Transdisciplinary entrustable professional activities.

Healthcare has become highly specialized. Specialists, in medicine as well as in nursing, determine much of the high quality of current health care. But healthcare has also become increasingly fragmented, with professionals trained in separate postgraduate silos, with boundaries often difficult to cross. While a century ago, generalists dominated patient care provision, now specialists prevail and risk becoming alienated from each other, losing the ability to adapt to neighboring professional domains. Current health care requires a flexible workforce, ready to serve in multiple contexts, as the COVID-19 crisis has shown.The new concept of transdisciplinary entrustable professional activities, EPAs applicable in more than one specialty, was recently conceived to enhance collaboration and transfer between educational programs in postgraduate nursing in the Netherlands.In this paper, we reflect on our experiences so far, and on practical and conceptual issues concerning transdisciplinary EPAs, such as: who should define, train, assess, and register transdisciplinary EPAs? How can different prior education prepare for similar EPAs? And how do transdisciplinary EPAs affect professional identity?We believe that transdisciplinary EPAs can contribute to creating more flexible curricula and hence to a more coherent, collaborative healthcare workforce, less determined by the boundaries of traditional specialties.

The Implementation of Entrustable Professional Activities in Postgraduate Medical Education in the Netherlands: Rationale, Process, and Current Status.

Postgraduate medical education in the Netherlands has adopted competency-based education since the turn of the century. In 2006, the CanMEDS competency framework was introduced. A 2013 government plan to reduce the length and budgets of training programs led the Dutch Association of Medical Specialists (DAMS) to respond with a proposal to create more flexibility and individualization rather than a blunt cut in the length across all training programs. DAMS launched a government-funded, nation-wide, 4-year project (2014-2018) to blueprint the reform of postgraduate medical education in this direction. To achieve competency-based individualization, the fixed duration of postgraduate programs was abandoned, and entrustable professional activities (EPAs) were introduced in all specialty programs. Implementation of this new generation of programs took place in 2017-2019 in all disciplines. The project focused on EPA-based individualization of all programs, while addressing issues of the continuity of patient care in time-variable programs and the legal and regulatory consequences of individualization. About 30 specialty programs were revised at national, regional, local, and individual levels to incorporate EPAs; portfolio systems were adapted, clinical competency committees were installed for all programs, and procedures for summative entrustment decision making were elaborated. This paper reports on the rationale and the process that led to a more time-variable postgraduate education landscape, and, on average, a shortening of training length by 3 months.

Isolation and characterization of human monoclonal antibodies from individuals infected with West Nile Virus.

Monoclonal antibodies (MAbs) neutralizing West Nile Virus (WNV) have been shown to protect against infection in animal models and have been identified as a correlate of protection in WNV vaccine studies. In the present study, antibody repertoires from three convalescent WNV-infected patients were cloned into an scFv phage library, and 138 human MAbs binding to WNV were identified. One hundred twenty-one MAbs specifically bound to the viral envelope (E) protein and four MAbs to the premembrane (prM) protein. Enzyme-linked immunosorbent assay-based competitive-binding assays with representative E protein-specific MAbs demonstrated that 24/51 (47%) bound to domain II while only 4/51 (8%) targeted domain III. In vitro neutralizing activity was demonstrated for 12 MAbs, and two of these, CR4374 and CR4353, protected mice from lethal WNV challenge at 50% protective doses of 12.9 and 357 mug/kg of body weight, respectively. Our data analyzing three infected individuals suggest that the human anti-WNV repertoire after natural infection is dominated by nonneutralizing or weakly neutralizing MAbs binding to domain II of the E protein, while domain III-binding MAbs able to potently neutralize WNV in vitro and in vivo are rare.

Affinity ranking of antibodies using flow cytometry: application in antibody phage display-based target discovery.

Application of antibody phage display to the identification of cell surface antigens with restricted expression patterns is often complicated by the inability to demonstrate specific binding to a certain cell type. The specificity of an antibody can only be properly assessed when the antibody is of sufficient high affinity to detect low-density antigens on cell surfaces. Therefore, a robust and simple assay for the prediction of relative antibody affinities was developed and compared to data obtained using surface plasmon resonance (SPR) technology. A panel of eight anti-CD46 antibody fragments with different affinities was selected from phage display libraries and reformatted into complete human IgG1 molecules. SPR was used to determine K(D) values for these antibodies. The association and dissociation of the antibodies for binding to CD46 expressed on cell surfaces were analysed using FACS-based assays. We show that ranking of the antibodies based on FACS data correlates well with ranking based on K(D) values as measured by SPR and can therefore be used to discriminate between high- and low-affinity antibodies. Finally, we show that a low-affinity antibody may only detect high expression levels of a surface marker while failing to detect lower expression levels of this molecule, which may lead to a false interpretation of antibody specificity.

