Electronic Medical Records - EMR

CureMD delivers knowledge when and where required through integrated applications and evidence based knowledge base, and alerting system. Rich functionalities spanning over forty modules and sub-systems directly connect with remote offices, pharmacies, labs and devices to deliver instant and complete access to all the information you need, when you need it.

CureMD supports continuity of care management through innovative tools that adapt to your unique workflow and clinical approach. Specialty specific, template driven, point and click technology accurately documents patient encounters and transactions.

CureMD simplifies decision making, streamlines operations and ensures compliance to industry standards and best practices, ultimately saving time and effort to maximize value and returns.

Features

* Problems & Complaints
* History (Present Illness, Family, Social, Medical)
* Vitals
* Review of Systems
* Physical Exam (Inspection, Palpation, Auscultation)
* Electronic Prescriptions (CPOE)
* Lab Interfaces
* Document Imaging
* Clinical Knowledge Base
* Decision Support
* Disease Management
* Workflow Editor
* Auto Note
* Referral Management



* Follow-up/Recall Tracking
* Patient Education
* Electronic Signature
* eFax Capability
* Voice Recognition
* Trending & Graphing
* Integrated PQRI
* Denial Management
* Treatment Plans/Order Sets
* Continuity of Care Document (CCD)
* Immunization Information System
* KPI Dashboard
* Biometric Authentication
* Integrated Clinical Reference Material
* Business Process Designer

Integrated Modules

* Patient Profile
* Enterprise Scheduling
* Eligibility Verification
* Electronic Billing
* Workflow Management
* E&M Coding Optimization



* Enterprise Messaging
* Calendar, Email & Reminders
* Notes & Task Management
* Audit Trail & Access Control
* Cure Patient Portal
* Data Mining Reports


Specialty Knowledge Base: (Click to find your Specialty Information)

Allergy

Allergy
Ambulatory Surgery Center Ambulatory Surgery Center
Cardiology

Cardiology
Dermatology Dermatology
Emergency Medicine

Emergency Medicine
Endocrinology

Endocrinology
General Surgery

General Surgery
Gastroenterology

Gastroenterology
Hand Surgery

Hand Surgery
Home Care

Home Care
Internal Medicine

Internal Medicine
Infectious Disease

Infectious Disease
Obstetrics /Gynecology

Obstetrics /Gynecology
Neurology

Neurology
Orthopedics

Orthopedics
Oncology

Oncology
Otolaryngology

Otolaryngology
Ophthalmology

Ophthalmology
Pediatrics

Pediatrics
Pain Management

Pain Management
Podiatry

Podiatry
Physical Medicine

Physical Medicine
Pulmonary

Pulmonary
Primary Care, Family Practice

Primary Care, Family Practice
Rheumatology

Rheumatology
Rehabilitative Medicine

Rehabilitative Medicine
Nursing Nursing Speech Therapy Speech Therapy
Sleep Sleep Vascular Surgery Vascular Surgery
Urology Urology Student and Employee Health Care Services Student and Employee Health Care Services


All-in-One Solution


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Electronic Medical Records (EMR)

CureMD Electronic Medical records is a browser based, customizable CCHIT certified solution designed to empower care providers of the internet age. CureMD EMR supports continuity of care management through innovative tools that adapt to your unique workflow and clinical approach.
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Practice Management System

CureMD PMS is a web based enterprise practice management solution designed to meet the broadest possible range of a modern practice's administrative, communication and fiscal management needs.
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Mobile Care Management

CureMobile† extends the functionality of CureMD by providing a complete, fully integrated point-of-care solution.
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Patient Portal

Facilitate your patients to securely request appointment and refills online, receive test results as they become available, utilize educational material and update their health status, history, demographics and insurance information while subscribing to valuable electronic services.
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Computerized Physician Order Entry

Electronic orders and results management for prescriptions, labs, procedures and radiology allow you to work more efficiently and make swift, well informed and confident decisions.
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Allergy (Immunology) EMR

CureMD Allergy & Immunology EMR is a configurable solution transforming the way Immunologists capture, manage and exchange patient clinical and financial information. The system offers built-in SOAP templates attuned to Allergy & Immunology. These readymade point & click templates cover most common Immunology treatments and allow complete customization to match your personalized practice needs.

In addition to standard EMR features, following Immunology specific functionalities are built in:

* Treatment protocols for Defense mechanisms & Inflammation
* Consolidation of vaccination data
* Generation of reminders and recall notifications
* Assessments of vaccination coverage
* Adverse event reporting
* Tracking of Immunodeficiencies & Immunomodulation
* Lifetime vaccination histories
* Tracking of Organ specific inflammatory diseases

The system enables Immunologists enhance their practice throughput by streamlining the entire set of operational procedures right from patient scheduling to treatment planning and beyond. Moreover, the system is embedded with all current ICD and CPT codes, allowing Immunologists capture, submit and track charges electronically. The latest version of the application also supports advanced features like KPI based digital dashboards, RightRemit, Auto Note and built in clinical decision support.


All-in-One Solution


Click for preview

Electronic Medical Records (EMR)

CureMD Electronic Medical records is a browser based, customizable CCHIT certified solution designed to empower care providers of the internet age. CureMD EMR supports continuity of care management through innovative tools that adapt to your unique workflow and clinical approach.
(Learn More)

Click for preview

Practice Management System

CureMD PMS is a web based enterprise practice management solution designed to meet the broadest possible range of a modern practice's administrative, communication and fiscal management needs.
(Learn More)

Click for preview

Mobile Care Management

CureMobile† extends the functionality of CureMD by providing a complete, fully integrated point-of-care solution.
(Learn More)

Click for preview

Patient Portal

Facilitate your patients to securely request appointment and refills online, receive test results as they become available, utilize educational material and update their health status, history, demographics and insurance information while subscribing to valuable electronic services.
(Learn More)

Click for preview

Computerized Physician Order Entry

Electronic orders and results management for prescriptions, labs, procedures and radiology allow you to work more efficiently and make swift, well informed and confident decisions.

Allergies

About Allergies
Dr.Shahid Abbas believes that there is lack of awareness in general public about allergies which are neither easily understood nor easily treated. Patient needs a great deal of information so that they can treat themselves. They should note early warning signs of allergies in children and adults and prevent serious and life threatening allergic conditions. Parents and teachers should note the early signs and symptoms in their children .

Types of Allergy
Hormone allergy is a type of allergic reaction experienced by women from before puberty to old age. It is a heightened or extra ordinary reaction to the normal function of hormones.And while there are many journal references to the connection between hormones and symptoms, I am aware of only one recent textbook that actually suggests a hormone allergy.
Mold Allergies
Most people will realize what they are reacting to because there are clearly defined SEASONS when the most common and the most powerful pollens occur. Fall, for example, is CANNABIS OR PIG WEED season. So, if you get a stuffy nose and a low-grade fever (up to 100 degrees) during August or September, you are probably having an allergy attack.
Food Allergies
If you are allergic to a food, you tend to LOVE IT or HATE IT; as such foods usually are addictive. As a result, most people will pick the foods to which they are MOST ALLERGIC. Most of my patients will find that they react to one or more of these foods when they re-introduce them following five days of avoidance. This is called UNMASKING the FOOD ALLERGY.
Do you know Allergy can Cause ( Symptoms )
ALLERGY CANNOT DO EVERY THING BUT CAN DO ANYTHING. Let me explain this in very simple words that allergy can effect every system in the body and can casue any of the following symptoms.
If all other medical causes of the following symptoms have been eliminated, the symptoms may be caused by allergy. This is especially true of symptoms that occur seasonally or that come and go.
ontact Information ( outstation Visits & Vaccine orders)
When you call, please let us know that you will be coming from out of town so we may help with accommodations. We suggest that you plan to travel to Islamabad the evening before and schedule your appointment early so there will be plenty of time to see you as a New Patient. Our office at Khyber Plaza, located on Fazal e Haque road, Blue Artea, behind Citi Bank.n Building.

Allergens
Allergy is an adverse immune reaction to a protein or allergen in our
environment that is normally harmless to the non-allergic individual.
It can manifest itself as itching of the skin, tissue swelling and
wheezing or even progress to full-blown anaphylaxis and death
A process of sensitisation must first take place

Hormone Allergy
Hormone allergy is a type of allergic reaction experienced by women from before puberty to old age. It is a heightened or extra ordinary reaction to the normal function of hormones.And while there are many journal references to the connection between hormones and symptoms, I am aware of only one recent textbook that actually suggests a hormone allergy.

Food

Food is any substance normally eaten or drunk by living organisms. The term food also includes liquid drinks. Food is the main source of energy and of nutrition for animals, and is usually of animal or plant origin.
There are various names for fake food including: pretend food, wax food, artificial food, faux food, replica food, imitation food, food replicas, false foods, food fakes and simulated food.
History
Fake food dishes in a restaurant in Japan.

Fake food dates back to the time of the Pharaohs of Egypt and perhaps before. When a King or Pharaoh died, they were often buried with everything they needed for their journey to the next world. Foods were preserved and laid to rest with them in their tomb.

