Polypeptides containing between 4 and 32 repeats of a resilin‐inspired sequence AQTPSSYGAP, derived from the mosquito Anopheles gambiae, have been used as tags on recombinant fusion proteins. These repeating polypeptides were inspired by the repeating structures that are found in resilins and sequence‐related proteins from various insects. Unexpectedly, an aqueous solution of a recombinant resilin protein displays an upper critical solution temperature (cold‐coacervation) when held on ice, leading to a separation into a protein rich phase, typically exceeding 200 mg/mL, and a protein‐poor phase. We show that purification of recombinant proteins by cold‐coacervation can be performed when engineered as a fusion partner to a resilin‐inspired repeat sequence. In this study, we demonstrate the process by the recombinant expression and purification of enhanced Green fluorescent protein (EGFP) in E. coli. This facile purification system can produce high purity, concentrated protein solutions without the need for affinity chromatography or other time‐consuming or expensive purification steps, and that it can be used with other bulk purification steps such as low concentration ammonium sulfate precipitation. Protein purification by cold‐coacervation also minimizes the exposure of the target protein to enhanced proteolysis at higher temperature. Biotechnol. Bioeng. 2012; 109: 2947–2954. © 2012 Wiley Periodicals, Inc.

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Objective Pulmonary complications are common following hematopoietic stem cell transplantation (HSCT). Numerous idiopathic post-transplantation pulmonary syndromes have been described. Patients at the severe end of this spectrum may present with hypoxemic respiratory failure and pulmonary infiltrates, meeting criteria for Acute Respiratory Distress Syndrome (ARDS). The incidence and outcomes of ARDS in this setting are poorly characterized. Design Retrospective cohort study Setting Mayo Clinic, Rochester, MN. Patients Patients undergoing autologous and allogeneic hematopoietic stem cell transplantation between 1/1/2005 and 12/31/2012. Interventions None Measurements and main results Patients were screened for ARDS development within one year of HSCT. ARDS adjudication was performed in accordance with the 2012 Berlin criteria. In total, 133 cases of ARDS developed in 2635 patients undergoing HSCT (5.0%). ARDS developed in 75 (15.6%) patients undergoing allogeneic HSCT and 58 (2.7%) patients undergoing autologous HSCT. Median time to ARDS development was 55.4 days (IQR: 15.1 to 139 days) in allogeneic HSCT and 14.2 days (IQR: 10.5 to 124 days) in autologous HSCT. 28-day mortality was 46.6%. At 12 months following HSCT, 89 (66.9%) patients who developed ARDS had died. Only 7 of 133 ARDS cases met criteria for engraftment syndrome, and 15 for diffuse alveolar hemorrhage. Conclusions ARDS is a frequent complication following HSCT, dramatically influencing patient-important outcomes. Most cases of ARDS following HSCT do not meet criteria for a more specific post-transplantation pulmonary syndrome. These findings highlight the need to better understand the risk factors underlying ARDS in this population, thereby facilitating the development of effective prevention strategies.

Background A detailed understanding of electronic health record (EHR) workflow patterns and information use is necessary to inform user-centered design of critical care information systems. While developing a longitudinal medical record visualization tool to facilitate electronic chart review (ECR) for medical intensive care unit (MICU) clinicians, we found inadequate research on clinician–EHR interactions. Objective We systematically studied EHR information use and workflow among MICU clinicians to determine the optimal selection and display of core data for a revised EHR interface. Methods We conducted a direct observational study of MICU clinicians performing ECR for unfamiliar patients during their routine daily practice at an academic medical center. Using a customized manual data collection instrument, we unobtrusively recorded the content and sequence of EHR data reviewed by clinicians. Results We performed 32 ECR observations among 24 clinicians. The median (interquartile range [IQR]) chart review duration was 9.2 (7.3–14.7) minutes, with the largest time spent reviewing clinical notes (44.4%), laboratories (13.3%), imaging studies (11.7%), and searching/scrolling (9.4%). Historical vital sign and intake/output data were never viewed in 31% and 59% of observations, respectively. Clinical notes and diagnostic reports were browsed ≥10 years in time for 60% of ECR sessions. Clinicians viewed a median of 7 clinical notes, 2.5 imaging studies, and 1.5 diagnostic studies, typically referencing a select few subtypes. Clinicians browsed a median (IQR) of 26.5 (22.5–37.25) data screens to complete their ECR, demonstrating high variability in navigation patterns and frequent back-and-forth switching between screens. Nonetheless, 47% of ECRs begin with review of clinical notes, which were also the most common navigation destination. Conclusion Electronic chart review centers around the viewing of clinical notes among MICU clinicians. Convoluted workflows and prolonged searching activities indicate room for system improvement. Using study findings, specific design recommendations to enhance usability for critical care information systems are provided.

