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Supported  by
CLINICAL PEDIATRIC ONLINE 

Yudhasmara Foundation

JL Taman Bendungan Asahan 5 Jakarta Indonesia

phone : 62(021) 70081995 – 5703646

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http://clinicalpediatric.wordpress.com/

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Review article Grading quality of evidence and strength of recommendations in clinical practice guidelines: Part 2 of 3. The GRADE approach to grading quality of evidence about diagnostic tests and strategies J. L. Brożek 1,2 , E. A. Akl 3 , R. Jaeschke 4 , D. M. Lang 5 , P. Bossuyt 6 , P. Glasziou 7 , M. Helfand 8 , E. Ueffing 9 , P. Alonso-Coello 10,11 , J. Meerpohl 12,13 , B. Phillips 14 , A. R. Horvath 15 , J. Bousquet 16 , G. H. Guyatt 4,17 , H. J. Schünemann 3,17 for the GRADE Working Group   1 Department of Epidemiology, Italian National Cancer Institute Regina Elena, Rome, Italy ;   2 Department of Medicine, Jagiellonian University School of Medicine, Krakow, Poland ;   3 Department of Medicine and Family Medicine, School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, NY, USA ;   4 Department of Medicine, McMaster University, Hamilton, ON, Canada ;   5 Allergy/Immunology Section, Asthma Center Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA ;   6 Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Centre, University of Amsterdam, Amsterdam, the Netherlands ;   7 Centre for Evidence-Based Medicine, Department of Primary Health Care, University of Oxford, Oxford, United Kingdom ;   8 Portland Veterans Administration Medical Center and Department of Medicine, Oregon Health & Science University, Portland, OR, USA ;   9 Centre for Global Health, Institute of Population Health, University of Ottawa, Ottawa, ON, Canada ;   10 Iberoamerican Cochrane Center, Servicio de Epidemiología Clínica y Salud Pública, Hospital de Sant Pau, Barcelona, Spain ;   11 Centro de Investigación Biomédica en Red de Epidemiología y Salud Pública (CIBERESP), Spain ;   12 German Cochrane Centre, Institute of Medical Biometry and Medical Informatics, University Hospital Freiburg, Freiburg, Germany ;   13 Division of Pediatric Hematology & Oncology, Department of Pediatrics, University Hospital Freiburg, Freiburg, Germany ;   14 Centre for Reviews and Dissemination, University of York, York, United Kingdom ;   15 Department of Clinical Chemistry, University of Szeged, Szeged, Hungary ;   16 Service des Maladies Respiratoires, Hôpital Arnaud de Villeneuve, INSERM, Montpellier, France ;   17 Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON, Canada Correspondence to Holger J. Schünemann, MD, PhD Department of Clinical Epidemiology and Biostatistics Faculty of Health Sciences McMaster University 1200 Main Street W Hamilton, ON Canada Copyright Journal compilation © 2009 Blackwell Munksgaard KEYWORDS clinical practice guidelines • diagnosis • evidence based medicine • grading ABSTRACT The GRADE approach to grading the quality of evidence and strength of recommendations provides a comprehensive and transparent approach for developing clinical recommendations about using diagnostic tests or diagnostic strategies. Although grading the quality of evidence and strength of recommendations about using tests shares the logic of grading recommendations for treatment, it presents unique challenges. Guideline panels and clinicians should be alert to these special challenges when using the evidence about the accuracy of tests as the basis for clinical decisions. In the GRADE system, valid diagnostic accuracy studies can provide high quality evidence of test accuracy. However, such studies often provide only low quality evidence for the development of recommendations about diagnostic testing, as test accuracy is a surrogate for patient-important outcomes at best. Inferring from data on accuracy that using a test improves outcomes that are important to patients requires availability of an effective treatment, improved patients’ wellbeing through prognostic information, or – by excluding an ominous diagnosis – reduction of anxiety and the opportunity for earlier search for an alternative diagnosis for which beneficial treatment can be available. Assessing the directness of evidence supporting the use of a diagnostic test requires judgments about the relationship between test results and patient-important consequences. Well-designed and conducted studies of allergy tests in parallel with efforts to evaluate allergy treatments critically will encourage improved guideline development for allergic diseases.

