Thesis (Ph.D.)--Boston University. / This study used the procedures of classical conditioning to investigate the possibility of producing asthmatic bronchospasm as a conditioned response. In order to carry out this study equipment was developed which permitted the experimental operations to be carried out while disguising the purpose of the experiment from the subjects. In the experiment, bronchospasm, induced by inhaled acetyl beta methacholine chloride, and shown to be highly similar to the condition of the lungs in asthma, was paired with auditory or visual stimuli. Similarly, Isuprel-induced relief of bronchospasm was paired with another exteroceptive stimulus in an attempt to condition the end of the attack. Subjects, on the average, received ten to fifteen conditioning trials depending on their cooperation and availability. Of four subjects who completed the necessary trials evidence for conditioning appeared in two. Magnitude of the conditioned responses is not great, producing, on the average, reduction of about 8% of the vital capacity in five minutes. Both of these subjects show conditioning to the experimental situation; one of the two, conditioning to the exteroceptive stimuli presented by the experimenter. The fact that conditioning did not automatically result from the experimental procedure and the complexity of the conditioning process apparent from detailed examination of the individual cases, led to discussion concerning the nature of conditioning, with special emphasis on the new area of interoceptive conditioning. The author takes the viewpoint that a central emotional-expectancy is an important aspect of conditioned visceral responses, and rejects connectionism between an external stimulus and a response. In addition, one peculiarity of the conditioning done in this experiment is noted. The unconditioned stimulus, rather than acting on the sensory nervous system, produces direct local change in the lungs. The resulting lack of representation of the UCS in the central nervous system is discussed in the reference to classical Pavlovian theory. The writer sees the application of interoceptive conditioning techniques as a fruitful method for further exploration of psychosomatic disorders. [TRUNCATED]

Asthma is a chronic disease of the lungs and respiratory passages. Hallmarks of asthma exacerbation, commonly referred to as an “asthma attack,” are bronchoconstriction, inflammation, and airway remodeling. Millions of people worldwide have asthma, with both children and adults affected by the disease. Asthma prevalence in the United States has been increasing on a yearly basis, and thus asthma is a serious health threat to people of all ages. Asthma can be controlled with short term bronchodilatory drugs and inhaled corticosteroids for long-term inflammation management. Pediatric asthma is particularly taxing, however, as it can cause numerous absences from school, frequent hospitalizations, and can be difficult for children to manage without close supervision. Many of these pediatric patients present in emergency departments, and are given oral or IV steroids to treat the asthma exacerbation. We specifically want to assess the effect of early administration of these steroids on the patient outcomes of admission rate and length of stay. We hypothesize that patients given steroids sooner rather than later are less likely to be admitted to inpatient status and will have a shorter stay in the emergency department. To test our hypotheses, we conducted a retrospective study in which we gathered pediatric patient data from August, 2011, to April, 2012. We included patients that presented with asthma exacerbation and recorded a number of metrics and variables for each patient, including time of steroid administration, admission status, and total length of stay in the emergency department. Steroid administration time was separated into two categories: administration pre or post-30 minutes of triage, and administration pre or post-60 minutes of triage. This data was logged, reviewed, and finally analyzed for statistical significance. Results of the study showed that there is no statistically significant association between time of steroid administration on admission rates. To assess the relationship of steroid administration time and length of stay in the emergency department, patients with the same admission status were compared against one another in order to eliminate potential confounding (i.e. length of stay for admitted patients who received steroids within 30 minutes was compared to that of admitted patients receiving steroids post-30 minutes, and so on). Overall, those patients receiving steroids tended to have a shorter mean length of stay in the emergency department. This finding was statistically significant for only one subset of the patient sample, however: discharged patients who received their steroids pre-60 minutes as opposed to post-60 minutes. While the data that we analyzed did not depict many statistically significant associations, it did reveal trends in outcomes that are associated with timing of steroid administration. With further study and an expanded sample size, these associations may prove to be of significance. From a clinical perspective, such findings could impact emergency asthma care, with early steroid administration becoming more of a priority in treatment protocols.

