Providing standardized, high-quality rehabilitation for critically ill patients is a crucial issue. In 2017, the Japanese Society of Intensive Care Medicine (JSICM) promulgated the “Evidence-Based Expert Consensus for Early Rehabilitation in the Intensive Care Unit” to advocate for the early initiation of rehabilitations in Japanese intensive care settings. Building upon this seminal work, JSICM has recently conducted a rigorous systematic review utilizing the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. This endeavor resulted in the formulation of Clinical Practice Guidelines (CPGs), designed to elucidate best practices in early ICU rehabilitation. The primary objective of this guideline is to augment clinical understanding and thereby facilitate evidence-based decision-making, ultimately contributing to the enhancement of patient outcomes in critical care settings. No previous CPGs in the world has focused specifically on rehabilitation of critically ill patients, using the GRADE approach. Multidisciplinary collaboration is extremely important in rehabilitation. Thus, the CPGs were developed by 73 members of a Guideline Development Group consisting of a working group, a systematic review group, and an academic guideline promotion group, with the Committee for the Clinical Practice Guidelines of Early Mobilization and Rehabilitation in Intensive Care of the JSICM at its core. Many members contributed to the development of the guideline, including physicians and healthcare professionals with multiple and diverse specialties, as well as a person who had been patients in ICU. Based on discussions among the group members, eight important clinical areas of focus for this CPG were identified. Fourteen important clinical questions (CQs) were then developed for each area. The public was invited to comment twice, and the answers to the CQs were presented in the form of 10 GRADE recommendations and commentary on the four background questions. In addition, information for each CQ has been created as a visual clinical flow to ensure that the positioning of each CQ can be easily understood. We hope that the CPGs will be a useful tool in the rehabilitation of critically ill patients for multiple professions.The online version contains supplementary material available at 10.1186/s40560-023-00697-w. Although advances in intensive care have increased the number of patients who can be saved, after being discharged from the hospital, those patients face a variety of problems that make it difficult for them to return to their daily lives. Rehabilitation for patients who had been critically ill is needed to prevent complications and facilitate the return to daily life of these individuals. In 2017, the Japanese Society of Intensive Care Medicine (JSICM) promulgated the “Evidence-Based Expert Consensus for Early Rehabilitation in the Intensive Care Unit” to advocate for the early initiation of rehabilitations in Japanese intensive care settings . The article was translated into English and published in the Journal of Intensive Care, the English-language journals of the society.The official name of the guideline is “the Japanese Clinical Practice Guidelines for Rehabilitation in Critically Ill Patients 2023,” abbreviated to J-ReCIP 2023.The purpose of the CPGs is to serve as a reliable guideline for rehabilitation of critically ill patients and to assist healthcare professionals in making appropriate decisions to improve the prognosis of these patients, as well as the quality of life (QOL) of the patients, their families, and care providers. At the same time, we also aim to identify future research questions.The target patient population includes patients entering the ICU, and their families and care providers. Patients in the process of recovery after discharge from the ICU, their families, and care providers are also included. Care providers in this guideline are assumed to be family members who provided care free-of-charge, rather than nurses, certified care workers, or other personnel. Patients and care providers included in this guideline are assumed to be adults, with the exception of those in some CQs.In the CPGs, we consider recommendations from the standpoint of the individual patient, family member, and care provider, rather than the general public.The target healthcare professionals are not only those who work with patients and their families in the ICU, but also those who work in general wards and outpatient clinics after patients leave the ICU.Although several CPGs mention rehabilitation of critically ill patients, such as the Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock  and the The GDG consisted of 17 members: one director, who was in charge of the Committee for the Clinical Practice Guidelines of Early Mobilization and Rehabilitation in Intensive Care of the JSICM, one chairperson, two vice-chairs, 12 committee members, and one advisor. The policy was to include a wide variety of professionals involved in rehabilitation, which included intensivists, emergency physicians, rehabilitation physicians, nurses, physical therapists, and other professionals involved in the rehabilitation of critically ill patients. The GDG selected CQs and PICOs for the CPGs, voted on the recommended text, and responded to public comments.The committee members served as group leaders and deputy group leaders of the WGs for each