Clinician Perception of Risk As a Barrier to Implementation of a High-sensitivity Troponin Accelerated Diagnostic Protocol.

BACKGROUND: To assess emergency department (ED) clinician perception of patient risk, we measured willingness to discharge patients categorized as increased risk by traditional risk stratification modalities for acute coronary syndrome but low risk by a validated high-sensitivity troponin accelerated diagnostic protocol (HST-ADP). METHODS: This was a cross-sectional descriptive survey study distributed to ED clinicians at an urban academic medical center. Four clinical vignettes classified hypothetical patients as low risk for 30-day acute coronary syndrome according to the 0-/1-hour HST-ADP. Vignettes additionally identified patients with History, Electrocardiogram, Age, Risk factors, and initial Troponin (HEART) scores of 4 or 6 (2 cases each). One patient in each subset had preexisting coronary artery disease (CAD). ED clinicians self-reported willingness to discharge patients from the ED on a 10-point Likert scale. RESULTS: Among 66 eligible participants, 36 (55%) participated in the survey. ED clinicians reported a mean willingness to discharge patients of 6.07 (95% confidence interval, 5.34-6.80). They reported higher mean willingness to discharge patients with HEART scores of 4 compared with those with HEART scores of 6 (mean difference, 3.61; 95% confidence interval, 2.19-5.03). There were no differences in willingness to discharge regarding presence or absence of CAD or between clinician types (attending, resident, advanced practice provider). CONCLUSIONS: ED clinicians accustomed to the HEART Pathway demonstrated limited willingness to discharge patients from the ED categorized as moderate risk by the HEART score despite simultaneous classification as low risk by the 0-/1-hour HST-ADP. Willingness to discharge was higher with lower HEART scores but not affected by the presence of CAD and did not vary between clinician types.

SUMO fusion technology for difficult-to-express proteins.

The demands of structural and functional genomics for large quantities of soluble, properly folded proteins in heterologous hosts have been aided by advancements in the field of protein production and purification. Escherichia coli, the preferred host for recombinant protein expression, presents many challenges which must be surmounted in order to over-express heterologous proteins. These challenges include the proteolytic degradation of target proteins, protein misfolding, poor solubility, and the necessity for good purification methodologies. Gene fusion technologies have been able to improve heterologous expression by overcoming many of these challenges. The ability of gene fusions to improve expression, solubility, purification, and decrease proteolytic degradation will be discussed in this review. The main disadvantage, cleaving the protein fusion, will also be addressed. Focus will be given to the newly described SUMO fusion system and the improvements that this technology has advanced over traditional gene fusion systems.