Please select the eligibility criteria that correspond to the clinical trial below.
Title: Effectiveness of a Multi-level Clinic and Family Asthma Intervention With a Randomized Control Trial
Brief Summary: The aim of this group-randomized trial was to test the effectiveness of a new comprehensive program, which the investigators called CALMA -plus, in increasing controller medication use and reducing asthma symptoms. CALMA-plus involved the CALMA home-based family intervention, plus educational training of physicians and nurses, as well as screening for asthma in clinics serving Medicaid island Puerto Rican children with asthma. Because the provider training was expected to have an impact on the entire clinical setting where trained providers work, as well as the patients using that setting, the investigators randomized clinic groups rather than individual patients. The investigators compared the CALMA-Plus intervention to a CALMA-only group, which the investigators expected to obtain the same benefits as the investigators have previously documented.


Options:
A: Inclusion Criteria:

1. A male or female subject must be 18 to 65 years of age.
2. Except for underlying airway disease, subject must be in good health as determined by medical history, targeted physical examination based on medical history, and vital signs (that include temperature, blood pressure, heart rate, and pulse oximetry).
3. Subject must be able to verbalize understanding of the informed consent form, verbalize willingness to complete all study procedures, and provide written informed consent (sign the informed consent form).
4. Subject must be willing to commit to participating in both the initial and cross-over stages of the study.
5. Dipstick analysis of subject's urine specimen must be negative or show only trace amounts of glucose, hemoglobin, and protein. A menstruating female who tests positive for urine hemoglobin may be retested.
6. Subject must have blood screening test results that are within normal limits (according to standards set within the Clinical Center) for the following tests: alanine transaminase (ALT), alkaline phosphatase (ALKP), activated partial thromboplastin time (APTT), and aspartate transaminase (AST).
7. Subject must have hematologic screening tests that are within a specified range, including hemoglobin of 10.9 g/dL, white blood cell count 2500/mm3, and platelet count 125,000/mm3 (all \<grade 1 on DAIDS severity scale).
8. A female subject must be post-menopausal (1 year without menses), have been surgically sterilized, practice abstinence, or use an effective method of birth control that may include an intrauterine device, spermicide, barrier, and hormonal contraception. A female subject must also have a negative serum test for pregnancy during the Screening period, and a negative urine test for pregnancy on the first day of drug or placebo administration.

Asthma Subjects:

1. Subject must have a clinically established diagnosis of asthma based upon a history of episodic symptoms of airway obstruction or airway hyper-responsiveness (i.e., wheezing).
2. Subject must have a documented increase in FEV1 or forced vital capacity (FVC) 12% (and at least 200 mL) from baseline after inhaling a short-acting bronchodilator; or a PC20FEV1 response to methacholine (i.e., the concentration of methacholine that produces a 20% decrease in FEV1 from the post-saline value during the methacholine challenge) of 8 mg/mL.
3. At the time of study enrollment, subject's asthma has been well-controlled for at least the past 3 months, as defined by the following:

   1. Daytime symptoms occur 2 days per week
   2. Normal daily activity is not limited by asthma
   3. Nocturnal symptoms/nighttime awakenings 2 times/month
   4. FEV1 80% predicted
   5. Use of short-acting beta-agonist 2 days/week
   6. Exacerbations requiring oral corticosteroids occur 2 times/year
   7. There has been no change in asthma medication dose or regimen within 3 months of study enrollment
   8. Not currently taking oral corticosteroids

Bronchiectasis Subjects:

1. Subject will be recruited from ongoing NIH natural history protocols (06-I-0217, 01-I-0202, and 09-I-0172) and/or the National Bronchiectasis Registry.
2. Subject must have a pre-established diagnosis of bronchiectasis based on chest computed tomography (CT) scan findings within 12 months of enrollment (no diagnostic CT scans will be performed during the Screening phase of this study).
3. Subject must not have overt allergic bronchopulmonary aspergillosis, cystic fibrosis, or primary ciliary dyskinesia.
4. Subject's bronchiectasis is stable as defined by the following:

   a. Less than 2 acute exacerbations in the preceding 12 months and none in the preceding 4 weeks, with acute exacerbation defined as persistent (\>24 hour) worsening of \>3 respiratory symptoms associated with bacterial infection including: i. Cough ii. Dyspnea iii. Hemoptysis iv. Increased sputum purulence or volume v. Chest pain b. No change in antimicrobial regimen for at least 3 months before enrollment c. FEV1 80% predicted d. Use of short-acting beta-agonist 2 days/week for at least the past 3 months e. No baseline requirement for oxygen supplementation f. Ability to maintain oxyhemoglobin saturation of 90% during and after 6-minute walk test g. Not currently taking oral corticosteroids