of the key clinical areas (hereinafter referred to as “areas”) described below, and with the assistance of the WGs described later, developed the CQs and PICOs, created the Evidence-to-Decision (EtD) table, drafted recommendations, and wrote the text. The advisors were positioned to provide overall advice and were not involved in specific tasks, including voting.In addition, the group leader and deputy group leader of each area, who are members of the committee, did not conduct SR in their area of responsibility. However, they could communicate with the person who conducted the SR via the mailing list as appropriate. In such cases, the Academic Guideline Promotion Group (described below) monitored the content of the communication to ensure that the opinions of the committee members did not influence the methods or results of the SR.The role of WGs was to assist the group leaders of each area, who were the committee members. The WG members were selected through an open recruitment process and consisted of experts from various professions, who assisted the group leaders in preparing the CQs, PICOs, EtD tables, and recommendations, as well as involved in SR, if desired. Overall, 43 individuals were assigned, with an average of 2–3 individuals per CQ.Systematic review members were recruited from among the working groups and also publicly from the JSICM members.This group ensured in the entire process that the development of the CPGs was carried out in a smooth and appropriate manner. The group drafted, prepared, and distributed various materials, provided advice to the committee members, and conducted peer review. The group monitored the discussions on the mailing lists of all areas and provided advice as necessary to ensure that the discussions proceeded smoothly. The group also worked to ensure that SR was conducted appropriately by creating videos for those parts of the SR that were difficult to understand.WG1. Exercise therapy in ICU (including respiratory physiotherapy).WG2. Neuromuscular electrical stimulation and in-bed cycle ergometer.WG3. Dysphagia rehabilitation.WG4. Standards for mobilization.WG5. Nutritional therapy.WG6. Rehabilitation for critically ill children.WG7. Rehabilitation after ICU discharge.WG8. Family visitation and family participation in rehabilitation.For the important clinical areas, the projected CQs were brainstormed within the GDG and were categorized into eight areas. The following WGs were responsible for each area.Patients who did not require intensive care in the ICU were not covered.To reflect the values of the patients and their families, one healthcare provider who had been admitted to an ICU due to a serious condition was added to one of the WGs. Care was taken to ensure that the other WGs could also ask the opinion of that member.Education was provided using videos and manuals to standardize knowledge among all the members.Public comments were sought from the JSICM, as well as the Japanese Association of Rehabilitation Medicine, the Japanese Society of Physical Therapy, the Japan Academy of Critical Care Nursing, and the Japanese Society of Dysphagia Rehabilitation when drafting the CQs and recommendations.Peer reviews of PICO, EtD tables, and texts were conducted anonymously by the committee members.As a general rule, discussions within the WGs were conducted via the emailing list, and members of the Academic Guideline Promotion Group monitored discussions in all areas to identify and correct inappropriate methods and discussions. When teleconferences were held exceptionally, basically, the Academic Guideline Promotion Group was also involved, and the discussions were recorded, so that the discussions could be reviewed.Declarations regarding conflicts of interest (COI) were made in accordance with the COI Management Guidelines of the Japanese Association of Medical Sciences, and COIs were confirmed by a group independent of the committee. Detailed information of COI and the roles in creating this guideline are summarized in Additional file The following activities were conducted to ensure quality and transparency.This guideline was developed with funds from the JSICM. No compensation was received by any member in the preparation of these guidelines. No intention or interest of the medical society was reflected in the development of the recommendations.A clinical flow Fig. , graphicThis guideline was developed through three major processes: (1) CQ drafting; 2) SR search, collection of evidence, integration, and evaluation of certainty; and (3) formulation of recommendations. Relevant information for a recommendation based on GRADE were available at Additional file  SR searcBased on the following rules for CQ drafting, CQ drafts were developed by the group leaders in the area with the assistance of the WG members and were approved by the committee after peer review by the committee members. After soliciting public comments from August 30 to September 10, 2021, the CQs were revised based on the received comments, after which 14 CQs were finalized by the committee.BQs are considered common knowledge, such as information written in textbooks. This guideline focuses on foreground questions (FQs) that contribute to decision-making. On the other hand, in some areas, the addition of BQs contributes to the dissemination of knowledge. The committee decided the policy on BQs that the number of