Modern times saw increased use of fake food. During the early Shōwa period, following Japan’s surrender ending World War II, Americans and Europeans traveled to Japan to help with the rebuilding efforts. Foreign travelers had difficulties reading Japanese menus, so Japanese artisans and candle makers quickly developed plates of wax foods for restaurants that made it easy for foreigners order something that looked good.[1] Paraffin was used to create fake food until the mid-1980s; because its colors faded when exposed to heat or sunlight, manufacturers later switched to vinyl chloride, which is "nearly eternal".[2]

[edit] Modern Use

Fake foods are used in many ways, such as props for backgrounds in movies, television shows, theatrical plays, television commercials, print ads and trade shows. Fake foods are also used to display lifelike replicas of real foods for restaurants, grocery chains, museums, banquet halls, casino buffets, cruise ships and in many other instances in which real foods can not be displayed. For instance, the American company Fake Foods began when fast food restaurant Wendy's needed fake kale for their salad bar display.[3]

Many of Japan’s restaurants still use fake foods to display their popular dishes in their windows and attract customers. The plastic replicas are much more expensive than the food they imitate, but can last indefinitely. For this reason, many companies that manufacture fake food have stagnant or declining profits.[4]

[edit] Manufacturing Process

Today’s manufacturing technologies and high quality plastic materials provide realistic-looking fake food replicas, and approximately 95% of all fake food is still handcrafted. Artisans and highly trained craftsmen make realistic fake food, often painting them by hand to create a realistic look and feel. Some Japanese fake food manufacturers mimic the actual cooking process, employing chef's knives to chop plastic vegetables and real hot oil to fry plastic shrimp.[5]

At the beginning of the production process, real food is dipped in silicone to create a mold. A liquid plastic of the correct color, typically vinyl chloride, is poured into the mold, then heated in an oven until it solidifies.[1] When a food is not available or it would disintegrate or melt in the mold while the mold is setting up, a clay model of the food must be sculpted first. After setting for ten to thirty minutes, any excess vinyl buildup is trimmed off. Next, the replica is painted either by hand or airbrush. If the food has many parts, such as a hamburger or sushi roll, the item is assembled from many vinyl pieces.

Food science

Food science is a study concerned with all technical aspects of food, beginning with harvesting or slaughtering, and ending with its cooking and consumption. It is considered one of the agricultural sciences, and is usually considered distinct from the field of nutrition.
Examples

Examples of the activities of food scientists include the development of new food products, design of processes to produce these foods, choice of packaging materials, shelf-life studies, sensory evaluation of the product with trained expert panels or potential consumers, as well as microbiological and chemical testing. Food scientists at universities may study more fundamental phenomena that are directly linked to the production of particular food product and its properties. In the U.S., food science is typically studied at land-grant universities.

Food science is a highly interdisciplinary applied science. It incorporates concepts from many different fields including microbiology, chemical engineering, biochemistry, and many others.

Some of the subdisciplines of food science include:

* Food safety - the causes, prevention and communication dealing with foodborne illness
* Food microbiology - the positive and negative interactions between micro-organisms and foods
* Food preservation - the causes and prevention of quality degradation
* Food engineering - the industrial processes used to manufacture food
* Product development - the invention of new food products
* Sensory analysis - the study of how food is perceived by the consumer's senses
* Food chemistry - the molecular composition of food and the involvement of these molecules in chemical reactions
* Food packaging - the study of how packaging is used to preserve food after it has been processed and contain it through distribution.
* Molecular gastronomy - the scientific investigation of processes in cooking, social & artistic gastronomical phenomena
* Food technology - the technological aspects
* Food physics - the physical aspects of foods (such as viscosity, creaminess, and texture)

The main organization in the United States regarding food science and food technology is the Institute of Food Technologists (IFT), headquartered in Chicago, Illinois, which is the US member organisation of the International Union of Food Science and Technology (IUFoST). The European national organisations are organised into the European Federation of Food Science and Technology (EFFoST), based at Wageningen University, the Netherlands.

Some popular books on some aspects of food science or kitchen science have been written by Harold McGee and Howard Hillman.

In the October 2006 issue of Food Technology, 2006-07 IFT President Dennis R. Heldman noted that the IFT Committee on Higher Education gave the current definition of food science as follows: "Food Science is the discipline in which the engineering, biological, and physical sciences are used to study the nature of foods, the causes of deterioration, the principles underlying food processing, and the improvement of foods for the consuming public."[1]

[edit] References

Allergy

Statistics

For reasons that are not entirely understood, the diagnosis of food allergies has apparently become more common in Western nations in recent times.[4] In the United States food allergy affects as many as 5% of infants less than three years of age[26] and 3% to 4% of adults.[27] There is a similar prevalence in Canada.[28]

The most common food allergens include peanuts, milk, eggs, tree nuts, fish, shellfish, soy, and wheat - these foods account for about 90% of all allergic reactions.[citation needed]

[edit] Differing views

Various medical practitioners have a differing views on food allergies. Irritable Bowel Syndrome (IBS) patients have been studied with regards to food allergies. Some studies have reported on the role of food allergy in IBS; only one epidemiological study on functional dyspepsia and food allergy has been published. However, since 2005 several studies have demonstrated strong correlation between IgG and/or IgE food allergy and IBS symptoms[29][30][31] The mechanisms by which food activates mucosal immune system are incompletely understood, but food specific IgE and IgG4 appeared to mediate the hypersensitivity reaction in a subgroup of IBS patients. Specific chemicals and receptors have been demonstrated to be critical in food allergy development in murine models.[32] Exclusion diets based on skin prick test, RAST for IgE or IgG4, hypoallergic diet and clinical trials with oral disodium cromoglycate have been conducted, and some success has been reported in a subset of IBS patients.[33]

Studies comparing skin prick testing and ELISA blood testing have found that the results of skin prick testing correlate poorly with symptoms of irritable bowel syndrome that correlate with food allergies demonstrated through ELISA testing and dietary challenge.[34]

Extensive clinical experience has demonstrated significant improvement of patients with IBS whose ELISA-based food allergy testing is positive and where treatment includes a careful exclusion diet.[35]

In addition, many practitioners of alternative medicine ascribe symptoms to food allergy where other doctors do not. The causal relationships between some of these conditions and food allergies have not been studied extensively enough to provide sufficient evidence to become authoritative. The interaction of histamine with the nervous system receptors has been demonstrated, but more study is needed.[36] Other immune response effects are commonly known (swelling, irritation, etc.), but their relationships to some conditions has not been extensively studied. Examples are arthritis, fatigue, headaches, and hyperactivity. Nevertheless, hypoallergenic diets reportedly can be of benefit in these conditions, indicating that the current medical views on food allergy may be too narrow.

[edit] In children

Milk and soy allergies in children can often go undiagnosed for many months, causing much worry for parents and health risks for infants and children. Many infants with milk and soy allergies can show signs of colic, blood in the stool, mucous in the stool, reflux, rashes and other harmful medical conditions.[citation needed] These conditions are often misdiagnosed as viruses or colic.

Some children who are allergic to cow's milk protein also show a cross sensitivity to soy-based products.[37] There are infant formulas in which the milk and soy proteins are degraded so when taken by an infant, their immune system does not recognize the allergen and they can safely consume the product. Hypoallergenic infant formulas can be based on hydrolyzed proteins, which are proteins partially predigested in a less antigenic form. Other formulas, based on free amino acids, are the least antigenic and provide complete nutrition support in severe forms of milk allergy.

Seventy-five percent of children who have allergies to milk protein are able to tolerate baked-in milk products, ie., muffins, cookies, cake.

About 50% of children with allergies to milk, egg, soy, and wheat will outgrow their allergy by the age of 6. Those that don't, and those that are still allergic by the age of 12 or so, have less than an 8% chance of outgrowing the allergy.[38]

Peanut and tree nut allergies are less likely to be outgrown, although evidence now shows[39] that about 20% of those with peanut allergies and 9% of those with tree nut allergies[40] will outgrow their allergies. In such a case, they need to consume nuts in some regular fashion to maintain the non-allergic status.[citation needed] This should be discussed with a doctor.

Those with other food allergies may or may not outgrow their allergies.

[edit] Labeling laws

In response to the risk that certain foods pose to those with food allergies, countries have responded by instituting labeling laws that require food products to clearly inform consumers if their products contain major allergens or by-products of major allergens.

[edit] United States law

Under the Food Allergen Labeling and Consumer Protection Act of 2004 (Public Law 108-282), companies are required to disclose on the label whether the product contains a major food allergen in clear, plain language. The allergens have to clearly be called out in the ingredient statement. Most companies list allergens in a statement separate from the ingredient statement.[41]

[edit] See also
Food portal

* Lactose intolerance
* Oral Allergy Syndrome
* Medical emergency
* Mast cell

food allergies

More rare food allergies

Likelihood of allergy can increase with exposure[citation needed]. For example, rice allergy is more common in East Asia where rice forms a large part of the diet.[13]

In Central Europe, celery allergy is more common. In Japan, allergy to buckwheat flour, used for Soba noodles, is more common.

Red meat allergy is extremely rare in the general population, but a geographic cluster of people allergic to red meat has been observed in Sydney, Australia.[14] There appears to be a possible association between localised reaction to tick bite and the development of red meat allergy.

Fruit allergies exist, such as to apples, pears, jackfruit, strawberries, etc.

Corn allergy may also be prevalent in many populations, although it may be difficult to recognize in areas such as the United States and Canada where corn derivatives are common in the food supply.[15]

[edit] Diagnosis

The best method for diagnosing food allergy is to be assessed by an allergist. The allergist will review the patient's history and the symptoms or reactions that have been noted after food ingestion. If the allergist feels the symptoms or reactions are consistent with food allergy, he/she will perform allergy tests.

Examples of allergy testing include:

* Skin prick testing is easy to do and results are available in minutes. Different allergists may use different devices for skin prick testing. Some use a "bifurcated needle", which looks like a fork with 2 prongs. Others use a "multi-test", which may look like a small board with several pins sticking out of it. In these tests, a tiny amount of the suspected allergen is put onto the skin or into a testing device, and the device is placed on the skin to prick, or break through, the top layer of skin. This puts a small amount of the allergen under the skin. A hive will form at any spot where the person is allergic. This test generally yields a positive or negative result. It is good for quickly learning if a person is allergic to a particular food or not, because it detects allergic antibodies known as IgE. Skin tests cannot predict if a reaction would occur or what kind of reaction might occur if a person ingests that particular allergen. They can however confirm an allergy in light of a patient's history of reactions to a particular food. Non-IgE mediated allergies cannot be detected by this method.

* Blood tests are another useful diagnostic tool for evaluating IgE-mediated food allergies. For example, the RAST (RadioAllergoSorbent Test)detects the presence of IgE antibodies to a particular allergen. A CAP-RAST test is a specific type of RAST test with greater specificity: it can show the amount of IgE present to each allergen.[16] Researchers have been able to determine "predictive values" for certain foods. These predictive values can be compared to the RAST blood test results. If a persons RAST score is higher than the predictive value for that food, then there is over a 95% chance the person will have an allergic reaction (limited to rash and anaphylaxis reactions) if they ingest that food.[citation needed] Currently, predictive values are available for the following foods: milk, egg, peanut, fish, soy, and wheat.[17][18][19] Blood tests allow for hundreds of allergens to be screened from a single sample, and cover food allergies as well as inhalants. However, non-IgE mediated allergies cannot be detected by this method.