Conclusions

The GRADE system provides a comprehensive and transparent approach for grading the quality of evidence and developing recommendations about diagnostic tests. GRADE stresses that test accuracy is a substitute for outcomes that are important to patients. Clinicians should always bear in mind that, whatever the test accuracy, application of any diagnostic test is of value only if it results in improved outcomes that are important for patients. Evaluation of diagnostic tests has recently accelerated, but the methodology of diagnostic research and number of performed studies lag far behind that for evaluating treatments. When looking for examples for this article, we were unable to identify any systematic review of diagnostic tests in allergy except for one health technology report on the diagnosis and management of work-related asthma (15). We encourage clinicians and researchers to engage actively in well-designed studies evaluating use of tests in allergy and to undertake systematic reviews of tests in allergy to identify areas where new studies are critically needed.

In the next article in this series, we will discuss how guideline panels and others making recommendations integrate the information about the quality of evidence and the estimated magnitude of the effects with controversial considerations of cost as well as patients’ values and preferences to arrive at final clinical recommendations.

Special Issue: Common Characteristics of Upper and Lower Airways in Rhinitis and Asthma: ARIA Update, in Collaboration with GA²LEN

Published Online: 8 Oct 2007

Journal compilation © 2009 Blackwell Munksgaard

Abstract |  References  |  Full Text: HTML, PDF (Size: 351K)  | Related Articles | Citation Tracking

A. A. Cruz ¹ , T. Popov ² , R. Pawankar ³ , I. Annesi-Maesano ⁴ , W. Fokkens ⁵ , J. Kemp ⁶ , K. Ohta ⁷ , D. Price ⁸ , J. Bousquet ⁹ on behalf of ARIA Initiative Scientific Committee

Correspondence to Alvaro A. Cruz ProAR – Rua Carlos Gomes, 270 40060-330 Salvador, Bahia
Brazil 

KEYWORDS

Consensus Definition of Nonallergic Rhinopathy, Previously Referred to as Vasomotor Rhinitis, Nonallergic Rhinitis, and/or Idiopathic Rhinitis

Kaliner, Michael A. MD; Baraniuk, James N. MD; Benninger, Michael MD; Bernstein, Jonathan A. MD; Lieberman, Phil MD; Meltzer, Eli O. MD; Naclerio, Robert M. MD; Settipane, Russell A. MD; Farrar, Judith R. PhD

Abstract:

Nonallergic vasomotor rhinitis (also referred to as nonallergic rhinitis and/or idiopathic rhinitis) is a term that has been used to describe a common nasal condition of unclear pathophysiology. The lack of straightforward diagnostic criteria is limiting; research for better treatment options requires the definition of homogeneous populations characterized by well-defined inclusion and exclusion criteria. Following considerable discussion and counterpoints at a roundtable conference convened in December 2008, we proposed to change the terminology to reference this condition as nonallergic rhinopathy. Nonallergic rhinopathy is a chronic nasal condition with symptoms that may be perennial, persistent, intermittent, or seasonal and/or elicited by recognized triggers. There is a well-recognized set of clinical exposures that lead to the symptoms, predominantly congestion and rhinorrhea. The clinical characteristics as outlined provide well-defined inclusion and exclusion criteria that should permit precise identification of patients for participation in clinical trials.

The papers presented in the first part of these proceedings were delivered at the roundtable meeting (December 13, 2008, Washington, DC) with the intent of reaching a consensus definition of nonallergic rhinopathy (formerly referred to as vasomotor rhinitis, nonallergic rhinitis, and/or idiopathic rhinitis). Consensus was attained following considerable discussion and counterpoints by all participants.

I. Nonallergic rhinopathy (NAR) is recommended to replace the term vasomotor rhinitis (VMR). VMR suggests that intrinsic nasal vascular and glandular abnormalities are the principle physiological causes of inflammation of the nasal mucous membrane. However, current information suggests that NAR is probably due to neurosensory abnormalities and does not include inflammation as an important component. Thus, we believe that it is more accurate to term this condition a rhinopathy (a disorder of the nose) rather than a form of rhinitis (inflammation of the nose). The single unequivocal criterion for these patients is that they are not allergic: nonallergic rhinopathy is a more appropriate term for this disorder.

