, listen to phloston!

Also, this whole IL-4 and IgE is the basis for the cleanliness hypothesis for asthma/allergies.

Theory is, when we are constantly clean as kids we have very little infectious agents around inducing IFN-Y and IL-2, thus we have low levels of those substances, thus low inhibition of Th2 cells. This leads to more active Th2 cells than Th1 cells. Th2 cells secrete IL-4 and IL-5 which induces class switching in B cells IgG to IgE and increased eosinophils (thanks to IL-5) and there you go, atopic dermatitis, atopic asthma with eosinophilia and the whole shebangs etc

EDIT: I think it was in the news some while back that they have extremely low levels of alleriges and asthma in the amish community. When I get kids im totally raising them in a dirty farm.

 

[Phloston]

I hate to be nitpicky (because we always hear that IL-4, 5 and 10 all favor B-cell isotype class-switching), but I had actually encountered in a practice question some time ago that IL-4's most important role is mainly increasing the number of Th2 cells. Then, Th2-secreted IL-5 is most important in the differentiation of B-cells (class-switching); I believe this is even in FA.

So yeah, IL-5 >> IL-4 for B-cell class-switching, but IL-4 >> IL-5 for the Th0 --> Th2 transition. IL-10 just functions to activate the Th2's so that they'll secrete IL-5.

So remember this by the order of 4 --> 10 --> 5, in terms of when they're most important.

I tend to remember a lot of the small detail, although I miss much of the bigger picture at times.

 

[Dallas]

I hate to be nitpicky (because we always hear that IL-4, 5 and 10 all favor B-cell isotype class-switching), but I had actually encountered in a practice question some time ago that IL-4's most important role is mainly increasing the number of Th2 cells. Then, Th2-secreted IL-5 is most important in the differentiation of B-cells (class-switching); I believe this is even in FA.

So yeah, IL-5 >> IL-4 for B-cell class-switching, but IL-4 >> IL-5 for the Th0 --> Th2 transition. IL-10 just functions to activate the Th2's so that they'll secrete IL-5.

So remember this by the order of 4 --> 10 --> 5, in terms of when they're most important.

I tend to remember a lot of the small detail, although I miss much of the bigger picture at times.

I have annotated the autocrine function of IL-4 on Th2 cells in my FA copy as well as an inhibitory signal to Th1 cells (like IFN-Y from Th1 inhibits Th2).

But so then does this mean that IL-4 release from Th2 cells mainly acts as an autocrine rather than IgE class switching? And that IL-5 is the main class switcher (into IgA) ?

 

[Phloston]

I just coincidentally encountered an explanation in Kaplan QBank saying that there are two things necessary for class-switching: 1) the CD40-CD40L interaction, and 2) IL-4 signalling (there is an IL-4 receptor on the B-cell).

I'm a bit shocked actually, since although, yes, we've heard IL-4, 5 and 10 are all necessary in class-switching to a degree, I had read with certainty somewhere (either USMLE Rx or GT) that IL-5 plays more of a direct role in class-switching compared to IL-4, and that the latter is mainly to increase Th2 cell count.

I guess we should stick with what we both already know: IL-4 --> IgG/E class-switching and IL-5 --> IgA class-switching.

 

[Belleza156]

tried both 'NK' and 'IL-2' cant find it, care to post q ID?

Tried to find it on UWorld and I couldn't but I just ran across one in Kaplan Qbank. Here is the Question as an attachment.

 

[Dallas]

Tried to find it on UWorld and I couldn't but I just ran across one in Kaplan Qbank. Here is the Question as an attachment.

Lol , I had a question about IL-2 and its role as an activator of immunesystem/therapy aldesleukin etc on the real step 1 today phloston.

Just to give u a heads up. I probably picked the right answer, much thanks to u , so big thank u!

 

[Belleza156]

Lol , I had a question about IL-2 and its role as an activator of immunesystem/therapy aldesleukin etc on the real step 1 today phloston.

Just to give u a heads up. I probably picked the right answer, much thanks to u , so big thank u!

Glad you got it down before the exam!

 

[Dallas]

Glad you got it down before the exam!

Yeah, but all in all there were 5-10q per block that were impossible to answer no matter how you reviewed. I'd say half of them you could probably answer if you remember that particular detail from your classes in school.

I had a q with 4 boxes where there were lines in each box, 1 horizontal, 1 vertical, 2 diagonal in each direction and all 4 sides of each box labeled superior inferior lateral medial, and then it asked how is the right external oblique muscle fibers oriented.

If you remember that from 1st year anatomy you'd be set. If not, youre ****ed cause its not in FA or Uworld

Also got a nice question about a guy with previously diagnosed pulmonary fibrosis who has been exercising on top of a high altitude mountain and is now unconcious and a O2 sat of 50%. What is the most likely mechanism of his low O2 sat.

So you have to know what happens in each and everyone of those 3 conditions and then integrate them all and pick the most likely answer.

Alot of multistep thinking.

 

[Belleza156]

Ugh you freaked me out. I pulled out my Rapid Review Physio book to see if any such example exists there, yea no. ...closest example is for oxygen diffusion impairment which is decreased in high altitude and pulmonary fibrosis. ....not looking forward to Thurs 🙁

Are the answer choices at least somewhat manageable or are there tons of options and they are all similar?

 

[Dallas]

Ugh you freaked me out. I pulled out my Rapid Review Physio book to see if any such example exists there, yea no. ...closest example is for oxygen diffusion impairment which is decreased in high altitude and pulmonary fibrosis. ....not looking forward to Thurs 🙁

Are the answer choices at least somewhat manageable or are there tons of options and they are all similar?