* Food challenges, especially double-blind placebo-controlled food challenges (DBPCFC), are the gold standard for diagnosis of food allergies, including most non-IgE mediated reactions. Blind food challenges involve packaging the suspected allergen into a capsule, giving it to the patient, and observing the patient for signs or symptoms of an allergic reaction. Due to the risk of anaphylaxis, food challenges are usually conducted in a hospital environment in the presence of a doctor.

* Additional diagnostic tools for evaluation of eosinophilic or non-IgE mediated reactions include endoscopy, colonoscopy, and biopsy.

Important differential diagnoses are:

* Lactose intolerance; this generally develops later in life but can present in young patients in severe cases. This is due to an enzyme deficiency (lactase) and not allergy. It occurs in many non-Western people.
* Celiac disease; this is an autoimmune disorder triggered by gluten proteins such as gliadin (present in wheat, rye and barley). It is a non-IgE mediated food allergy by definition.
* Irritable bowel syndrome (IBS)
* C1 esterase inhibitor deficiency (hereditary angioedema); this rare disease generally causes attacks of angioedema, but can present solely with abdominal pain and occasional diarrhea.

[edit] Pathophysiology
For more details on this topic, see allergy.

Generally, introduction of allergens through the digestive tract is thought to induce immune tolerance. In individuals who are predisposed to developing allergies (atopic syndrome), the immune system produces IgE antibodies against protein epitopes on non-pathogenic substances, including dietary components.[citation needed] The IgE molecules are coated onto mast cells, which inhabit the mucosal lining of the digestive tract.

Upon ingesting an allergen, the IgE reacts with its protein epitopes and release (degranulate) a number of chemicals (including histamine), which lead to oedema of the intestinal wall, loss of fluid and altered motility. The product is diarrhea.[citation needed]

Any food allergy has the potential to cause a fatal reaction.

[edit] Causes

The immune system's eosinophils, once activated in a histamine reaction, will register any foreign proteins they see. One theory regarding the causes of food allergies focuses on proteins presented in the blood along with vaccines, which are designed to provoke an immune response. Influenza vaccines and the Yellow Fever vaccine are still egg-based, but the Measles-Mumps-Rubella vaccine stopped using eggs in 1994.[20] However large scientific studies do not support this theory, especially as it applies to autoimmune disease.[21]

Another theory focuses on whether an infant's immune system is ready for complex proteins in a new food when it is first introduced.[22]

One hypothesis at this time is the Hygiene hypothesis. While there is no proof for the hygiene hypothesis, people speculate[citation needed] that in modern, industrialized nations, such as the United States, food allergies are more common due to the lack of early exposure to dirt and germs, in part due to the over-use of antibiotics and antibiotic cleansers. This hypothesis is based partly on studies showing less allergy in third world countries.[citation needed] Some research suggests[citation needed] that the body, with less dirt and germs to fight off, turns on itself and attacks food proteins as if they were foreign invaders.

Antibiotics have also been implicated in Leaky Gut Syndrome which is another possible cause of food allergies[citation needed].

A lower incidence of food allergies in the developing world could also be due to differences in diet from the West and less exposure to food allergens.

Others have found that food allergies are due to widespread usage of baby skin-care products that contain allergens, such as lotions based upon peanut oil. These skin-care products are cheaper to manufacture than non-allergenic ones and using them sensitizes the baby, which later develops into a food allergy. This theory has yet to come with sufficient explanation as to why the occurrence of allergies has been on a steady rise in the last two decades.

[edit] Prevention

According to a report issued by the American Academy of Pediatrics, "There is evidence that breastfeeding for at least 4 months, compared with feeding infants formula made with intact cow milk protein, prevents or delays the occurrence of atopic dermatitis, cow milk allergy, and wheezing in early childhood."[23]

[edit] Treatment

The mainstay of treatment for food allergy is avoidance of the foods that have been identified as allergens.

If the food is accidentally ingested and a systemic reaction occurs, then epinephrine (best delivered with an autoinjector of epinephrine such as an Epipen or Twinject) should be used. It is possible that a second dose of epinephrine may be required for severe reactions.[citation needed] The patient should also seek medical care immediately.

At this time, there is no cure for food allergies.[24] There are no allergy desensitization or allergy "shots" available for food allergies.[citation needed] Some doctors feel they do not work in food allergies because even minute amounts of the food in question or even food extracts (as in the case of allergy shots) can cause an allergic response in many sufferers.

Ronald van Ree of Amsterdam University expects that vaccines can in theory be created using genetic engineering to cure allergies. If this can be done, food allergies could be eradicated in about ten years.[25]

Food allergy

A food allergy is an adverse immune response to a food protein.[1][2] Food allergy is distinct from other adverse responses to food, such as food intolerance, pharmacologic reactions, and toxin-mediated reactions.
The food protein triggering the allergic response is termed a food allergen. It is estimated that up to 12 million Americans have food allergies,[3] and the prevalence is rising.[4] Six to eight percent of children under the age of three have food allergies and nearly four percent of adults have them.[5] Food allergies cause roughly 30,000 emergency room visits and 100 to 200 deaths per year in the United States.[6] The most common food allergies in adults are shellfish, peanuts, tree nuts, fish, and eggs,[5] and the most common food allergies in children are milk, eggs, peanuts, and tree nuts.[5]

Treatment consists of avoidance diets, in which the allergic person avoids all forms of the food to which they are allergic. For people who are extremely sensitive, this may involve the total avoidance of any exposure with the allergen, including touching or inhaling the problematic food as well as touching any surfaces that may have come into contact with it. Areas of research include anti-IgE antibody (omalizumab, or Xolair) and specific oral tolerance induction (SOTI), which have shown some promise for treatment of certain food allergies. People diagnosed with a food allergy may carry an autoinjector of epinephrine such as an EpiPen or Twinject, wear some form of medical alert jewelry, or develop an emergency action plan, in accordance with their doctor.

Signs and symptoms

Classic immunoglobulin-E (IgE)-mediated food allergies are classified as type-I immediate hypersensitivity reactions. These allergic reactions have an acute onset (from seconds to one hour) and may include

* Angioedema: soft tissue swelling, usually involving the eyelids, face, lips, and tongue. Angioedema may result in severe swelling of the tongue as well as the larynx (voice box) and trachea, resulting in upper airway obstruction and difficulty breathing.
* Hives
* Itching of the mouth, throat, eyes, skin
* Nausea, vomiting, diarrhea, stomach cramps, and/or abdominal pain. This group of symptoms is termed gastrointestinal hypersensitivity or anaphylaxis.
* Rhinorrhea, nasal congestion
* Wheezing, scratchy throat, shortness of breath, or difficulty swallowing
* Anaphylaxis: a severe, whole-body allergic reaction that can result in death (see below)

The reaction may progress to anaphylactic shock: A systemic reaction involving several different bodily systems including hypotension (low blood pressure),loss of consciousness, and possibly death. Allergens most frequently associated with this type of reaction are peanuts, nuts, milk, egg, and seafood, though many food allergens have been reported as triggers for anaphylaxis.

Food allergy is thought to develop more easily in patients with the atopic syndrome, a very common combination of diseases: allergic rhinitis and conjunctivitis, eczema and asthma.[8] The syndrome has a strong inherited component; a family history of allergic diseases can be indicative of the atopic syndrome.

Conditions caused by food allergies are classified into 3 groups according to the mechanism of the allergic response:

1. IgE-mediated (classic):

* Type-I immediate hypersensitivity reaction (symptoms described above)
* Oral allergy syndrome

2. IgE and/or non-IgE-mediated:

* Allergic eosinophilic esophagitis
* Allergic eosinophilic gastritis
* Allergic eosinophilic gastroenteritis

3. Non-IgE mediated:

* Food protein-induced Enterocolitis syndrome (FPIES)
* Food protein proctocolitis/proctitis
* Food protein-induced enteropathy. An important example is Coeliac disease, which is an adverse immune response to the protein gluten.
* Milk-soy protein intolerance (MSPI) is a non-medical term used to describe a non-IgE mediated allergic response to milk and/or soy protein during infancy and early childhood. Symptoms of MSPI are usually attributable to food protein proctocolitis or FPIES.
* Heiner syndrome - lung disease due to formation of milk protein/IgG antibody immune complexes (milk precipitins) in the blood stream after it is absorbed from the GI tract. The lung disease commonly causes bleeding into the lungs and results in pulmonary hemosiderosis.

[edit] The big eight

The most common food allergies are:[9]

* Dairy allergy
* Egg allergy
* Peanut allergy
* Tree nut allergy
* Seafood allergy
* Shellfish allergy
* Soy allergy
* Wheat allergy

These are often referred to as "the big eight."[10] They account for over 90% of the food allergies in the United States.[11]

The top allergens vary somewhat from country to country but milk, eggs, peanuts, treenuts, fish, shellfish, soy, wheat and sesame tend to be in the top 10 in many countries.[citation needed] Allergies to seeds - especially sesame - seem to be increasing in many countries.[12]

Allergy?

What is an Allergy?

The topic of allergies has become routine in our lives, and certainly most everyone has an idea of what an allergy is. Allergies are so common a subject in fact, it seems acceptable to discuss your allergies at a cocktail party with strangers.

An allergy is an abnormal reaction by a person's immune system against a normally harmless substance. A person without allergies would have no reaction to this substance, but when a person who is allergic encounters the trigger, the body reacts by releasing chemicals which cause allergy symptoms. However, just because there is a cause and effect between exposure to a substance and the development of symptoms does not always mean that a person is allergic to that substance. For example, medications have known and expected side effects; a person experiencing one of these side effects is not necessarily allergic to that medication
What is Happening During an Allergic Reaction?