Exclusion Criteria:

1. Subject has received any investigational drug or vaccine within 4 weeks prior to study drug dosing, or is planning to participate in another investigational drug or vaccine trial prior to completion of this study.
2. Subject is currently taking theophylline or oral corticosteroids.
3. Subject is allergic to milk or milk products.
4. Subject currently smokes tobacco or has smoked tobacco within 1 year prior to study enrollment.
5. Subject has a baseline requirement for oxygen supplementation.
6. Subject is unable to maintain an oxyhemoglobin saturation of 90% during and after 6-minute walk test.
7. The subject tests positive for human immunodeficiency virus (HIV), for hepatitis B virus (HBV), or hepatitis C virus (HCV).
8. The subject's resting blood pressure is outside normal limits (defined as: systolic 90-140 mmHg; diastolic 50-90 mm Hg).
9. The subject's heart rate is less than 45 or greater than 100 beats per minute at rest.
10. The subject weighs less than 45 kg.
11. The subject has a Body Mass Index of greater than 35 kg/m2.
12. The subject has experienced an episode of acute upper respiratory tract infection, pneumonia, otitis, bronchitis, or sinusitis within 6 weeks of study enrollment.
13. The subject has an oral temperature above 37.8°C (100°F).
14. The subject has any surgical, medical, or laboratory condition that, in the judgment of the clinical investigator, might interfere with the safety, distribution, metabolism, or excretion of the drug.
15. The subject has overt primary ciliary dyskinesia, allergic bronchopulmonary aspergillosis, or cystic fibrosis.
16. The subject has previous or current history of the following conditions: renal, hepatic, cardiac, hematologic (including sickle cell disease), muscular, neurological, metabolic, or immunological disorders, malignancy, hepatitis or cirrhosis, transplant recipients, HIV-infection, or other immunosuppressive illness, which could, in the opinion of the study investigators, compromise subject safety or interfere with the assessment of study drug safety.
17. A female who is pregnant or breast-feeding.
18. A subject who has received blood products within 6 months of study enrollment.
19. The subject has donated or lost more than 500 mL of blood in the 3 months prior to screening.
20. The subject has clinically significant medical or psychological conditions that would compromise the subject's safety, influence the results of the study, affect the subject's ability to participate in the study, or impair the subject's ability to provide informed consent.
21. The subject has a history of alcoholism, drug dependence, or significant psychiatric illness within 2 years of study enrollment.
22. The subject uses anticoagulant medications or drugs with known potential for hepatotoxicity as such agents could interfere with relevant safety assessments.
B: Inclusion Criteria:

* Inclusion criteria required that the child have at least one claim with a diagnostic code for asthma or reactive airway disease (International Classification of Diseases (ICD 9) diagnostic code 493.xx) and in the last year period had either1) been hospitalized for asthma
* had at least 2 Emergency Department (ED) visits
* 3-5 ambulatory visits due to asthma
* utilized asthma medications from 2 of the following therapeutic categories: Anticholinergics, cromolyn, sympathomimetics, steroid inhalants, methylxanthines, leukotriene inhibitors, or corticosteroids.

Exclusion Criteria:

* currently participating in another asthma study
* no appropriate address for follow-up in the claims data.
C: Inclusion criteria:

1. All patients and their parents (or legally accepted caregiver) must sign and date an informed consent consistent with ICH-GCP guidelines and local legislation prior to participation in the trial.
2. Male or female patients between 12 and 17 years of age.
3. All patients must have at least a 3 months history of asthma at the time of enrolment into the trial. The diagnosis of asthma has to be confirmed at visit 1 with a bronchodilator reversibility test.
4. All patients must have been on maintenance treatment with inhaled corticosteroids at a stable medium dose for at least 4 weeks before Visit 1.
5. All patients must be symptomatic (partly controlled) at Visit 1 (screening) and at randomisation defined by an Asthma Control Questionnaire (ACQ) mean score of more than or equal to 1.5.
6. All patients must have a pre-bronchodilator FEV1 more than or equal to 60% and less than or equal to 90% of predicted normal at Visit 1. Variation of absolute FEV1 values of Visit 1 as compared to Visit 2 must be within ± 30%.
7. All patients must have an increase in FEV1 of equal or above 12% and 200 mL after 400 µg salbutamol (albuterol) at Visit 1. If patients in the lower age range (e.g., 12 to 14 year olds) exhibit a very small total lung volume, positive reversibility testing might be based solely on the relative (12%) post-bronchodilator response.
8. All patients should be never-smokers or ex-smokers who stopped smoking at least one year prior to enrolment.
9. Patients should be able to use the Respimat® inhaler correctly.
10. Patients must be able to perform all trial related procedures including technically acceptable spirometric manoeuvres.

Exclusion criteria:

1. Patients with a significant disease other than asthma.
2. Patients with clinically relevant abnormal screening haematology or blood chemistry
3. Patients with a history of congenital or acquired heart disease, and/or have been hospitalised for cardiac syncope or failure during the past year.
4. Patients with any unstable or life-threatening cardiac arrhythmia or cardiac arrhythmia requiring intervention or a change in drug therapy within the past year.
5. Patients with malignancy for which the patient has undergone resection, radiation therapy or chemotherapy within the last five years.
6. Patients with lung diseases other than asthma (e.g. Cystic Fibrosis). In case of ex-premature infants, a history of significant bronchopulmonary dysplasia will be regarded as exclusion criterion.
7. Patients with known active tuberculosis.
8. Patients with significant alcohol or drug abuse within the past two years.
9. Patients who have undergone thoracotomy with pulmonary resection.
10. Patients who are currently in a pulmonary rehabilitation program or have completed a pulmonary rehabilitation program in the 6 weeks prior to the screening visit (Visit 1).
11. Patients with known hypersensitivity to anticholinergic drugs, Benzalkonium chloride (BAC), Ethylenediaminetetraacetic acis (EDTA) or any other components of the tiotropium inhalation solution.
12. Pregnant or nursing adolescent female patients
13. Sexually active female patients of child-bearing potential not using a highly effective method of birth control.
14. Patients who have taken an investigational drug within 4 weeks prior to Visit 1.
15. Patients who have been treated with long-acting anticholinergics (e.g. tiotropium -Spiriva) within four weeks prior to screening (Visit 1).
16. Patients who are unable to comply with pulmonary medication restrictions prior to randomisation.
17. Patients who have been treated with Anti-IgE treatment (Omalizumab Xolair) within the last 6 months prior to screening.
18. Patients who have been treated with systemic (oral or intravenous) corticosteroids within 4 weeks prior to screening (Visit 1).
19. Patients who have been treated with long-acting theophylline preparations within 2 weeks prior to screening (Visit 1) or during the run-in period
20. Patients who have been treated with other non-approved and according to international guidelines not recommended ¿experimental¿ drugs for routine asthma therapy.
21. Patients with any acute asthma exacerbation or respiratory tract infection in the 4 weeks prior to Visit 1.
22. Patients requiring 10 or more puffs of rescue medication (salbutamol/albuterol) per day on more than 2 consecutive days during the run-in period.
23. Patients who have previously been randomised in this trial or are currently participating in another study.
24. Patients who are being treated with oral beta-blocker medication.
25. Patients with a known narrow-angle glaucoma, or any other disease where anticholinergic treatment is contraindicated.
26. Patients with renal impairment, as defined by a creatinine clearance less than 50 mL/min/1.73 m2 Body Surface Area as calculated by Schwartz formula.
D: Inclusion Criteria:

* diagnosis of mild asthma, currently well controlled requiring only a bronchodilator (e.g. salbutamol) as needed and infrequently
* has allergies that trigger asthma
* responds to methacholine challenge at 16mg/ml or less
* has FEV1 \> 69.5% predicted

Exclusion Criteria:

* respiratory illness within 4 weeks
* other medical condition assessed by the principal investigator that would put the participant at risk or influence the integrity of the data
* pregnant or lactating females
* hypersensitivity to ibuprofen

Answer: B