Yeah, I mean you are going to get 5-10 qs like that every block, either answer choices are so similar you have 3 you think could be right and just have to go with your gut feeling, or all answer choices have stuff youve never heard before.

I had one malaria q, with classic malaria histology slide and presentation, thought I was golden for this, asked for appropriate drugs.

None of the 5 answers had any drugs I had ever heard before, and I studied pharm pretty darn well both in school and in reviewing for step 1. All questions listed 2 drugs, and I came down to 2 choices, both had a drug in them that ended with quanone or something that felt familiar, i went 50/50 and just picked one realizing I have no idea what the hell im doing on this q since only 1 of the 2 drugs in either answer choice ended in a familiar ending and the other drug was some bizarre never before seen drug. Frustrating but what u gonna do, memorize harrisons, a full pharm reference of every drug ever, etc?

 

[Belleza156]

Yeah, I mean you are going to get 5-10 qs like that every block, either answer choices are so similar you have 3 you think could be right and just have to go with your gut feeling, or all answer choices have stuff youve never heard before.

I had one malaria q, with classic malaria histology slide and presentation, thought I was golden for this, asked for appropriate drugs.

None of the 5 answers had any drugs I had ever heard before, and I studied pharm pretty darn well both in school and in reviewing for step 1. All questions listed 2 drugs, and I came down to 2 choices, both had a drug in them that ended with quanone or something that felt familiar, i went 50/50 and just picked one realizing I have no idea what the hell im doing on this q since only 1 of the 2 drugs in either answer choice ended in a familiar ending and the other drug was some bizarre never before seen drug. Frustrating but what u gonna do, memorize harrisons, a full pharm reference of every drug ever, etc?

LOL yea right! Not even if I had all the time in the world to study.

I went to CDC's page to look up if there are any malaria treatments with weird names. Everything listed is the normal stuff, maybe it was an experimental question?

http://www.cdc.gov/malaria/resources/pdf/treatmenttable.pdf


Ex that statement, looks like there is a non oral malaria drug for severe malaria: ARTESUNATE........never heard of it.

 

[san2]

kaplan me immuno + fa immuno + uworld is all you need for immuno

 

[Boardz]

kaplan me immuno + fa immuno + uworld is all you need for immuno

go away. everyone knows kaplan me is the biggest waste of time ever like your stupid spam posts.

 

[Phloston]

kaplan me immuno + fa immuno + uworld is all you need for immuno

go away. everyone knows kaplan me is the biggest waste of time ever like your stupid spam posts.

👍

Why hasn't a moderator blocked this person's account already? Every comment from him or her is a Kaplan advertisement and it's clear that he or she works for Kaplan and/or has an agenda. Yet again, if SDN blocked the account, he or she would just make a new one most likely.

 

[Aclamity]

👍

Why hasn't a moderator blocked this person's account already? Every comment from him or her is a Kaplan advertisement and it's clear that he or she works for Kaplan and/or has an agenda. Yet again, if SDN blocked the account, he or she would just make a new one most likely.

I"m actually surprised he hasn't started advertising from multiple accounts ALREADY. That would be the smarter/more convincing way to do it

But looking at his post history I think he might be a real person with just some unhealthy love for kaplan.

 

[Dallas]

LOL yea right! Not even if I had all the time in the world to study.

I went to CDC's page to look up if there are any malaria treatments with weird names. Everything listed is the normal stuff, maybe it was an experimental question?

http://www.cdc.gov/malaria/resources/pdf/treatmenttable.pdf


Ex that statement, looks like there is a non oral malaria drug for severe malaria: ARTESUNATE........never heard of it.

Right, I think I picked that answer

It had Artesunate + Atovaquone as the choice I think i picked (btw ive never heard of either drug, but -quone sounded familiar)

there also was an answer with [WEIRD ASS DRUG] + Mefloquine

and rest of answers were [never heard of drug before] + [never heard of drug before] (and they are not on CDCs list)

So , not too easy if you havent studied CDC malaria drugs in depth 🙂

 

[Phloston]

Right, I think I picked that answer

It had Artesunate + Atovaquone as the choice I think i picked (btw ive never heard of either drug, but -quone sounded familiar)

there also was an answer with [WEIRD ASS DRUG] + Mefloquine

and rest of answers were [never heard of drug before] + [never heard of drug before] (and they are not on CDCs list)

So , not too easy if you havent studied CDC malaria drugs in depth 🙂

I've definitely heard of atovaquone + progaunil before. I believe this was in USMLE Rx.

However, "Artemether-lumefantrine" = wtf = I've never heard of those before = I don't want to memorize those but I will bc I'm OCD.

 

[Dallas]

I've definitely heard of atovaquone + progaunil before. I believe this was in USMLE Rx.

However, "Artemether-lumefantrine" = wtf = I've never heard of those before = I don't want to memorize those but I will bc I'm OCD.

Yeah Atovaquone is out there, it was in Deja Review Pharm, I didnt have time to read through it before the exam though :/

Please realize Phloston there were only 3-5 questions per block like this.
The rest were straightforward enough if you know FA, Uworld and all the other recommended review books cold.

You will get left field questions on the different subjects where you can only answer them if you have a masters degree in that particular subject, hopefully most of them are just experimental questions and wont count towards your score.

 

[thinker]

We've heard about Artesunate here during class work but probably because my school is in the Middle east so malaria is more of a relevant topic. But not sure why would i pick it in particular vs Malarone (Atovaquone-proguanil)


*ah so your answer it had Artesunate + Atovaquone... weird.. no idea really. Maybe only if your patient had some contraindication to Quinines? (so no Mefloquine?)