Background: Mast cells are known to play a role in the pathophysiology of asthma. Determining their contribution to the development of asthma symptoms has been difficult as they remain tissue-resident and do not usually migrate into the airway lumen for detection using expectorated sputum. Objectives: We investigated the presence and activity of mast cells in the blood and sputum of healthy controls and patients with moderate to severe asthma and the relationship with clinical characteristics of asthma and their associated microenvironment. Methods: Cell-free sputum supernatant was used to detect levels of soluble tryptase and T2 and non-T2 cytokines by ELISA. RNA/cDNA isolated from sputum cells measured expression levels of eosinophil and mast cell-specific genes by digital PCR. Relevant clinical characteristics and measurements of lung function, airway hyperresponsiveness, FeNO, blood eosinophils, IgE and tryptase were collected. Results: Tryptase was detectable in the fluid phase portions of sputum, irrespective of the inflammation based on the differential cell count, and was significantly different than healthy controls. Eosinophil and mast cell-specific genes were detected in sputum cells at levels significantly different than healthy controls. Sputum tryptase was not associated with any phenotype or severity of asthma but identified some associations with clinical characteristics. It is associated with a unique cytokine signature. Conclusion: Differences were seen between eosinophilic and non-eosinophilic phenotypes in sputum supernatant and sputum cells. Eosinophil and mast cell-specific genes were detected in sputum cells but were not associated with asthma severity. Greater levels of cytokines IL-4 and IL-13 in sputum, suggest presence of mast cells in the airway epithelium that contribute to mucus secretion observed in patients with uncontrolled symptoms of asthma. Further investigations hope to identify the relationship of mast cells with the quantification of mucus in these patients to understand and confirm those with a predominant mast cell component. / Thesis / Master of Science (MSc) / In patients with asthma, mast cells are one of the inflammatory cells normally associated with allergies however, they also function by non-allergic mechanisms (bacteria, viruses, fungus, pollutants). Inflammatory cells cause swelling of the bronchial tubes, tightening/spasm of the bronchial muscles, and mucus production. The level of inflammation is measured in lung fluids such as sputum, but the mast cell remains in the lung tissue and therefore difficult to detect. When mast cells are activated they release mediators such as tryptase, that travel through the lung tissue. Tryptase was detected in the sputum of patients with moderate to severe asthma, with levels significantly greater than in healthy people. The level of sputum tryptase was independent of other inflammatory cells such as eosinophils, and was associated with biomarkers related to excess secretion of mucus. Further research hopes to understand if the mucus is related to the activity of the mast cell.

No description available.

Background: Asthma Link is a program that aims to increase adherence to inhaled corticosteroids among children with persistent asthma by delivering evidence-based school-supervised therapy. This program, which leverages existing infrastructure, improves asthma outcomes in children from low-income, minority families. Our aim was to elicit the perspectives of school nurses who supervise preventive medication administration. Methods: Semi-structured qualitative interviews were conducted with 12 school nurses participating in Asthma Link. Thematic analysis was used to identify themes related to barriers and facilitators to preventive medication delivery. Results: Barriers described by school nurses included communication challenges with families and providers, inconsistent supplies of the preventive medicine at school, and the perception by some families and nurses that preventive therapy should be provided at home. Facilitators included the ease of incorporating preventive medication delivery into morning routines, recognizing the positive impacts on children from families with limited resources, feeling part of the preventive health care team, and being well-positioned to engage families in preventive asthma care. Conclusions: To facilitate Asthma Link adoption, it is critical to incorporate school nurse feedback in the program’s protocol refinement. School-supervised asthma therapy programs are advised to engage school nurses in the opportunity to provide preventive care, streamline communication, and address social and logistical challenges which may impede families from bringing medication to school.

Atopic asthma is a complex disease process that has a significant social, personal and economic burden across all ages. Leukotriene-receptors are involved in the cascade of inflammation that may result in symptoms of atopy and asthma. Two leukotriene receptors have been identified in the lung. The cysteinyl leukotriene receptor 1 and cysteinyl leukotriene receptor 2 genes (i.e., CYSLTR1 and CYSLTR2) have been sequenced, and a number of single nucleotide polymorphisms (SNPs) within these genes have been identified.The purpose of this study was to: (1) Determine the relationship between CYSLTR1 genotypes, CYSLTR2 genotype, atopy, elevated IgE level, and eosinophilia, (2) Determine the relationship between CYSLTR1 genotypes, CYSLTR2 genotype, asthma, and atopic asthma, and (3) Determine the degree of interaction between CYSLTR2 genetic variation and gender in atopic asthma.Nested within two sub-studies of the Tucson Epidemiological Study of Airway Obstructive Disease (TESAOD) study, a prospective longitudinal cohort, 853 individuals were entered into this study. Study criteria included Non-Hispanic white adults, who consented to genetic testing in the two sub-studies. Tagging SNPs of the CYSLTR1 and CYSLTR2 genes were genotyped. Serum IgE status and eosinophilia were obtained from existing dataset. Questionnaires collected in the parent study were used to obtain demographic and clinical data.SNP rs321006 in the CYSLTR1 gene was associated with atopy among Non-Hispanic white women. Assuming a recessive model, among female Non-Hispanic white adults, the odds of having rs321073 CC genotype was 5.82 times higher among those with atopic asthma than those without atopic asthma. No gene by gender interaction was found between SNP of interest in CYSLTR2 and atopic asthma. Genetic association of SNPs rs321006 with atopy and rs321073 with atopic asthma are novel findings to date.Implications for nurses, clinicians, and scientists include better understanding of associations of these genetic variations with asthma, atopy, and atopic asthma that can generate further inquiry into other mechanisms of atopic asthma. These novel genetic associations with atopy and atopic asthma may have the potential for personalized medicine that might afford patients with appropriate treatment based on their genotype.

