Applying GRADE for diagnosis 61 2 Describe the time interval and any interventions between index test(s) and reference standard The sIgE-test was done before the nasal challenge, but no time frame has been described. Was there an appropriate interval between index test(s) and reference standard? Probably yes Did all patients receive a reference standard? Yes/no/unclear Did patients receive the same reference standard? Yes/no/unclear Were all patients included in the analysis? Yes/no/unclear Could the patient flow have introduced bias? RISK: LOW/HIGH/UNCLEAR Burden No studies. Management – allergen avoidance measures Sheikh, 2010 [4] Author Sheikh Year of publication 2010 Journal Cochrane Database of Systematic Reviews Study design Systematic review of RCT’s Study population Patients with doctor-diagnosed allergic rhinitis, and confirmed house dust mite allergy by an objective test such as skin prick testing, allergen specific-IgE concentrations or provocation testing Description of the intervention (including dosage and duration) House dust mite control measures: High efficiency particulate air (HEPA) filters, acaricides, barrier bedding (=allergy control bedding), barrier bedding and acaricide Description of control group Placebo or different house dust mite control measures Outcomes Primary: quality of life, sick leave, nasal symptom scores, adverse outcome. Secondary: nasal peak inspiratory flow, nasal provocation test, rhinomanometry, medication usage, compliance with treatment, drop-outs, change in house dust mite level achieved Effect on outcome measures (nasal / ocular symptoms, concentration, sleep problems, absenteeism from school / work, quality of life) High risk of bias in included studies, due to lack of information about randomisation procedures, lack of blinding in studies, absence of intention-to-treat design, generally small numbers, high drop-out. No meta-analyses due to few trials uncovered and clinical heterogeneity, thus narrative review of results of different interventions: HEPA filters: Study Reisman 1990: 32 from 40 patients evaluated: aggregated rhinitis and asthma symptom scores/medication scores: lower after active filtration vs placebo: day 8.79 vs 10.38, night 8.28 vs 9.90 (no statistical testing for total score). Nasal congestion, discharge, eye irritation, and upper airway itching reduced statistically significant, whereas cough, asthma and medication use did not. Acaricides: Study Kniest 1991: 20 patients: symptom scores 9-12 months vs 0-3 months lower in acaricide group vs control group; no absolute symptom scores. Study Bernstein 1995: 32 children, no disaggregated symptom scores for asthma and rhinitis. Barrier bedding (=allergy control bedding): Study Moon 1999: 29 from 30 patients evaluated: Mean daily symptom scores: decreased after 4 weeks in experimental group with 2.9 vs 0.3 in control group, statistically significant. Study Terreehorst 2003: 232 patients from 279 evaluated). No significant differences in symptom scores. Study Ghazala 2004: 26 from 30
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