BQs should not be minimized.Draft recommendations for the finalized CQs were developed in each area, and after mutual peer review by the committee members, revisions were made until the committee reached an agreement rate of at least 90%, thus building consensus. Votes for and against the BQs were made by anonymous online voting. Voting for the BQ began on March 27, 2022, and was finalized on July 6, 2022.Types of evidence: Only Randomized Controlled Trial (RCT) was included in the CPGs.Database: Literature were obtained by electronic searches of MEDLINE (via PubMed), the Japan Medical Abstracts Society, and the Cochrane Central Register of Controlled Trials databases.Basic search policy: The PICO format was used to search for literature The basic format was a combination of P and I, while C was also sometimes specified. O was not included in the search formula. Only papers published in English and Japanese were included, and those for which only abstracts were published were not included.Target period of search: The search period was defined to cover papers registered in the database by October 18, 2021.Method of evaluation and integration of evidence: The Cochrane RoB tool for RCTs (RoB 1.0) was used to assess bias risk in individual RCT studies.The evidence profile based on the GRADE system was developed by the SR group. The committee members and WG members collaborated to develop the EtD table and draft recommendation text based on the evidence profile. Recommendations were determined by consensus of the committee as indicated below.The RAND/UCLA method (modified Delphi method)  was usedAfter the vote, a committee session (panel meeting) was held to reach a consensus.The strengths of recommendations indicated by the GRADE system are classified as recommended = “1”, suggested = “2”, not suggested = “3”, and not recommended = ”4″. The certainty of evidence was classified as follows: high = “A”, moderate = “B”, low = “C”, and very low = “D”.For Median < 7.5 or DI ≥ 0.2, the committee discussed and revised the EtD and recommended text and re-voted. For Median ≥ 7.5 and DI < 0.2, if there were important comments from committee members, the committee discussed and, if necessary, revised the EtD and the recommended text, and then re-voted. If there were no important comments, the results of the vote were reviewed and consensus was reached. During the first vote on the draft recommendation, there were important comments on all CQs. Consensus was reached at subsequent committee meetings and a re-vote was held. After the re-vote, all recommendations were approved.The text was prepared by the WG members under the responsibility of the group leaders of each area. The draft text was revised by the committee until the approval rate reached 90% or more. All the main texts were approved on December 17, 2022.We invited public comments on the recommendations. An external assessment was conducted. The final version of the guidelines was finalized with reference to the above assessment.These CPGs are to be revised every 4 years. The next revision is scheduled for 2027. The Intensive Care and Early Rehabilitation Committee will continue to monitor publications, and if important findings are published before the revision and the need for immediate revision arises, the Intensive Care and Early Rehabilitation Committee may discuss and revise the CPGs.To evaluate the validity of this guideline, an external assessment was conducted by experts in methodology, the Japanese Association of Rehabilitation Medicine, and the Japanese Association for Acute Medicine experts. We revised this CPG based on experts’ evaluation.Answer: We suggest the introduction of a rehabilitation protocol for critically ill patients (Grade 2D: Certainty of evidence = “Very low”).N = 595) showed a significantly higher standardized mean difference (SMD) of 0.62 . For ADL , the estimated effect size was a significantly higher SMD of 0.15 (95% CI 0.27 lower to 0.57 higher). Regarding muscle strength , the estimated effect size was a significantly higher mean difference (MD) of 4.52 (95% CI 1.54 lower to 10.59 higher). As for the duration of mechanical ventilation , the estimated effect size was a significantly shorter MD of 1.28 days (95% CI 1.68 days shorter to 0.87 days shorter). Finally, for ICU length of stay , the estimated effect size indicated a significantly shorter MD of 1.53 days (95% CI 2.3 days shorter to 0.77 days shorter). Rates of delirium during ICU stay were not reported. The SMDs for fundamental activities and ADLs were small. However, all reported outcomes favored the intervention group, and beneficial effects were judged as “moderate”. Conversely, the estimated effect size for all adverse events  was 24 fewer events per 1000 individuals (95% CI 61 fewer to 71 more), indicating a “trivial” undesirable effect. Based on these findings, the positive effects were deemed “moderate,” the negative effects were considered “trivial,” and the recommendation learned toward favoring the intervention.Early rehabilitation for critically ill patients has been reported to contribute to preventing muscle weakness and improving exercise capacity and activities of daily living (ADL). However, in clinical practice, the timing and content of rehabilitation varies among different facilities, leading to variability in its effectiveness. Nevertheless, initiating rehabilitation