During an allergic process, the substance responsible for causing the allergy, or allergen, binds to allergic antibodies present on allergic cells in a person's body, including mast cells and basophils. These cells then release chemicals such as histamine and leukotrienes, resulting in allergic symptoms.

Watch a video demonstrating the allergic response.
How do Allergies Start?

The allergic person can make allergic antibodies, or IgE, against a variety of allergens, including pollens, molds, animal danders, dust mites, foods, venoms and medications. This occurs through a process called sensitization, where a person’s immune system is exposed to enough of the allergen to make the body produce allergic antibodies to that substance.

With later exposures, that same allergen binds to its corresponding IgE on allergic cells, and the body reacts with symptoms of allergies. Allergic symptoms can vary somewhat with the type of allergen and route of exposure (airborne pollen exposure may cause different symptoms than eating a food to which you are allergic).

Learn how to avoid allergic triggers and avoid specific food allergens.
When and Why do People Develop Allergies?

It is unknown why some people develop allergies and some don’t. Allergies seem to run in families, and in some cases family members can share allergies to specific foods or medications. It appears that the allergic response was once meant to protect the body against parasitic infections, although now seems to be an abnormal response to non-infectious triggers.

Allergies can occur at any time during our lives, but are more common to occur during childhood or young adulthood.

Learn how you can possibly prevent the onset of allergies and asthma.

Next: Find out what symptoms indicate that you may have allergies.

Sources:

American Academy of Allergy, Asthma and Immunology and National Institute of Allergy and Infectious Diseases.

DISCLAIMER: The information contained in this site is for educational purposes only, and should not be used as a substitute for personal care by a licensed physician. Please see your physician for diagnosis and treatment of any concerning symptoms or medical condition.
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Cause Of Asthema

sthma is caused by environmental and genetic factors,[11] which can influence how severe asthma is and how well it responds to medication.[12] Some environmental and genetic factors have been confirmed by further research, while others have not been.

[edit] Environmental

Many environmental risk factors have been associated with asthma development and morbidity in children, but a few stand out as well-replicated or that have a meta-analysis of several studies to support their direct association.

Environmental tobacco smoke, especially maternal cigarette smoking, is associated with high risk of asthma prevalence and asthma morbidity, wheeze, and respiratory infections.[13] Poor air quality, from traffic pollution or high ozone levels, has been repeatedly associated with increased asthma morbidity and has a suggested association with asthma development that needs further research.[13][14]

Recent studies show a relationship between exposure to air pollutants (e.g. from traffic) and childhood asthma [15]. This research finds that both the occurrence of the disease and exacerbation of childhood asthma are affected by outdoor air pollutants.

Caesarean sections have been associated with asthma when compared with vaginal birth; a meta-analysis found a 20% increase in asthma prevalence in children delivered by Caesarean section compared to those who were not. It was proposed that this is due to modified bacterial exposure during Caesarean section compared with vaginal birth, which modifies the immune system (as described by the hygiene hypothesis).[16]

Psychological stress has long been suspected of being an asthma trigger, but only in recent decades has convincing scientific evidence substantiated this hypothesis. Rather than stress directly causing the asthma symptoms, it is thought that stress modulates the immune system to increase the magnitude of the airway inflammatory response to allergens and irritants.[13][17]

Viral respiratory infections at an early age, along with siblings and day care exposure, may be protective against asthma, although there have been controversial results, and this protection may depend on genetic context.[13][18][19]

Antibiotic use early in life has been linked to development of asthma in several examples; it is thought that antibiotics make one susceptible to development of asthma because they modify gut flora, and thus the immune system (as described by the hygiene hypothesis).[20] The hygiene hypothesis is a hypothesis about the cause of asthma and other allergic disease, and is supported by epidemiologic data for asthma. For example, asthma prevalence has been increasing in developed countries along with increased use of antibiotics, c-sections, and cleaning products.[16][20][21] All of these things may negatively affect exposure to beneficial bacteria and other immune system modulators that are important during development, and thus may cause increased risk for asthma and allergy.

Recently scientists connected the rise in prevalence of asthma, to the rise in use of paracetamol, suggesting the possibility that paracetamol can cause asthma.[22]

[edit] Genetic

Over 100 genes have been associated with asthma in at least one genetic association study.[23] However, such studies must be repeated to ensure the findings are not due to chance. Through the end of 2005, 25 genes had been associated with asthma in six or more separate populations:[23]

* GSTM1
* IL10
* CTLA-4
* SPINK5
* LTC4S



* LTA
* GRPA
* NOD1
* CC16
* GSTP1



* STAT6
* NOS1
* CCL5
* TBXA2R
* TGFB1



* IL4
* IL13
* CD14
* ADRB2 (β-2 adrenergic receptor)
* HLA-DRB1



* HLA-DQB1
* TNF
* FCER1B
* IL4R
* ADAM33

Many of these genes are related to the immune system or to modulating inflammation. However, even among this list of highly replicated genes associated with asthma, the results have not been consistent among all of the populations that have been tested.[23] This indicates that these genes are not associated with asthma under every condition, and that researchers need to do further investigation to figure out the complex interactions that cause asthma. One theory is that asthma is a collection of several diseases, and that genes might have a role in only subsets of asthma. For example, one group of genetic differences (single nucleotide polymorphisms in 17q21) was associated with asthma that develops in childhood.[24]

[edit] Gene–environment interactions

Research suggests that some genetic variants may only cause asthma when they are combined with specific environmental exposures, and otherwise may not be risk factors for asthma.[11]

The genetic trait, CD14 single nucleotide polymorphism (SNP) C-159T and exposure to endotoxin (a bacterial product) are a well-replicated example of a gene-environment interaction that is associated with asthma. Endotoxin exposure varies from person to person and can come from several environmental sources, including environmental tobacco smoke, dogs, and farms. Researchers have found that risk for asthma changes based on a person’s genotype at CD14 C-159T and level of endotoxin exposure.[25]
CD14-endotoxin interaction based on CD14 SNP C-159T[25] Endotoxin levels CC genotype TT genotype
High exposure Low risk High risk
Low exposure High risk Low risk

[edit] Risk factors

Studying the prevalence of asthma and related diseases such as eczema and hay fever have yielded important clues about some key risk factors. The strongest risk factor for developing asthma is a family history of atopic disease; [26] this increases one's risk of hay fever by up to 5x and the risk of asthma by 3-4x. [27] In children between the ages of 3-14, a positive skin test for allergies and an increase in immunoglobulin E increases the chance of having asthma. [28] In adults, the more allergens one reacts positively to in a skin test, the higher the odds of having asthma.[29]

Because much allergic asthma is associated with sensitivity to indoor allergens and because Western styles of housing favor greater exposure to indoor allergens, much attention has focused on increased exposure to these allergens in infancy and early childhood as a primary cause of the rise in asthma. [30][31] Primary prevention studies aimed at the aggressive reduction of airborne allergens in a home with infants have shown mixed findings. Strict reduction of dust mite allergens, for example, reduces the risk of allergic sensitization to dust mites, and modestly reduces the risk of developing asthma up until the age of 8 years old. [32][33][34][35] However, studies also showed that the effects of exposure to cat and dog allergens worked in the converse fashion; exposure during the first year of life was found to reduce the risk of allergic sensitization and of developing asthma later in life.[36][37][38]

The inconsistency of this data has inspired research into other facets of Western society and their impact upon the prevalence of asthma. One subject that appears to show a strong correlation is the development of asthma and obesity. In the United Kingdom and United States, the rise in asthma prevalence has echoed an almost epidemic rise in the prevalence of obesity. [39][40] In Taiwan, symptoms of allergies and airway hyperreactivity increased in correlation with each 20% increase in body-mass index.[41]

[edit] Hygiene hypothesis
Main article: Hygiene hypothesis

One theory for the cause of the increase in asthma prevalence worldwide is the so-called "hygiene hypothesis" — that the rise in the prevalence of allergies and asthma is a direct and unintended result of the success of modern hygienic practices in preventing childhood infections. Studies have shown repeatedly that children coming from environments one would expect to be less hygienic (East Germany vs. West Germany,[42] families with many children,[43][44][45] day care environments,[46][47]) tended to result in lower incidences of asthma and allergic diseases. This seems to run counter to the logic that viruses are often causative agents in exacerbation of asthma [48][49][50] Additionally, other studies have shown that viral infections of the lower airway may in some cases induce asthma, as a history of bronchiolitis or croup in early childhood is a predictor of asthma risk in later life. [51] Studies which show that upper respiratory tract infections are protective against asthma risk also tend to show that lower respiratory tract infections conversely tend to increase the risk of asthma. [52]

[edit] Population disparities

Asthma prevalence in the US is higher than in most other countries in the world, but varies drastically between diverse US populations.[13] In the US, asthma prevalence is highest in Puerto Ricans, African Americans, Filipinos and Native Hawaiians, and lowest in Mexicans and Koreans.[53][54][55] Mortality rates follow similar trends, and response to Ventolin is lower in Puerto Ricans than in African Americans or Mexicans.[56][57] As with worldwide asthma disparities, differences in asthma prevalence, mortality, and drug response in the US may be explained by differences in genetic, social and environmental risk factors.

Asthma prevalence also differs between populations of the same ethnicity who are born and live in different places.[58] US-born Mexican populations, for example, have higher asthma rates than non-US born Mexican populations that are living in the US.[59] This probably reflects differences in social and environmental risk factors associated with acculturation to the US.[citation needed]

Asthma prevalence and asthma deaths also differ by gender. Males are more likely to be diagnosed with asthma as children, but asthma is more likely to persist into adulthood in females.[60] Sixty five percent more adult women than men will die from asthma.[citation needed] This difference may be attributable to hormonal differences, among other things. In support of this, girls who reach puberty before age 12 were found to have a later diagnosis of asthma more than twice as much as girls who reach puberty after age 12.[citation needed] Asthma is also the number one cause of missed days from school.[citation needed]

[edit] Socioeconomic factors

The incidence of asthma is highest among low-income populations (asthma deaths are most common in low to middle income countries [2]), which in the western world are disproportionately ethnic minorities[61] and are more likely to live near industrial areas. Additionally, asthma has been strongly associated with the presence of cockroaches in living quarters, which is more likely in such neighborhoods.