Asthma is a chronic respiratory disease affecting over 300 million individuals worldwide (Akinbami et al., 2012; Brashers, 2010). Despite increased knowledge regarding the mechanisms and pathophysiology of asthma and increased treatment options, the prevalence of asthma in the United States continues to rise (Akinbami et al., 2012). Evidence-based guidelines on the treatment and management of asthma have been available for over 20 years and the use of Asthma Action Plans (AAP) has been consistently recommended to provide patients with the self-management skills to control asthma symptoms. However, research has consistently demonstrated underutilized AAPs as a method to decrease asthma exacerbations. The purpose of this DNP project was to develop and implement a quality improvement (QI) initiative with Internal and Family Medicine in Mesa-Gilbert, Arizona that will improve asthma clinical management by providing the patient self-management skills needed to control the symptoms, prevent complications, and improve outcomes through the implementation of AAP standards for patients diagnosed with asthma. Using the Plan-Do-Study-Act (PDSA) method to promote quality improvement (QI), a root cause analysis was conducted to evaluate the current processes within the clinic. The QI team agreed upon a process change, which was implemented to promote the identification of patients with asthma so that an AAP could be implemented. The low rates of patients identified during the time period in which this QI project was conducted presented a limitation as to whether the process change was truly effective. This project discussed the process of QI using the PDSA Model for Improvement and need for evidence-based practice to promote improved patient outcomes. Further PDSA cycles and additional time are required to fully incorporate process change and to determine the effectiveness of the intervention.

by Chan Tung. / Thesis (M.Phil.)--Chinese University of Hong Kong, 1998. / Includes bibliographical references (leaves 85-102). / Abstract and questionnaire also in Chinese. / Abstract --- p.i / Chinese abstract --- p.ii / Table of contents --- p.iii / Acknowledgment --- p.v / List of tables --- p.vi / List of figures --- p.vii / Glossary of terms and abbreviations --- p.viii / Chapter Chapter 1 --- Introduction --- p.1 / Chapter 1.1 --- Asthma epidemiology --- p.1 / Chapter 1.2 --- Aim of study --- p.3 / Chapter Chapter 2 --- Literature review --- p.4 / Chapter 2.1 --- Definitions of asthma --- p.4 / Chapter 2.2 --- Questionnaire in asthma epidemiological surveys --- p.7 / Chapter 2.3 --- Asthma prevalence studies in Western populations --- p.9 / Chapter 2.4 --- Asthma prevalence studies in Hong Kong --- p.13 / Chapter 2.4.1 --- Adult asthma --- p.14 / Chapter 2.4.2 --- Childhood asthma --- p.15 / Chapter 2.4.3 --- Asthma mortality --- p.17 / Chapter 2.5 --- Environmental risk factors of asthma --- p.17 / Chapter 2.5.1 --- Allergens --- p.19 / Chapter 2.5.2 --- Air pollution --- p.23 / Chapter 2.5.3 --- Environmental tobacco smoke --- p.27 / Chapter 2.5.4 --- Viral infections --- p.29 / Chapter 2.5.5 --- Dietary factors --- p.30 / Chapter 2.5.6 --- Allergen avoidance --- p.32 / Chapter Chapter 3 --- Epidemiological survey --- p.34 / Chapter 3.1 --- Subjects and methods --- p.34 / Chapter 3.1.1 --- Subjects --- p.34 / Chapter 3.1.2 --- Written questionnaire --- p.35 / Chapter 3.1.3 --- Video questionnaire --- p.36 / Chapter 3.1.4 --- Bronchial hyperresponsiveness testing --- p.38 / Chapter 3.2 --- Results --- p.42 / Chapter 3.3 --- Discussion --- p.55 / Chapter Chapter 4 --- Environmental survey --- p.63 / Chapter 4.1 --- Subjects and methods --- p.63 / Chapter 4.1.1 --- Subjects --- p.63 / Chapter 4.1.2 --- Questionnaire survey --- p.63 / Chapter 4.1.3 --- Allergen sampling --- p.64 / Chapter 4.2 --- Results --- p.68 / Chapter 4.3 --- Discussion --- p.73 / Chapter Chapter 5 --- Overall discussion and conclusions --- p.81 / References --- p.85 / Appendix