The human antibody repertoire specific for rabies virus glycoprotein as selected from immune libraries.

Antibody phage display technology was used to identify human monoclonal antibodies that neutralize rabies virus (RV). A phage repertoire was constructed using antibody genes harvested from the blood of vaccinated donors. Selections using this repertoire and three different antigen formats of the RV glycoprotein (gp) resulted in the identification of 147 unique antibody fragments specific for the RV gp. Analysis of the DNA sequences of these antibodies demonstrated a large variation in the heavy- and light-chain germ-line gene usage, suggesting that a broad antibody repertoire was selected. The single-chain variable fragment (scFv) antibodies were tested in vitro for RV neutralization, resulting in 39 specificities that neutralize the virus. Of the scFv clones, 21 were converted into full-length human IgG(1) format. Analysis of viral escape variants and binding competition experiments indicated that the majority of the neutralizing antibodies are directed against antigenic site III of the RV gp. The obtained specificities expand the set of human anti-RV antibodies eligible for inclusion in an antibody cocktail aimed for use in rabies post-exposure prophylaxis.

Novel rabies virus-neutralizing epitope recognized by human monoclonal antibody: fine mapping and escape mutant analysis.

Anti-rabies virus immunoglobulin combined with rabies vaccine protects humans from lethal rabies infections. For cost and safety reasons, replacement of the human or equine polyclonal immunoglobulin is advocated, and the use of rabies virus-specific monoclonal antibodies (MAbs) is recommended. We produced two previously described potent rabies virus-neutralizing human MAbs, CR57 and CRJB, in human PER.C6 cells. The two MAbs competed for binding to rabies virus glycoprotein. Using CR57 and a set of 15-mer overlapping peptides covering the glycoprotein ectodomain, a neutralization domain was identified between amino acids (aa) 218 and 240. The minimal binding region was identified as KLCGVL (aa 226 to 231), with key residues K-CGV- identified by alanine replacement scanning. The critical binding region of this novel nonconformational rabies virus epitope is highly conserved within rabies viruses of genotype 1. Subsequently, we generated six rabies virus variants escaping neutralization by CR57 and six variants escaping CRJB. The CR57 escape mutants were only partially covered by CRJB, and all CRJB-resistant variants completely escaped neutralization by CR57. Without exception, the CR57-resistant variants showed a mutation at key residues within the defined minimal binding region, while the CRJB escape viruses showed a single mutation distant from the CR57 epitope (N182D) combined with mutations in the CR57 epitope. The competition between CR57 and CRJB, the in vitro escape profile, and the apparent overlap between the recognized epitopes argues against including both CR57 and CRJB in a MAb cocktail aimed at replacing classical immunoglobulin preparations.

A novel helper phage that improves phage display selection efficiency by preventing the amplification of phages without recombinant protein.

Phage display is a widely used technology for the isolation of peptides and proteins with specific binding properties from large libraries of these molecules. A drawback of the common phagemid/helper phage systems is the high infective background of phages that do not display the protein of interest, but are propagated due to non-specific binding to selection targets. This and the enhanced growth rates of bacteria harboring aberrant phagemids not expressing recombinant proteins leads to a serious decrease in selection efficiency. Here we describe a VCSM13-derived helper phage that circumvents this problem, because it lacks the genetic information for the infectivity domains of phage coat protein pIII. Rescue of a library with this novel CT helper phage yields phages that are only infectious when they contain a phagemid-encoded pIII-fusion protein, since phages without a displayed protein carry truncated pIII only and are lost upon re-infection. Importantly, the CT helper phage can be produced in quantities similar to the VCSM13 helper phage. The superiority of CT over VCSM13 during selection was demonstrated by a higher percentage of positive clones isolated from an antibody library after two selection rounds on a complex cellular target. We conclude that the CT helper phage considerably improves the efficiency of selections using phagemid-based protein libraries.