Asthma incidence and quality of treatment varies among different racial groups, though this may be due to correlations with income (and thus affordability of health care) and geography. For example, African Americans are less likely to receive outpatient treatment for asthma despite having a higher prevalence of the disease. They are much more likely to have emergency room visits or hospitalization for asthma, and are three times as likely to die from an asthma attack compared to whites. The prevalence of "severe persistent" asthma is also greater in low-income communities compared with communities with better access to treatment.[62][63]

[edit] Asthma and athletics
See also: Exercise-induced asthma

Asthma appears to be more prevalent in athletes than in the general population. One survey of participants in the 1996 Summer Olympic Games, in Atlanta, Georgia, U.S., showed that 15% had been diagnosed with asthma, and that 10% were on asthma medication.[64]

There appears to be a relatively high incidence of asthma in sports such as cycling, mountain biking, and long-distance running, and a relatively lower incidence in weightlifting and diving. It is unclear how much of these disparities are from the effects of training in the sport.[64][65]

[edit] Occupational asthma
Main article: Occupational asthma

Asthma as a result of (or worsened by) workplace exposures is the world's most commonly reported occupational respiratory disease. Still most cases of occupational asthma are not reported or are not recognized as such. Estimates by the American Thoracic Society (2004) suggest that 15–23% of new-onset asthma cases in adults are work related.[66] In one study monitoring workplace asthma by occupation, the highest percentage of cases occurred among operators, fabricators, and laborers (32.9%), followed by managerial and professional specialists (20.2%), and in technical, sales, and administrative support jobs (19.2%). Most cases were associated with the manufacturing (41.4%) and services (34.2%) industries.[66] Animal proteins, enzymes, flour, natural rubber latex, and certain reactive chemicals are commonly associated with work-related asthma. When recognized, these hazards can be mitigated, dropping the risk of disease.[67]

[edit] Pathophysiology

Asthma is an airway disease that can be classified physiologically as a variable and partially reversible obstruction to air flow, and pathologically with overdeveloped mucus glands, airway thickening due to scarring and inflammation, and bronchoconstriction, the narrowing of the airways in the lungs due to the tightening of surrounding smooth muscle. Bronchial inflammation also causes narrowing due to edema and swelling caused by an immune response to allergens.

[edit] Bronchoconstriction
Inflamed airways and bronchoconstriction in asthma. Airways narrowed as a result of the inflammatory response cause wheezing.

During an asthma episode, inflamed airways react to environmental triggers such as smoke, dust, or pollen. The airways narrow and produce excess mucus, making it difficult to breathe. In essence, asthma is the result of an immune response in the bronchial airways.[68]

The airways of asthmatics are "hypersensitive" to certain triggers, also known as stimuli (see below). (It is usually classified as type I hypersensitivity.)[69][70] In response to exposure to these triggers, the bronchi (large airways) contract into spasm (an "asthma attack"). Inflammation soon follows, leading to a further narrowing of the airways and excessive mucus production, which leads to coughing and other breathing difficulties. Bronchospasm may resolve spontaneously in 1–2 hours, or in about 50% of subjects, may become part of a 'late' response, where this initial insult is followed 3–12 hours later with further bronchoconstriction and inflammation.[71]

The normal caliber of the bronchus is maintained by a balanced functioning of these systems, which both operate reflexively. The parasympathetic reflex loop consists of afferent nerve endings which originate under the inner lining of the bronchus. Whenever these afferent nerve endings are stimulated (for example, by dust, cold air or fumes) impulses travel to the brain-stem vagal center, then down the vagal efferent pathway to again reach the bronchial small airways. Acetylcholine is released from the efferent nerve endings. This acetylcholine results in the excessive formation of inositol 1,4,5-trisphosphate (IP3) in bronchial smooth muscle cells which leads to muscle shortening and this initiates bronchoconstriction.

[edit] Bronchial inflammation

The mechanisms behind allergic asthma—i.e., asthma resulting from an immune response to inhaled allergens—are the best understood of the causal factors. In both asthmatics and non-asthmatics, inhaled allergens that find their way to the inner airways are ingested by a type of cell known as antigen-presenting cells, or APCs. APCs then "present" pieces of the allergen to other immune system cells. In most people, these other immune cells (TH0 cells) "check" and usually ignore the allergen molecules. In asthmatics, however, these cells transform into a different type of cell (TH2), for reasons that are not well understood.

The resultant TH2 cells activate an important arm of the immune system, known as the humoral immune system. The humoral immune system produces antibodies against the inhaled allergen. Later, when an asthmatic inhales the same allergen, these antibodies "recognize" it and activate a humoral response. Inflammation results: chemicals are produced that cause the wall of the airway to thicken, cells which produce scarring to proliferate and contribute to further 'airway remodeling', causes mucus producing cells to grow larger and produce more and thicker mucus, and the cell-mediated arm of the immune system is activated. Inflamed airways are more hyper-reactive, and will be more prone to bronchospasm.

The "hygiene hypothesis" postulates that an imbalance in the regulation of these TH cell types in early life leads to a long-term domination of the cells involved in allergic responses over those involved in fighting infection. The suggestion is that for a child being exposed to microbes early in life, taking fewer antibiotics, living in a large family, and growing up in the country stimulate the TH1 response and reduce the odds of developing asthma. [72]

[edit] Stimuli

* Allergens from nature, typically inhaled, which include waste from common household pests, the house dust mite and cockroach, as well as grass pollen, mold spores, and pet epithelial cells;[73]
* Indoor air pollution from volatile organic compounds, including perfumes and perfumed products. Examples include soap, dishwashing liquid, laundry detergent, fabric softener, paper tissues, paper towels, toilet paper, shampoo, hairspray, hair gel, cosmetics, facial cream, sun cream, deodorant, cologne, shaving cream, aftershave lotion, air freshener and candles, and products such as oil-based paint. [7][73]
* Medications, including aspirin,[74] β-adrenergic antagonists (beta blockers),[75] and penicillin.[76]
* Food allergies such as milk, peanuts, and eggs. However, asthma is rarely the only symptom, and not all people with food or other allergies have asthma.[77]
* Use of fossil fuel related allergenic air pollution, such as ozone, smog, summer smog, nitrogen dioxide, and sulfur dioxide, which is thought to be one of the major reasons for the high prevalence of asthma in urban areas.[7]
* Various industrial compounds and other chemicals, notably sulfites; chlorinated swimming pools generate chloramines—monochloramine (NH2Cl), dichloramine (NHCl2) and trichloramine (NCl3)—in the air around them, which are known to induce asthma.[78]
* Early childhood infections, especially viral upper respiratory tract infections. Children who suffer from frequent respiratory infections prior to the age of six are at higher [79] risk of developing asthma, particularly if they have a parent with the condition. However, persons of any age can have asthma triggered by colds and other respiratory infections even though their normal stimuli might be from another category (e.g. pollen) and absent at the time of infection. In many cases, significant asthma may not even occur until the respiratory infection is in its waning stage, and the person is seemingly improving. [7] In children, the most common triggers are viral illnesses such as those that cause the common cold.[80]
* Exercise or intense use of respiratory system. The effects of which differ somewhat from those of the other triggers, since they are brief. They are thought to be primarily in response to the exposure of the airway epithelium to cold, dry air.
* Hormonal changes in adolescent girls and adult women associated with their menstrual cycle can lead to a worsening of asthma. Some women also experience a worsening of their asthma during pregnancy whereas others find no significant changes, and in other women their asthma improves during their pregnancy.[7]
* Psychological stress. There is growing evidence that psychological stress is a trigger. It can modulate the immune system, causing an increased inflammatory response to allergens and pollutants.[17]
* Cold weather can make it harder for asthmatics to breathe.[81] Whether high altitude helps or worsens asthma is debatable and may vary from person to person.[82]

[edit] Pathogenesis

The fundamental problem in asthma appears to be immunological: young children in the early stages of asthma show signs of excessive inflammation in their airways. Epidemiological findings give clues as to the pathogenesis: the incidence of asthma seems to be increasing worldwide, and asthma is now very much more common in affluent countries.

In 1968 Andor Szentivanyi first described The Beta Adrenergic Theory of Asthma; in which blockage of the Beta-2 receptors of pulmonary smooth muscle cells causes asthma.[83] Szentivanyi's Beta Adrenergic Theory is a citation classic[84] using the Science Citation Index and has been cited more times than any other article in the history of the Journal of Allergy and Clinical Immunology.

In 1995 Szentivanyi and colleagues demonstrated that IgE blocks beta-2 receptors.[85] Since overproduction of IgE is central to all atopic diseases, this was a watershed moment in the world of allergy.[86]

[edit] Asthma and sleep apnea

It is recognized with increasing frequency that patients who have both obstructive sleep apnea and asthma often improve tremendously when the sleep apnea is diagnosed and treated.[87] CPAP is not effective in patients with nocturnal asthma only.[88]

[edit] Asthma and gastro-esophageal reflux disease

If gastro-esophageal reflux disease (GERD) is present, the patient may have repetitive episodes of acid aspiration. GERD may be common in difficult-to-control asthma, but according to one study, treating it does not seem to affect the asthma.[89]

[edit] Diagnosis

Asthma is defined simply as reversible airway obstruction. Reversibility occurs either spontaneously or with treatment. The basic measurement is peak flow rates and the following diagnostic criteria are used by the British Thoracic Society:[90]

* ≥20% difference on at least three days in a week for at least two weeks;
* ≥20% improvement of peak flow following treatment, for example:
o 10 minutes of inhaled β-agonist (e.g., salbutamol);
o six weeks of inhaled corticosteroid (e.g., beclometasone);
o 14 days of 30 mg prednisolone.
* ≥20% decrease in peak flow following exposure to a trigger (e.g., exercise).

In many cases, a physician can diagnose asthma on the basis of typical findings in a patient's clinical history and examination. Asthma is strongly suspected if a patient suffers from eczema or other allergic conditions—suggesting a general atopic constitution—or has a family history of asthma. While measurement of airway function is possible for adults, most new cases are diagnosed in children who are unable to perform such tests.