II. NAR is defined by clinical characteristics, which are summarized below and described in detail in the series of related articles from the consensus conference.

A. NAR is a chronic disease with some, but not necessarily all, of the following symptoms:

1. Primary symptoms:

a. Nasal congestion.

b. Rhinorrhea.

2. Other associated symptoms:

a. Postnasal drip in the absence of a pharyngeal cause of mucus hypersecretion or acid reflux disease.

b. Throat clearing.

c. Cough.

d. Eustachian tube dysfunction (ear pressure/popping/pain).

e. Sneezing.

f. Hyposmia.

g. Facial pressure/headache.

B. Symptoms of NAR may be perennial, persistent, or seasonal (i.e., climatic-see below) and/or elicited by defined triggers. These triggers may include the following:

1. Cold air.

2. Changes in climate (such as temperature, humidity, and barometric pressure).

3. Strong smells (such as perfume, cooking smells, flowers, and chemical odors).

4. Environmental tobacco smoke.

5. Changes in sexual hormone levels.

6. Pollutants and chemicals (e.g., volatile organics).

7. Exercise.

8. Alcohol ingestion.Symptoms may be described as perennial, persistent, intermittent, or seasonal and occur in response to climatic shifts in temperature, humidity, and barometric pressure. A patient’s symptoms may be brought on by 1 or more of the defined precipitants. There are no current data indicating that patients responsive to environmental climate changes as a trigger differ from those triggered by perfumes or strong smells. Moreover, there is no current information suggesting that a patient with this set of clinical symptoms and characteristics, and for whom no triggers are identified, differ from patients with clearly defined triggers. Thus, NAR may be diagnosed regardless of the presence or the absence of defined triggers.

C. There is a female-to-male incidence ratio for NAR of 2:1 to 3:1.

D. NAR presents predominantly with adult onset.

E. The nasal mucosa in NAR usually appears normal, but may sometimes appear red and beefy with scant mucus.

F. NAR is associated with negative or irrelevant skin prick tests or antigen-specific IgE tests (formerly referred to as radioallergosorbent tests).

G. NAR may present with concomitant conditions such as the following:

1. Food-related rhinorrhea.

2. Mild nasal eosinophilia (<5%).

3. Eustachian tube dysfunction (ear pressure/popping/pain).

4. Senile rhinitis.

H. NAR symptoms are not caused by other known etiological factors for rhinopathy, such as the following:

1. Chronic rhinosinusitis or nasal polyps.

2. Nonallergic rhinitis with eosinophilia syndrome with nasal eosinophilia >5%.

3. Aspirin-related chronic rhinosinusitis, nasal polyps, or asthma, although NAR is usually seen as one of the clinical characteristics of aspirin-exacerbated respiratory disease.

4. Infectious rhinitis or rhinosinusitis (eg, viral upper respiratory infections, bacterial/fungal rhinosinusitis, and bacterial rhinitis).

5. Anatomical abnormalities.

6. Drug usage (e.g., adverse effect of systemic medication and excess use of topical decongestants).

7. Cerebrospinal fluid leak.

8. Pregnancy.

III. In summary, nonallergic rhinopathy is a chronic condition with symptoms that may be perennial and/or elicited by recognized triggers. The clinical characteristics provide well-defined inclusion and exclusion criteria that should permit precise identification of patients with this disease category for further study. The next issue of this journal will include our recommendations for those inclusion and exclusion criteria based on the in-depth discussion and counterpoints at the roundtable meeting.

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Salehi, Tahmineh MD; Pourpak, Zahra MD, PhD; Karkon, Shahnaz MD; Shoormasti, Raheleh Shokouhi MSc; Sabzevari, Samineh Kamali MSc; Movahedi, Masoud MD; Gharagozlou, Mohammad MD; Moin, Mostafa MD

World Allergy Organization Journal:

July 2009 – Volume 2 – Issue 7 – pp 123-127

Abstract

Context: Food allergy plays a significant pathogenic role among children with atopic dermatitis (AD).

Objective: The aims of this study were to evaluate allergy to egg in these children and determine the egg specific immunoglobulin E (IgE) cutoff point.

