Corticosteroid Responsiveness Following Mepolizumab in Severe Eosinophilic Asthma-A Randomized, Placebo-Controlled Crossover Trial (MAPLE).

BACKGROUND: Mepolizumab inhibits IL-5 activity and reduces exacerbation frequency and maintenance oral corticosteroid (OCS) dosage in patients with severe eosinophilic asthma (SEA). Some patients remain dependent on OCS despite anti-IL-5 treatment, suggesting residual corticosteroid-responsive mechanisms. OBJECTIVE: To determine the clinical and anti-inflammatory effects of OCS in patients with SEA on mepolizumab. METHODS: We conducted a randomized, triple-blind, placebo-controlled crossover trial of prednisolone (0.5 mg/kg/d, maximum 40 mg/d, for 14 ± 2 days) in adults with SEA after 12 or more weeks of mepolizumab. We compared change in asthma symptoms, quality of life, lung function measured by spirometry and airwave oscillometry, fractional exhaled nitric oxide, and blood and sputum eosinophil cell count after prednisolone and placebo treatment. RESULTS: A total of 27 patients completed the study. Prednisolone did not improve 5-item Asthma Control Questionnaire (mean difference in change for prednisolone vs placebo, -0.23; 95% CI, -0.58 to 0.11), mini-Asthma Quality of Life Questionnaire (0.03; 95% CI, -0.26 to 0.42), St. George's Respiratory Questionnaire (0.24; 95% CI, -3.20 to 3.69), or Visual Analogue Scale scores for overall asthma symptoms (0.11; 95% CI, -0.58 to 0.80). The mean difference for FEV1 in favor of prednisolone was 105 mL (95% CI, -4 to 213 mL); forced expiratory flow at 25% and 75% 484 mL/s (95% CI, 151 to 816 mL/s); fractional exhaled nitric oxide reduction 41% (95% CI, 25% to 54%); blood eosinophil count reduction 49% (95% CI, 31% to 62%); and percentage of sputum eosinophil reduction 71% (95% CI, 26% to 89%). CONCLUSIONS: OCS improved small-airway obstruction and reduced biomarkers of type 2 inflammation but had no significant effect on symptoms or quality of life in patients with SEA receiving treatment with mepolizumab.

Pilot Study of a Two-Step Delirium Detection Protocol Administered By Certified Nursing Assistants, Physicians, and Registered Nurses.

The feasibility and acceptability of a two-step screening protocol for delirium identification was pilot tested. Step 1, a screening tool, comprises two items: "Please tell me the day of the week," and "Please tell me the months of the year backwards starting with December." If either/both items are incorrect, Step 2, a 3-minute diagnostic assessment, follows. Trained researchers enrolled 24 hospitalized older adults and identified 22% to be delirious after a reference standard assessment. Thereafter, physicians and RNs completed the two-step protocol, whereas certified nursing assistants (CNAs) completed the screener only, on the same patients. All three clinical assessments were successfully completed in 100% of enrolled participants and within the target 2-hour time window in 91%. The screener and two-step protocol achieved high sensitivities and specificities in RNs, CNAs, and physicians. Qualitative information on barriers to and facilitators of implementation was also collected. Nurses and other clinicians can feasibly implement this ultra-brief screener and two-step protocol, which holds promise to improve delirium identification. [Journal of Gerontological Nursing, 44(5), 18-24.].

When study participants are vulnerable: getting and keeping the right team.

BACKGROUND: Research assistants (RAs) are critical members of all research teams. When a study involves vulnerable populations, it is particularly important to have the right team members. AIM: To describe the motivations, personal characteristics and team characteristics that promoted the job satisfaction of RAs who worked on two multi-year, randomised clinical trials involving older adults with dementia. DISCUSSION: A survey was conducted with 41 community members who worked as RAs for up to five years. Measures included demographics, work engagement, personality and characteristics of effective teams, as well as open-ended questions about respondents' experiences of the study. Quantitative analyses and coding of open-ended responses were used to summarise results. Almost all the RAs surveyed joined the team because of previous experiences of interacting with cognitively impaired older people. The RA respondents scored higher in 'dedication to work', 'extraversion', 'agreeableness' and 'conscientiousness' than average. An important aspect of their job satisfaction was team culture, including positive interpersonal interaction and the development of supportive team relationships. CONCLUSION: A positive work culture provides RAs with an opportunity to work with a study population that they are personally driven to help, and promotes motivation and satisfaction in team members. IMPLICATIONS FOR PRACTICE: Results from this study can guide the recruitment, screening and retention of team members for studies that include vulnerable populations.

Implementing Nurse-Facilitated Person-Centered Care Approaches for Patients With Delirium Superimposed on Dementia in the Acute Care Setting.

Little is understood about the use of person-centered care (PCC) for individuals with delirium superimposed on dementia (DSD), especially in the acute care setting. As part of a larger clinical trial, the purpose of the current exploratory study was to describe examples and qualitatively derived themes of nurse-facilitated PCC for hospitalized older adults with dementia and delirium. A total of 750 delirium rounds were analyzed across three diverse acute care sites. Qualitative derived themes of PCC included: (a) Knowing the Patient's Baseline; (b) Knowing the Patient's Interests and Values; (c) Enhancing Sensory Abilities to Communicate; (d) Individualizing Cognitive Stimulation; and (e) Enhancing Behavioral Approaches to Comfort and Sleep. Barriers included failure to see the patient as an individual and lack of time. Principles of PCC were effectively used, demonstrating the potential for PCC to ease the burden of DSD for all members of the health care team. [Journal of Gerontological Nursing, 43(12), 21-28.].

Barriers and facilitators to implementing delirium rounds in a clinical trial across three diverse hospital settings.

Delirium occurs in more than half of hospitalized older adults with dementia, substantially worsening outcomes. The use of multiple strategies and a local opinion leader, unit champion, has cumulative and lasting effects compared with single-strategy interventions. The purpose of this article is to describe the early barriers and facilitators to rounding with unit champions in a cluster randomized clinical trial in Year 2 of a 5-year trial (5R01NR011042-02). This is a mixed-method study nested within an ongoing multisite cluster-randomized, controlled clinical trial. Descriptive and comparative statistics were collected on N = 192 nursing rounds. Qualitative data were thematically analyzed. On average, rounds lasted 25.54 min (SD = 13.18) and were conducted with the unit champion 64% of the time. This is one of the first studies to systematically address quantitative and qualitative barriers and facilitators to nurse-led delirium rounds, demonstrating the gradual adoption of an intervention in diverse clinical settings.

Pay attention! The critical importance of assessing attention in older adults with dementia.

Attention is an important cognitive domain that is affected in Alzheimer's disease and other dementias. It influences performance in most other cognitive domains, as well as activities of daily living. Nurses are often unaware of the critical importance of assessing attention as part of the overall mental status examination. This article addresses an important gap in nurses' knowledge. The authors present a brief overview of attention as a critical cognitive domain in dementia; review instruments/methods for standardizing and enhancing the assessment of attention; and offer ways to help ensure that best practices in the assessment, recognition, and documentation of inattention are implemented in the clinical area. Clinical resources that practicing nurses may find helpful are included.