In children, the key to asthma diagnosis is the sound of wheezing or a high-pitched sound upon exhalation. Other clues are recurrent wheezing, breathing difficulty, or chest tightness, or a history of coughing that is worse at night. The doctor should also know if the child's symptoms are worse with exercise, colds,or exposure to certain irritants such as smoke, emotional stress, or changes in the weather. [72]

Other information important to diagnosis is the age at which symptoms began and how they progressed, the timing and pattern of wheezing, when and how often a child had to visit a clinic or hospital emergency department because of symptoms, whether the child ever took bronchodilator medication for the symptoms and the nature of the response to medication. [72]

Although pediatricians may tend to ask parents for information about their children's symptoms, studies suggest that children themselves are reliable sources as early as age 7 and perhaps even as early as age 6.[91]

In adults and older children, diagnosis can be made with spirometry or a peak flow meter (which tests airway restriction), looking at both the diurnal variation and any reversibility following inhaled bronchodilator medication. The latest guidelines from the U.S. National Asthma Education and Prevention Program (NAEPP) recommend spirometry at the time of initial diagnosis, after treatment is initiated and symptoms are stabilized, whenever control of symptoms deteriorates, and every 1 or 2 years on a regular basis.[92]

The NAEPP guidelines do not recommend testing peak expiratory flow as a regular screening method, because it is more variable than spirometry. However, testing peak flow at rest (or baseline) and after exercise can be helpful, especially in young asthmatics who may experience only exercise-induced asthma. It may also be useful for daily self-monitoring and for checking the effects of new medications.[92] Peak flow readings can be charted on graph paper charts together with a record of symptoms or use peak flow charting software. This allows patients to track their peak flow readings and pass information back to their doctor or nurse.[93]

In the Emergency Department doctors may use a capnography which measures the amount of exhaled carbon dioxide,[94] along with pulse oximetry which shows the percentage of hemoglobin that is carrying oxygen, to determine the severity of an asthma attack as well as the response to treatment.

More recently, exhaled nitric oxide has been studied as a breath test indicative of airway inflammation in asthma.

[edit] Differential diagnosis
This section does not cite any references or sources. Please help improve this article by adding citations to reliable sources. Unsourced material may be challenged and removed. (November 2008)

Before diagnosing someone as asthmatic, alternative possibilities should be considered. A clinician taking a history should check whether the patient is using any known bronchoconstrictors (substances that cause narrowing of the airways, e.g. certain anti-inflammatory agents or beta-blockers). Among elderly patients, the presenting symptom may be fatigue, cough, or difficulty breathing, all of which may be erroneously attributed to COPD, congestive heart failure, or simple aging.[95]

After a pulmonary function test has been carried out, radiological tests, such as a chest X-ray or CT scan, may be required to exclude the possibility of other lung diseases. Occasionally, a bronchial challenge test may be performed using methacholine or histamine to assess bronchial hyperresponsiveness.

Chronic obstructive pulmonary disease, which closely resembles asthma, is correlated with more exposure to cigarette smoke, an older patient, less symptom reversibility after bronchodilator administration (as measured by spirometry), and decreased likelihood of family history of atopy.[96]

Pulmonary aspiration, whether direct due to dysphagia (swallowing disorder) or indirect (due to acid reflux), can show similar symptoms to asthma. However, with aspiration, fevers might also indicate aspiration pneumonia. Direct aspiration (dysphagia) can be diagnosed by performing a Modified Barium Swallow test and treated with feeding therapy by a qualified speech therapist. If the aspiration is indirect (from acid reflux) then treatment directed at this is indicated.

In some people, asthma-like symptoms may be triggered by gastroesophageal reflux disease, which can be treated with suitable antacids.

A majority of children who are asthma sufferers have an identifiable allergy trigger. Specifically, in a 2004 study, 71% had positive test results for more than 1 allergen, and 42% had positive test results for more than 3 allergens.[97]

The majority of these triggers can often be identified from the history; for instance, asthmatics with hay fever or pollen allergy will have seasonal symptoms, those with allergies to pets may experience an abatement of symptoms when away from home, and those with occupational asthma may improve during leave from work. Allergy tests can help identify avoidable symptom triggers.

Asthma is categorized by the United States National Heart, Lung, and Blood Institute as falling into one of four categories: intermittent, mild persistent, moderate persistent and severe persistent. The diagnosis of "severe persistent asthma" occurs when symptoms are continual with frequent exacerbations and frequent night-time symptoms, result in limited physical activity and when lung function as measured by PEV or FEV1 tests is less than 60% predicted with PEF variability greater than 30%.

[edit] Prevention and Control

Prevention of the development of asthma is different from prevention of asthma episodes. Aggressive treatment of mild allergy with immunotherapy has been shown to reduce the likelihood of asthma development. In controlling symptoms, the crucial first step in treatment is for patient and doctor to collaborate in establishing a specific plan of action to prevent episodes of asthma by avoiding triggers and allergens, regularly testing for lung function, and using preventive medications (see especially "Control of Environmental Factors" @ http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm.)

Current treatment protocols recommend controller medications such as an inhaled corticosteroid, which helps to suppress inflammation and reduces the swelling of the lining of the airways, in anyone who has frequent (greater than twice a week) need of relievers or who has severe symptoms. If symptoms persist, additional controller drugs are added until almost all asthma symptoms are prevented. With the proper use of control drugs, asthmatics can avoid the complications that result from overuse of rescue medications.

Asthmatics sometimes stop taking their controller medication when they feel fine and have no problems breathing. This often results in further attacks after a time, and no long-term improvement.

The only preventive agent known is allergen immunotherapy. Controller medications include the following:

* Inhaled glucocorticoids are the most widely used prevention medications and normally come as inhaler devices (ciclesonide, beclomethasone, budesonide, flunisolide, fluticasone, mometasone, and triamcinolone). Long-term use of corticosteroids can have many side effects including a redistribution of fat, increased appetite, blood glucose problems and weight gain. High doses of steroids may cause osteoporosis. These side effects are generally not seen with the inhaled steroids when used in conventional doses for control of asthma due to the smaller dose which is targeted to the lungs, unlike the higher doses of oral or injected preparations. Patients on the highest doses of inhaled steroids should take prophylactic treatment (usually Calcium and exercise, but sometimes Fosamax or similar) to prevent osteoporosis. Deposition of steroids in the mouth may result in oral thrush. Deposition near the vocal cords can cause hoarse voice. These may be minimised by rinsing the mouth with water after inhaler use, as well as by using a spacer. Spacers also generally increase the amount of drug that reaches the lungs. A new agent, ciclesonide, is inactive until activated in the lung. For this reason changing to ciclesonide can relieve dysphonia in some patients.
* Leukotriene modifiers (montelukast, zafirlukast, pranlukast, and zileuton) provide both anti-spasm and anti-inflammatory effects. In general they are weaker than inhaled corticosteroids, but the do not have any steroid side-effects and the benefit is additive with inhaled steroid.
* Mast cell stabilizers (cromoglicate (cromolyn), and nedocromil). These medications are believed to prevent the initiation of the allergy reaction, by stabilizing the mast cell. They are not effective once the reaction has already begun, and typically must be used 4 times a day for maximal effect. But they do truly prevent asthma symptoms and are nearly free of side-effects.
* Antimuscarinics/anticholinergics (ipratropium, oxitropium, and tiotropium). These agents both relieve spasm and reduce formation of mucous. They are more effective in patients with empysema or 'smokers lung.' They are rarely effective in asthma and are not true asthma controller medications.
* Methylxanthines (theophylline and aminophylline). These agents are bronchodilators with minimal anti-inflammatory effect. At one time they were the only effective asthma medications available. They are sometimes considered if sufficient control cannot be achieved with inhaled glucocorticoid, leukotriene modifier, and long-acting β-agonist combintaions.
* Antihistamines are often used to treat the nasal allergies which can accompany asthma. Older agents are too drying and can result in thick mucous so should be avoided. Newer antihistamines which do not have this effect can safely be used by asthmatics.
* Allergy Desensitization, also known as allergy immunotherapy, may be recommended in some cases where allergy is the suspected cause or trigger of asthma. Allergy shots are dangerous in severe asthma and in uncontrolled asthma. However if allergy immunotherapy is started early in the disease there is a good chance that a remission of asthma can be induced (aka "asthma cure"). Typically the need for medication is reduced by about half with injection allergy immunotherapy, when done correctly. If a patient is only allergic to one or two items, oral allergy immunotherapy can be used. This is safe, much easier in young children, and is about half as effective. Unfortunately if a patient is allergic to more than 2 or 3 items then oral therapy cannot be given in a dose which is proven safe and effective.
* Omalizumab, an IgE blocker, can help patients with severe allergic asthma that is not well controlled with other drugs. It is expensive, but not compared with hospitalization(s). It requires regular injections.
* Methotrexate is occasionally used in some difficult-to-treat patients.
* If chronic acid indigestion (GERD) contributes to a patient's asthma, it should also be treated, because it may prolong the respiratory problem.
* Chronic sinus disease may be a contributing factor in difficult to control asthma, and should be evaluated.

[edit] Trigger avoidance

As is common with respiratory disease, smoking is believed to adversely affect asthmatics in several ways, including an increased severity of symptoms (likely due to increased inflammation[98]), a more rapid decline of lung function, and decreased response to preventive medications.[99] Automobile emissions are considered an even more significant cause and aggravating factor.[citation needed] Asthmatics who smoke or who live near traffic[citation needed] typically require additional medications to help control their disease. Furthermore, exposure of both non-smokers and smokers to wood smoke, gas stove fumes and second-hand smoke is detrimental, resulting in more severe asthma, more emergency room visits, and more asthma-related hospital admissions.[100] Smoking cessation and avoidance of second-hand smoke is strongly encouraged in asthmatics.[101] Air filters and room air cleaners may help prevent some asthma symptoms.[102] Ozone is also considered as a major factor in increasing asthma.[103]

For those in whom exercise can trigger an asthma attack (exercise-induced asthma), higher levels of ventilation and cold, dry air tend to exacerbate attacks. For this reason, activities in which a patient breathes large amounts of cold air, such as skiing and running, tend to be worse for asthmatics, whereas swimming in an indoor, heated pool with warm, humid air is less likely to provoke a response.[8]

[edit] Diet and Supplements
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Eating a healthy balanced diet with plenty of fruits and vegetables is important to staying healthy, particularly for people with asthma. Recent clinical studies have shown that people with asthma tend to eat fewer fruits and vegetables and are often deficient in nutrients such as Vitamin C, Magnesium and Selenium[citation needed]. In addition, increased intake of Omega 3 Fatty Acids has been shown to decrease inflammation[citation needed].