Design and Setting: It was a cross-sectional study that took place at Immunology, Asthma and Allergy Research Institute from 2005 to 2007.

Methods: Children younger than 14 years old with AD entered the study. Careful medical histories were taken and skin prick and Immuno-CAP tests with the most commonly offending foods (cow’s milk, egg, wheat, peanut, and soy) were performed. Children with a clear, positive history of food allergy and a positive IgE-mediated test or those with positive responses to both IgE-mediated tests were determined to have food allergies. The egg-specific IgE level cutoff point was determined.

Results: A hundred patients entered the study (from 2 months to 12 years old). They were divided into 3 age groups: first <2 years, second from 2 to <6 years, and third from 6 to 14 years. The most common food allergens were egg (39.22%) in the first, cow’s milk (35.13%) and egg (32.43%) in the second, and peanut (25%) and egg (16.67%) in the third group. The egg-specific IgE cutoff point value was 0.62 kUA/L (kilounits of allergen-specific IgE per liter). The positive predictive value was 95%.

Conclusion: Prevalence of egg allergy is highly significant in patients with AD.To use egg-specific IgE level cutoff point, the patient population under study must be considered.

REFERENCES

Gawlik, Radoslaw MD; Pitsch, Tomas; DuBuske, Lawrence MD

Allergic disease induced by animal exposure is a common phenomenon worldwide. Whereas cat and dog dander exposure are well recognized as causative of allergic rhinitis, allergic asthma, and contact urticaria, horse allergy can present with anaphylaxis. Horse allergy is induced by exposure to the major horse allergens Equ 1 through 5. The severity of the symptoms may be related to the level of exposure. Greatest risk of anaphylaxis occurs in those sensitized patients who have large amounts of animal allergen exposure, such as when in a barn, or when an animal bite occurs exposing sensitized persons to large quantities of the animal allergen that resides in the saliva. Horse allergy may be successfully treated with allergen specific immunotherapy.

Allergic diseases are among the most common afflictions worldwide. Allergy to pets, such as cats and dogs, causes significant morbidity in children. The most commonly reported manifestations of pet allergy include asthma, contact urticaria, angioedema, and contact dermatitis. Horses are arguably the most important animal in history to be domesticated. For centuries, horses have been used as a means of transportation, pleasure, work, and even war. Today horses are rarely used for work in developed countries but are widely owned for recreational activities. Horses have been recognized as an important source of allergens. Horse allergy occurs in people who regularly work with horses, either professionally or for recreational purposes, and in people indirectly exposed to horses through allergens on riding clothes. Despite the presence of horses in a variety of recreational, sporting, and work environments, there are only a few reports of anaphylactic episodes resulting from horse allergy

REFERENCES

Naclerio, Robert MD

Abstract

Background: The parasympathetic nervous system contributes to the pathophysiology of multiple forms of allergic and nonallergic rhinitis. Stimulation of the parasympathetic nervous system leads to glandular activation, which produces watery secretions. In excess, these secretions discharge from the anterior Nares and produce the symptom of watery anterior rhinorrhea.

Method: Review of literature.

Results: Treatment with topical, intranasal anticholinergic drugs inhibits activation of the nasal mucosal glands and is effective in reducing the watery secretions associated with parasympathetic stimulation of the glands with little, if any, effect on the symptoms of congestion and sneezing. In general, these drugs have no systemic adverse effects, but can cause crusting and local irritation.

Conclusion: Anticholinergic drugs are useful for the treatment of anterior rhinorrhea associated with allergic and nonallergic rhinitis.

The nervous system plays an important role in nasal physiology and pathophysiology by functioning to provide rapid responses to physical and chemical stimuli. The sensory, parasympathetic, and sympathetic systems all contribute to these responses. Up-regulation of this system can occur at any level and is referred to as neural hyperresponsiveness.

Central neuronal reflexes involving the parasympathetic nervous system are the best studied component of the nasal nervous system and contribute to multiple forms of rhinitis. Stimulation of the trigeminal nerve sends inputs to the midbrain, where parasympathetic impulses originate, and subsequently move to the nose via the preganglionic fibers (superior salivary nucleus, CN VII through facial genu, greater petrosal, vidian), where they synapse in the pterygopalatine ganglion. Postganglionic nerves travel with branches of the nasopalatine nerve to the minor salivary glands in the nose.