Thesis (M.S.)--Boston University / The purpose of this study is to explore the social factors which are present in the children and adults with a diagnosis of bronchial asthma and to learn the role of the social worker in the treatment of these cases. The writer hopes to find out the ways in which the medical social worker can help the asthmatic patient benefit from the medical treatment he is receiving. The writer sets forth the following questions to be answered: 1) What are the reasons for referral to the socia~ service department? 2) What are the factors in the environment which seem to be impeding treatment? 3) What methods are ; used by the social worker in trying to remove the obstacles? 4) To what extent is it possible to achieve these objectives?

Asthma is the most common long-term condition in children in the United Kingdom (UK). Asthma-related hospitalisations and mortality are disproportionally higher in the UK, compared with other European countries, however the reasons for this disparity remain unclear. A putative explanation is that that prevalence of suboptimal asthma control in children in the UK is higher than in continental Europe. If this is indeed correct, then the drivers of suboptimal control, such as poor adherence to therapy resulting from poor understanding of the role of preventer medication (inhaled corticosteroids (ICS)) in UK children would be of significant clinical interest. Therefore, in this thesis, I sought to first identify the levels of asthma control and medication adherence in a non-random sample of London secondary school children. Then, I used focus groups to further highlight the barriers to good medication adherence, and generate insights into potential solutions. To achieve these aims, I developed and implemented an online questionnaire to be delivered in schools, which included the validated Asthma Control Test (ACT). Methods: This thesis is divided into three main sections. The first and second sections include original data from an observational research study, which collected data about asthma control, from 24 London secondary schools between December 2014 and March 2016. The aim of the first section was to assess current levels of asthma control and medication adherence among children with asthma in London secondary schools. Data were collected using an online questionnaire, which included the validated ACT to measure asthma control, as well as additional questions about knowledge, healthcare use, medication use, school attendance, lifestyle and emotion and behaviour, using the validated Me and My School (M&MS) questionnaire. The second section of this thesis includes data generated from six focus groups, conducted in four London secondary schools with 56 students. In order to generate data to inform future interventions, discussions focused on the barriers to medication adherence among teenagers, and how these barriers could be addressed. The third section comprises a systematic review of school-based self-management interventions for children with asthma. The review uses a mixed-methods approach, and includes both quantitative and qualitative study data. A process evaluation is also included, to identify intervention elements that are associated with implementation success. Results: 766 children with asthma from 24 schools were surveyed. Almost half of the students (45.7%; n = 350) had poor asthma control by ACT score. Adherence with asthma medication was low, regardless of asthma control (56.2% self-reported forgetting to use their ICS "preventer" inhaler; 29% self-reported not using their SABA "reliever" inhaler when they needed it, at least some of the time). Health care involvement was relatively high, with at least one unplanned GP visit, due to asthma in the previous four weeks, reported by 28.1% of students; at least one unplanned hospital visit was self-reported by 15.7% of students; and at least one unplanned school nurse visit due to asthma was self-reported by 16% of students. At least one whole school absence was reported by 20.9% of students. Unplanned medical care and school absences were higher among children with poor asthma control, according to the ACT. Themes from focus groups suggested that social stigma, fear of embarrassment, forgetfulness, and incorrect attitudes towards medication were all contributory factors to poor medication adherence. Communications with healthcare professionals were also identified as key unmet needs of teenagers with asthma. The findings from the meta-analyses, included in the systematic review of school-based self-management interventions, showed that such interventions were effective in improving several outcomes, largely related to healthcare use. These included hospitalisations, emergency department (ED) visits, and health-related quality of life. There was no evidence that school-based interventions improved school absences, experiences of day and night time symptoms, or the use of medication. The findings from the analysis of the process evaluation studies showed that a theoretical framework is important in the development of a successful intervention. Conclusions: First, in a large non-random sample of secondary school children with asthma, the proportion of children with suboptimal control is worryingly high, and this is associated with general poor adherence to prescribed therapy asthma. Second, focus groups identified practical and social barriers to good adherence, that should be addressed in future studies. Third, previous studies suggest that school based interventions are effective in reducing incidences of unplanned and urgent healthcare use. The systematic review included studies that included relatively hard-to-reach populations, suggesting that such interventions may be effective across diverse populations, including those considered hard-to-reach. The findings in this thesis informed the development of a school-based self-management intervention, to be piloted in London secondary schools, and an NIHR-funded global research group award on improving asthma control in African children.