Vitamin C is a key vitamin antioxidant present in the extracellular fluid lining the lungs. Low intake of Vitamin C has been related to pulmonary dysfunction and several studies have shown that increasing Vitamin C intake may improve lung function in people with asthma and provide a protective effect against exercise-induced asthma.[104] While results have been positive, it is unlikely that Vitamin C alone will attenuate the effects of asthma. Larger and methodologically stronger studies are necessary before Vitamin C can be recommended for people with asthma.[105]

Magnesium is an essential mineral that has been shown to provide bronchodilating effects in people with asthma[citation needed]. In addition, clinical studies have shown that people with asthma may be deficient in Magnesium and that this mineral may play a role in asthma[citation needed]. However, it has not yet been unequivocally established that all asthmatics are deficient in this important mineral, because it is difficult to measure. More studies are needed to determine the role of Magnesium supplementation in the treatment for asthma. It is proven, however, that Magnesium sulfate intravenous treatment greatly improves pulmonary function when used in addition to conventional treatment in severe acute asthma attacks.[106]

Selenium is a trace mineral that is essential to good health. It is thought that deficiency of selenium may play some role in the development of asthma[citation needed]. Because selenium is important to the production of antioxidants, it is said that selenium deficiency may increase oxidative stress on the body, which may be a factor in chronic diseases such as asthma[citation needed]. Some clinical studies suggest that selenium supplementation for people with chronic asthma may help to improve symptoms[citation needed], however more research is needed to confirm these results.[107]

[edit] Treatment

Perhaps the most important step in controlling asthma is establishing a partnership between doctor and patient (whether child or adult) to create a specific, customized plan for proactively monitoring and managing symptoms. It is essential to be certain that someone who has asthma understands (and takes an active part in deciding) what needs to be accomplished, including reducing exposure to allergens, taking medical tests to assess the severity of symptoms, and possibly using medications. The treatment plan should be written down, consulted at every visit, and adjusted according to changes in symptoms.[108]

The most effective treatment for asthma is identifying triggers, such as pets or aspirin, and limiting or eliminating exposure to them. If trigger avoidance is insufficient, medical treatment is available. Desensitization has been suggested as a possible cure.[109] Additionally, some trial subjects were able to remove their symptoms by retraining their breathing habits with the Buteyko method.[110]

Other forms of treatment include relief medication, prevention medication, long-acting β2-agonists, and emergency treatment.

[edit] Medical

Asthma

Asthma is a chronic inflammation of the lungs in which the airways (bronchi) are reversibly narrowed. Asthma affects 7% of the population, or 20 million Americans,[1][2] and 300 million worldwide.[3] During attacks (exacerbations), the smooth muscle cells in the bronchi constrict, and the airways become inflamed and swollen. Breathing becomes difficult, and asthma causes 4,000 deaths a year in the U.S. Attacks can be prevented by avoiding triggering factors and by drug treatment. Drugs are used for acute attacks, commonly inhaled β2-agonists. In more serious cases, drugs are used for long-term prevention, starting with inhaled corticosteroids, and then long-acting β2-agonists if necessary. Leukotriene antagonists are less effective than corticosteroids but have no side effects. Monoclonal antibodies such as mepolizumab and omalizumab are sometimes effective. Prognosis is good with treatment.

In contrast to chronic obstructive pulmonary disease and chronic bronchitis, the inflammation of asthma is reversable. In contrast to emphysema, asthma affects the bronchi, not the alveoli.

The National Heart, Lung and Blood Institute defines asthma as a common chronic disorder of the airways characterized by variable and recurring symptoms, airflow obstruction, bronchial hyperresponsiveness (bronchospasm), and an underlying inflammation.[4]

Public attention in the developed world has recently focused on asthma because of its rapidly increasing prevalence, affecting up to one in four urban children.
Classification

Signs and symptoms

Because of the spectrum of severity within asthma, some asthmatics only rarely experience symptoms, usually in response to triggers, where as other more severe asthmatics may have marked airflow obstruction at all times.

Asthma exists in two states: the steady-state of chronic asthma, and the acute state of an acute asthma exacerbation. The symptoms are different depending on what state the asthmatic is in.

Common symptoms of asthma in a steady-state include: nighttime coughing, shortness of breath with exertion but no dyspnea at rest, a chronic 'throat-clearing' type cough, and complaints of a tight feeling in the chest. Severity often correlates to an increase in symptoms. Symptoms can worsen gradually and rather insidiously, up to the point of an acute exacerbation of asthma. It is a common misconception that all asthmatics wheeze—some asthmatics never wheeze, and their disease may be confused with another Chronic obstructive pulmonary disease such as emphysema or chronic bronchitis.

An acute exacerbation of asthma is commonly referred to as an asthma attack. The cardinal symptoms of an attack are shortness of breath (dyspnea), wheezing and chest tightness.[7] Although the former is "often regarded as the sine qua non of asthma.[8] some patients present primarily with coughing, and in the late stages of an attack, air motion may be so impaired that no wheezing may be heard.[9].When present the cough may sometimes produce clear sputum. The onset may be sudden, with a sense of constriction in the chest, breathing becomes difficult, and wheezing occurs (primarily upon expiration, but can be in both respiratory phases). It is important to note inspiratory stridor without expiratory wheeze however, as an upper airway obstruction may manifest with symptoms similar to an acute exacerbation of asthma, with stridor instead of wheezing, and will remain unresponsive to bronchodilators.

Help for Cancer Patients

If you are one of the millions of people who have heard those three little but life-changing words, “you have cancer,” then you know that making an informed decision about cancer treatment is one of the most important and potentially life-saving things you can do.

The NexProfiler Treatment Option Tools can help you make more educated decisions together with your physicians about the treatment options that are best for you.

The Treatment Decision Tool provides:

* A list of treatment options and possible side effects tailored to your specific clinical status
* Reports including the pros and cons of each type of treatment
* Questions to ask your doctor

The information provided in the NexProfiler Tool for Cancer is updated on a regular basis by the NexCura Medical Editorial Board, which is comprised of experts in cancer research and treatment. It is based on clinical research published in leading medical journals.

To use the NexProfiler Tool for Cancer, NexCura requires you to register an email address to be used as your username and a password. Please note that disclosing your personal information is optional when you use this tool.

Any information provided to NexCura is subject to their privacy policy, which we recommend you read. The National Foundation for Cancer Research maintains its own privacy policy and does not have access to the information you provide to NexCura. If you have any further questions, please email the National Foundation for Cancer Research at info@nfcr.org.

This free treatment decision support tool is brought to you by the National Foundation for Cancer Research and NexCura.

Colon CancerOverview

The colon and rectum are parts of the body's digestive system and together form a long, muscular tube called the large intestine. The colon is the first 6 feet of the large intestine and the rectum is the last 8-10 inches. Treatment approaches differ between cancers of the colon or rectum and are, therefore, discussed separately. A separate section has been created for Rectal Cancer.

Adenocarcinoma refers to cancer that begins in the cells that line the colon or large intestine and accounts for over 90%-95% of cancers originating in the colon. Other cancers, including carcinoid tumors and leiomyosarcoma, also originate in the colon, but are not referred to as colon cancer. This treatment overview deals only with adenocarcinoma of the colon, which will be referred to as colon cancer.

The treatment of colon cancer typically consists of surgery and/or chemotherapy and may involve several physicians, including a gastroenterologist, a surgeon, a medical oncologist and other specialists. Care must be carefully coordinated between the various treating physicians involved in managing the cancer.

Colon cancer begins in cells that line the colon. As the cells increase in number, they spread circumferentially around the colon like a "napkin ring." If detected early, cancer cells may only be found in the colon. If not detected early, the cancer may invade adjacent organs and spread through the lymph and blood systems throughout the body to the liver, lungs and other organs.
Personalized Cancer Care Center

After colon cancer has been diagnosed, tests will be performed to determine the extent and characteristics of the cancer. Based on these tests, treatment of colon cancer is personalized for each individual.

Staging
Determining the stage of the cancer or the extent of the spread requires a number of tests and is ultimately confirmed by surgical removal of the cancer and exploration of the abdominal cavity. The following tests may be used to look for cancer in the chest, abdomen and pelvis.

Computed Tomography (CT) Scan: A CT scan is a technique for imaging body tissues and organs, during which X-ray transmissions are converted to detailed images, using a computer to synthesize X-ray data. A CT scan is conducted with a large machine positioned outside the body that can rotate to capture detailed images of the organs and tissues inside the body. This method is more sensitive and precise than an X-ray.

Magnetic Resonance Imaging (MRI): MRI uses a magnetic field rather than X-rays, and can often distinguish more accurately between healthy and diseased tissue. MRI gives better pictures of tumors located near bone than CT, does not use radiation as CT does, and provides pictures from various angles that enable doctors to construct a three-dimensional image of the tumor.

Colonoscopy: Because 3-5% of patients with a colon cancer can already have an additional cancer in their colon, colonoscopy is routinely recommended to identify whether a second cancer is present in the colon prior to surgery. During a colonoscopy, a long flexible tube that is attached to a camera is inserted through the rectum, allowing physicians to examine the internal lining of the colon for polyps or other abnormalities. Patients are given medication to minimize discomfort. The physician may perform a biopsy in order to collect samples of suspicious tissues or cells for closer examination.

Ultrasound: Ultrasound is a technique that uses sound waves to differentiate tissues based on varying tissue density. Ultrasound can be used transdermally (through the skin), transrectally (using a small probe inserted into the rectum) or intraoperatively (during surgery or during colonoscopy, which is called endoscopic ultrasound). Transrectal or endoscopic ultrasound may be used in conjunction with CT or MRI scans to help with staging.