Acetylcholine is released from the postganglionic nerves and stimulates muscarinic receptors on the glands. There are 5 muscarinic receptor subtypes, labeled M1 to M5. M1, M2, and M3 receptors are found on glands, arteries, veins, and epithelium. M4 receptors are found on arteries, and M5 receptors are found on glands and arteries. M3 is the most common receptor subtype. M1, M3, and M5 couple to inositol polyphosphate, whereas M2 and M4 inhibit the generation of cAMP. In addition to secreting acetylcholine, postganglionic fibers release vasoactive intestinal peptide, peptide histidine methionine, and peptide histidine valine. Postganglionic nerve bodies also contain nitric oxide synthase. These latter substances may be responsible for atropine-resistant vasodilatation associated with parasympathetic stimulation.

Anticholinergic agents block the binding of acetylcholine to the muscarinic receptors. The drugs can be delivered topically or systemically. Methacholine challenges of the nasal mucosa, which stimulates the gland directly via muscarinic receptors, have been used to show the effectiveness and duration of the action of anticholinergic drugs

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In recent years, the number of children with allergies to food, pollens, latex and other allergens has grown dramatically. There has also been a surge in the number of children with asthma, and other allergic conditions, such as the skin disorders contact dermatitis and eczema. Childhood asthma is among the most serious and widespread health risks afflicting children today.

Allergy is a disorder of the immune system often also referred to as atopy. Allergic reactions occur to normally harmless environmental substances known as allergens; these reactions are acquired, predictable, and rapid. Strictly, allergy is one of four forms of hypersensitivity and is called type I (or immediate) hypersensitivity. It is characterized by excessive activation of certain white blood cells called mast cells and basophils by a type of antibody known as IgE, resulting in an extreme inflammatory response. Common allergic reactions include eczema, hives, hay fever, asthma, food allergies, and reactions to the venom of stinging insects such as wasps and bees.

Mild allergies like hay fever are highly prevalent in the human population and cause symptoms such as allergic conjunctivitis, itchiness, and runny nose. Allergies can play a major role in conditions such as asthma. In some people, severe allergies to environmental or dietary allergens or to medication may result in life-threatening anaphylactic reactions and potentially death.

A variety of tests now exist to diagnose allergic conditions; these include testing the skin for responses to known allergens or analyzing the blood for the presence and levels of allergen-specific IgE. Treatments for allergies include allergen avoidance, use of anti-histamines, steroids or other oral medications, immunotherapy to desensitize the response to allergen, and targeted therapy.

Clinical immunology is the study of diseases caused by disorders of the immune system (failure, aberrant action, and malignant growth of the cellular elements of the system). It also involves diseases of other systems, where immune reactions play a part in the pathology and clinical features.

The diseases caused by disorders of the immune system fall into two broad categories: immunodeficiency, in which parts of the immune system fail to provide an adequate response (examples include chronic granulomatous disease), and autoimmunity, in which the immune system attacks its own host’s body (examples include systemic lupus erythematosus, rheumatoid arthritis, Hashimoto’s disease and myasthenia gravis). Other immune system disorders include different hypersensitivities, in which the system responds inappropriately to harmless compounds (asthma and other allergies) or responds too intensely.

The most well-known disease that affects the immune system itself is AIDS, caused by HIV. AIDS is an immunodeficiency characterized by the lack of CD4+ (”helper”) T cells and macrophages, which are destroyed by HIV.

Clinical immunologists also study ways to prevent transplant rejection, in which the immune system attempts to destroy allografts or xenografts.

Supported  by
CLINICAL PEDIATRIC ONLINE

Yudhasmara Foundation

mail : JL Taman Bendungan Asahan 5 Jakarta Indonesia 10210

phone : 62(021) 70081995 – 5703646

email : judarwanto@gmail.com,

http://clinicalpediatric.wordpress.com/

Editor in Chief :

Dr WIDODO JUDARWANTO

email : judarwanto@gmail.com

Copyright © 2009, Clinical Pediatric Online Information Education Network. All rights reserved.