Background: This study determines the effects of a routine assessment (Treatment as Usual, TAU) versus a risk communication intervention (Risk) versus a Goal-Setting, Planning and Self-Monitoring (GPS) intervention on periodontal disease patients' clinical and psychological outcomes. Methods:In a three-arm randomized controlled trial (RCT; registration: ISRCTN59696243) adults (N = 97) judged to have moderate oral hygiene attended a primary dental care setting for a standard consultation. Intervention participants received an individualized calculation of their periodontal disease risk using only the Previser Risk Calculator (Risk group) or supplemented with a GPS-behavioral intervention (GPS group). Clinical, behavioral and psychological measures were obtained at baseline, 4 and 12 weeks later.Results: Percent plaque reduced significantly (P < 0.05) in intervention groups but not in TAU group. Percent of sites bleeding-on-probing reduced in all groups, but the effect was more pronounced in the intervention groups. Interdental cleaning frequency improved only in the intervention groups (P < 0.05). Brushing frequency and probing depths showed little variation across time/groups. Disease risk and most thoughts about periodontal disease changed across time (P < 0.05). Conclusions:A simple behavioral intervention using individualized periodontal disease risk communication, with or without GPS, reduced plaque and bleeding and increased interdental cleaning over 12 weeks. This is the first study in the field to show that risk communication and behavioral techniques such as Goal-Setting, Planning and Self-Monitoring can improve periodontal outcomes. K E Y W O R D Sbehavioral science, clinical trial(s), public health, risk 948

Electronic chart review of historical data is an important, prevalent, and potentially time-consuming activity among medical ICU clinicians who would benefit from improved information display systems.

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BackgroundPatients with severe sepsis generally respond well to initial therapy administered in the emergency department (ED), but a subset later decompensate and require unexpected transfer to the intensive care unit (ICU). This study aimed to identify clinical factors that can predict patients at increased risk for delayed transfer to the ICU and the association of delayed ICU transfer with mortality.MethodsThis is a nested case-control study in a prospectively collected registry of patients with severe sepsis and septic shock at two EDs. Cases had severe sepsis and unexpected ICU transfer within 48 h of admission from the ED; controls had severe sepsis but remained in a non-ICU level of care. Univariate and multivariate regression analyses were used to identify predictors of unexpected transfer to the ICU, which was the primary outcome. Differences in mortality between these two groups as well as a cohort of patients directly admitted to the ICU were also calculated.ResultsOf the 914 patients in our registry, 358 patients with severe sepsis were admitted from the ED to non-ICU level of care; 84 (23.5%) had unexpected ICU transfer within 48 h. Demographics and baseline co-morbidity burden were similar for patients requiring versus not requiring delayed ICU transfer. In unadjusted analysis, lactate ≥4 mmol/L and infection site were significantly associated with unexpected ICU upgrade. In forward selection multivariate logistic regression analysis, lactate ≥4 mmol/L (OR 2.0, 95% CI 1.03, 3.73; p = 0.041) and night (5 PM to 7 AM) admission (OR 1.9, 95% CI 1.07, 3.33; p = 0.029) were independent predictors of unexpected ICU transfer. Mortality of patients who were not upgraded to the ICU was 8.0%. Patients with unexpected ICU upgrade had similar mortality (25.0%) to those patients with severe sepsis/septic shock (24.6%) who were initially admitted to the ICU, despite less severe indices of illness at presentation.ConclusionsSerum lactate ≥4 mmol/L and nighttime admissions are associated with unexpected ICU transfer in patients with severe sepsis. Mortality among patients with delayed ICU upgrade was similar to that for patients initially admitted directly to the ICU.