Surgery
Upon completion of the clinical staging evaluation, surgery is performed to remove the cancer along with part of the normal adjacent colon and determine the level of spread within the colon and abdomen. Surgery is performed through an abdominal incision or through a laparoscope. Laparoscopic surgery is less invasive and involves the insertion of surgical instruments through very small incisions in the abdomen. Patients experience faster healing times compared with traditional abdominal surgery, and their outcomes with regard to cancer recurrence and survival have been shown in some trials to be similar.[1] It is important for patients to discuss the risks and benefits of the two techniques with their doctor, as laparoscopic surgery is not yet the standard of care, but is still considered investigational.

Following surgical removal of colon cancer and examination of removed tissue under a microscope, a final "pathologic" stage will be given.

KRAS Testing
For patients with metastatic colon cancer (cancer that has spread to distant sites in the body), a sample of the cancer may be tested for mutations in the KRAS gene.[2] Cancers that contain KRAS mutations are unlikely to respond to two targeted therapies that may be used in the treatment of metastatic colorectal cancer: Erbitux® (cetuximab)[3] and Vectibix® (panitumumab).[4]

All treatment information concerning colon cancer is categorized and discussed by the stage. In order to learn more about the most recent information available concerning the treatment of colon cancer, click on the appropriate stage.

Stage I: Cancer is confined to the lining of the colon.

Stage II: Cancer may penetrate the wall of the colon into the abdominal cavity or other adjacent organs but does not invade any local lymph nodes.

Stage III: Cancer invades one or more of the local lymph nodes but has not spread to other distant organs.

Stage IV: Cancer has spread to distant locations in the body, which may include the liver, lungs, bones or other sites.

Recurrent/Relapsed: Colon cancer has progressed or returned (recurred/relapsed) following initial treatment.

Breast Cancer
Overview

Breast cancer is a common malignancy, with ~180,000 new cases diagnosed in the United States each year.[1] The disease occurs most frequently in women and rarely, in men. The breasts are glands that produce and release milk in women in association with pregnancy. Breast cancer develops from cells in the breast.

The normal breast has 6 to 9 overlapping sections called lobes and within each lobe are several smaller lobules that contain the cells that produce milk. The lobes and lobules are linked by thin tubes called ducts, which lead to the nipple in the center of the breast. The spaces around the lobules and ducts are filled with fat. Lymph vessels carry colorless fluid called lymph, which contains important immune cells. The lymph vessels lead to small bean-shaped structures called lymph nodes. Clusters of lymph nodes are found in the axilla (under the arm), above the collarbone, and in the chest.

The suspicion of breast cancer first arises when a lump is detected in the breast during breast examination or a suspicious area is identified during screening mammography. In order to diagnose the cause of the suspicious area or lump in the breast, a physician will perform a biopsy. A biopsy can be performed on an outpatient basis. During a biopsy, a physician removes cells for examination in the laboratory to determine whether cancer is present. Other information obtained from the biopsy sample will play an important role in treatment decisions. If the biopsy indicates that cancer is present, additional surgery may be performed after the patient and doctor select a course of treatment.

There are many types of breast tumors. Some breast tumors are benign (not cancerous). Benign breast tumors such as fibroadenomas or papillomas do not spread outside of the breast and are not life threatening. Other breast tumors are malignant (cancerous). The most common type of breast cancer is called ductal carcinoma and begins in the lining of the ducts. Another type of cancer is called lobular carcinoma, which arises in the lobules.
Personalized Cancer Care Center

When cancer is identified in the biopsy specimen, several other tests may be performed on the specimen in order to further classify the cancer and determine the optimal treatment strategy. Based on the stage of the cancer and the results of these tests, treatment of breast cancer is personalized for each individual. Treatment may involve surgery, radiation therapy, chemotherapy, targeted therapy, and/or hormonal therapy.

Stage: Stage is a measure of the extent of the cancer, and is based on the size of the tumor and the presence or absence of lymph node metastases and distant metastases. Determining the stage of the cancer may require a number of procedures, such as blood tests, chest x-rays, mammography, computed tomography (CT), or magnetic resonance imaging (MRI). For patients with early-stage cancer, the spread of the cancer to the axillary (under the arm) lymph nodes may be assessed through either sentinel lymph node biopsy or axillary lymph node dissection. Axillary lymph node dissection involves the removal of many axillary lymph nodes; the procedure can be associated with chronic side effects such as pain, limited shoulder motion, numbness, and swelling. Sentinel lymph node biopsy is a more recent procedure that involves the removal of only a small number of nodes, or even a single node. If the sentinel lymph nodes are negative (show no evidence of cancer), then no further lymph node surgery is required. Sentinel lymph node biopsy is becoming more widely adopted in the clinical setting for determining whether cancer has spread to the lymph nodes in women with localized breast cancer.

HER2 status: Twenty to thirty percent of breast cancers overexpress (make too much of) a protein known as HER2. Overexpression of this protein leads to increased growth of cancer cells. Fortunately, the development of treatments that specifically target HER2-positive cells – such as Herceptin® (trastuzumab) and Tykerb® (lapatinib) -- has improved outcomes among women with HER2-positive breast cancer. For this reason, HER2 status should be accurately measured on all breast cancers.

Hormone receptor status: Some breast cancer cells express an abundance of receptors for the female hormones estrogen and/or progesterone. These cancers-- called hormone receptor-positive --are typically associated with a better prognosis and are treated differently from breast cancers that are hormone receptor-negative. Patients with hormone receptor-positive breast cancer often receive treatment with hormonal therapy, such as tamoxifen or an aromatase inhibitor. For more information, go to Hormonal Therapy.

Predicting the need for chemotherapy: Among women with early-stage breast cancer, the expression, or activity, of certain genes has been linked with the likelihood of cancer recurrence and chemotherapy benefit; testing tumor tissue for the expression of these genes can provide important information about prognosis and likely response to treatment.

A genomic test that is included in guidelines from both the American Society of Clinical Oncology (ASCO) and the National Comprehensive Cancer Network (NCCN) is Oncotype DX®. Based on the expression of 21 genes, this test provides information about recurrence risk and likely chemotherapy benefit among women with newly diagnosed breast cancer that has not spread to the lymph nodes (node-negative) and is hormone receptor-positive. Oncotype DX has also shown promising results in women with node-positive breast cancer.[2]

For more information about OncotypeDX, visit http://www.mytreatmentdecision.com/

Predicting drug metabolism: Another type of test that may prove important is the assessment of inherited genetic variation that influences drug metabolism (the processing of drugs by the body). In the case of tamoxifen, for example, differences in effectiveness may be explained at least in part by inherited differences in a gene known as CYP2D6.[3] Most people have two functional versions of this gene and are able to effectively process tamoxifen. Some people, however, have versions of this gene that are less effective at processing tamoxifen. Testing patients for these gene variants could help doctors identify patients who are less likely to respond to tamoxifen. A currently available test is AmpliChip®, which assesses CYP2D6 as well as CYP2C19 (another gene involved in drug metabolism). Additional data are required, however, before formal recommendations can be developed about this type of testing.[4]

For more information about AmpliChip, visit http://www.amplichip.us/.
Learn More

Patients who have already undergone surgery and lymph node evaluation and know their stage of cancer may select from the options below. In order to learn more about surgery and sentinel lymph node dissection, go to Surgery for Breast Cancer.

Carcinoma In Situ: Approximately 15-20% of breast cancers are very early in their development. These are sometimes referred to as carcinoma in situ and consist of two types: ductal carcinoma in situ (DCIS), which originates in the ducts and lobular carcinoma in situ (LCIS), which originates in the lobules. DCIS is the precursor to invasive cancer and LCIS is a risk factor for developing cancer.

Stage I: Cancer is confined to a single site in the breast, is less than 2 centimeters (3/4 inch) in size and has not spread outside the breast.

Stage IIA: Cancer has spread to involve underarm lymph nodes and is less than 2 centimeters (3/4 inch) in size or the primary cancer itself is 2-5 centimeters (3/4-2 inches) and has not spread to the lymph nodes.

Stage IIB: Cancer has spread to involve underarm lymph nodes and/or the primary cancer is greater than 5 centimeters (2 inches) in size and does not involve any lymph nodes.

Stage IIIA: Cancer is smaller than 5 centimeters (2 inches) and has spread to the lymph nodes under the arm or the lymph nodes are attached to each other or to other structures or the primary cancer is larger than 5 centimeters (2 inches) and has spread to the lymph nodes under the arm.

Stage IIIB: Cancer directly involves the chest wall or has spread to internal lymph nodes on the same side of the chest.

Inflammatory: Inflammatory breast cancer is a special class of breast cancer that is rare. The breast looks as if it is inflamed because of its red appearance and warmth. The skin may show signs of ridges and wheals or it may have a pitted appearance. Inflammatory breast cancer tends to spread quickly.

Stage IV: Cancer has spread to distant locations in the body, which may include the liver, lungs, bones or other sites.

Recurrent/Relapsed: The breast cancer has progressed or returned (recurred/relapsed) following an initial treatment.
References:

[1] American Cancer Society. Cancer Facts & Figures 2007. Available at: http://www.cancer.org/docroot/stt/stt_0.asp (Accessed December 10, 2007).

[2] Albain K, Barlow W, Shak S et al. Prognostic and predictive value of the 21-gene recurrence score assay in postmenopausal, node-positive, ER-positive breast cancer (S8814,INT0100). Presented at the 30th Annual San Antonio Breast Cancer Symposium. San Antonio, TX, December 13-16, 2007. Abstract #10.

[3] Schroth W, Antoniadou L, Fritz P et al. Breast cancer treatment outcome with adjuvant tamoxifen relative to patient CYP2D6 and CYP2C19 genotypes. Journal of Clinical Oncology. 2007;25:5187-5193.

[4] Desta Z, Flockhart DA. Germline pharmacogenetics of tamoxifen response: have we learned enough? Journal of Clinical Oncology. 2007;5147-5149.

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