Feasibility of a Novel Real-Time Provider Teaching Intervention in Acute Exacerbation of Chronic Obstructive Pulmonary Disease.

Background: It is not known whether an intervention using real-time provider teaching in acute exacerbation of chronic obstructive pulmonary disease (AECOPD) improves provider knowledge and/or patient outcomes. Objective: To pilot the combination of a novel, real-time provider teaching intervention delivered by subspecialists to Internal Medicine trainees with a traditional patient education and medication reconciliation (PEMR) intervention and to assess the impact of these interventions on provider knowledge regarding COPD and patient care. Methods: This was a single-center, nonrandomized, quality-improvement study. Patients admitted with AECOPD were prospectively identified between June 19 and November 20, 2019. Patients with asthma, lung cancer, or interstitial lung disease were excluded. The primary care team received a novel intervention featuring in-person, real-time teaching, covering Global Initiative on Chronic Obstructive Lung Disease COPD groups and management, including pulmonary rehabilitation referral. Providers completed a knowledge assessment before and after their real-time teaching session. Provider knowledge scores before and after teaching were compared using McNemar's test. Patients received a traditional PEMR intervention from a nurse practitioner and/or clinical pharmacist. A retrospective chart review was conducted for 50 historical control patients admitted with AECOPD to obtain preintervention rates of discharge on long-acting bronchodilators and referral to pulmonary rehabilitation. The proportions of patients discharged on long-acting bronchodilators and referred to pulmonary rehabilitation in the intervention group were compared with the preintervention historical control patients using chi-square testing. Results: Seventy-one providers caring for patients with AECOPD received real-time teaching. Postintervention, there was significant improvement in knowledge scores pertaining to Global Initiative on Chronic Obstructive Lung Disease groups and exacerbation risk (81% correct vs. 43% on pretest; P < 0.001) and guideline-directed treatment (83% correct vs. 28% on pretest; P < 0.001). Out of 44 eligible patients, 75% (n = 33 patients) received the PEMR intervention. Ninety percent of patients (n = 40 patients) were discharged on any long-acting inhaler, similar to the group of preintervention control subjects. Pulmonary rehabilitation referrals were made for 50% of patients (n = 22 patients) compared with 6% of preintervention control subjects (n = 3 patients; P < 0.001). Conclusion: In this single-center quality-improvement study, the combination of a novel, real-time provider teaching intervention and a traditional PEMR intervention improved provider knowledge and was associated with increased referrals to pulmonary rehabilitation.

Personal receptor repertoires: olfaction as a model.

BACKGROUND: Information on nucleotide diversity along completely sequenced human genomes has increased tremendously over the last few years. This makes it possible to reassess the diversity status of distinct receptor proteins in different human individuals. To this end, we focused on the complete inventory of human olfactory receptor coding regions as a model for personal receptor repertoires. RESULTS: By performing data-mining from public and private sources we scored genetic variations in 413 intact OR loci, for which one or more individuals had an intact open reading frame. Using 1000 Genomes Project haplotypes, we identified a total of 4069 full-length polypeptide variants encoded by these OR loci, average of ~10 per locus, constituting a lower limit for the effective human OR repertoire. Each individual is found to harbor as many as 600 OR allelic variants, ~50% higher than the locus count. Because OR neuronal expression is allelically excluded, this has direct effect on smell perception diversity of the species. We further identified 244 OR segregating pseudogenes (SPGs), loci showing both intact and pseudogene forms in the population, twenty-six of which are annotatively "resurrected" from a pseudogene status in the reference genome. Using a custom SNP microarray we validated 150 SPGs in a cohort of 468 individuals, with every individual genome averaging 36 disrupted sequence variations, 15 in homozygote form. Finally, we generated a multi-source compendium of 63 OR loci harboring deletion Copy Number Variations (CNVs). Our combined data suggest that 271 of the 413 intact OR loci (66%) are affected by nonfunctional SNPs/indels and/or CNVs. CONCLUSIONS: These results portray a case of unusually high genetic diversity, and suggest that individual humans have a highly personalized inventory of functional olfactory receptors, a conclusion that might apply to other receptor multigene families.