according to a standardized protocol can lead to benefits, such as reduced duration of mechanical ventilation, shorter ICU stay, and improved ADL. Therefore, investigating the effectiveness of implementing protocolized rehabilitation program in the ICU holds clinical significance. According to the results of our SR, 23 RCTs that met the PICO were included –27. A meAnswer: We suggest conducting multiple daily rehabilitation sessions for critically ill patients (GRADE 2D: Certainty of Evidence = “Very Low”).N = 216) was an MD of 3.00 higher (0.33 higher to 5.67 higher), while for ADLs , the estimated effect size was an SMD of 0.22 higher (0.05 lower to 0.5 higher). As for muscle strength , the estimated effect size was an MD of 2.17 lower (5.62 lower to 1.29 higher). Furthermore, the estimated effect size for duration of mechanical ventilation  was an MD of 2.26 days shorter (3.86 days shorter to 0.65 days shorter), and for ICU length of stay  the estimated effect size was an MD of 2.24 shorter days (4.02 shorter to 0.46 shorter). There were no reported rates of delirium during ICU stay. Clinically significant outcomes, such as fundamental and ADL, duration of mechanical ventilation, and ICU length of stay, favored the intervention group. Conversely, muscle strength demonstrated superiority in the control group, but its significance was deemed lower compared to fundamental activities and ADL, and its overall impact on the effects was considered minimal. Although the SMD/MD for basic activities and ADL were small, the beneficial effects were categorized as “moderate.” Conversely, the estimated effect size for all adverse events  was more than 10 individuals per 1000 individuals (95% CI 10 fewer to 20 more), indicating a “trivial” adverse effect. Based on these findings, the beneficial effects were categorized as “moderate,” the adverse effects as “trivial,” and the recommendation was “probably in favor of the intervention.”Early rehabilitation for critically ill patients has been reported to contribute to the prevention of muscle weakness and improving exercise capacity and ADL. The significance of early rehabilitation in this population has been increasingly recognized in recent years. Furthermore, although it is based on small-scale studies, some studies research has indicated that conducting multiple daily rehabilitation sessions (two or more times) enhances the Medical Research Council sum score (MRC-SS) after ICU admission . HoweverAnswer: We suggest performing neuromuscular electrical stimulation for critically ill patients (GRADE 2B: Certainty of evidence = “Moderate”).We suggest performing in-bed cycle ergometer (GRADE 2D: Certainty of evidence = “Very low”).We suggest performing both neuromuscular electrical stimulation and in-bed cycle ergometer (GRADE 2B: Certainty of evidence = “Moderate”).ICU patients commonly experience muscle weakness due to accelerated protein catabolism associated with severe conditions, such as sepsis , which cIn the SR, we identified 19 RCTs on neuromuscular electrical stimulation –54, 10 RN = 106) was an MD of 10.76 points higher (95% CI 12.95 points lower to 34.48 points higher). For the MRC-SS , the estimated effect size was an MD of 4.68 points higher (95% CI 2.66 points lower to 12.03 points higher). The estimated effect size for muscle mass  was an MD of 0.37 mm higher (95% CI 2.57 mm lower to 3.30 mm higher). For the duration of mechanical ventilation , the estimated effect size was an MD of 1.0 day shorter (95% CI 2.18 days shorter to 0.18 days longer). The estimated effect size for length of hospital stays  was an MD of 3.77 days shorter (95% CI 7.98 days shorter to 0.43 days longer). There were no reported RCTs regarding the 6-min walk distance (6MWD). All outcomes favored the intervention, and the desirable effect was deemed “moderate.” The estimated effect size for all adverse events  was 140 fewer events per 1000 individuals (95% CI 380 fewer to 100 more), indicating a “trivial” undesirable effect. Given the moderate desirable effect and trivial undesirable effect, we determined “favors the intervention”.Regarding neuromuscular electrical stimulation, the estimated effect sizes for ADL (Barthel Index)  was an MD of 53.0 m longer (95% CI 16.85 m shorter to a 122.85 m longer). For the MRC-SS, the estimated effect size  was an MD of 0.19 points lower (95% CI 2.91 points lower to 2.53 points higher). The estimated effect size for muscle mass  was an MD of 2.75 mm higher (95% CI 4.17 mm lower to 9.67 mm higher). The estimated effect size for duration of mechanical ventilation  was an MD of 0.76 days longer (95% CI 0.69 days shorter to 2.2 days longer). The estimated effect size for length of hospital stays  was an MD of 1.28 days shorter (95% CI 5.44 days shorter to 2.88 days longer). There were no reported RCTs regarding ADL. Each outcome shows a different direction, but considering the highest importance placed on the 6MWD, which favored the intervention, the desirable effect was deemed “small.” The estimated effect size for all adverse events  was 0 fewer events per 1000 individuals (95% CI 60 more to 60 fewer), indicating a “trivial” undesirable effect. Given that the desirable effect was “small”, and the undesirable effect was “trivial,” we determined "probably favors the intervention”.Regarding in-bed cycle ergometer, the estimated effect size for the 6MWD  was an SMD of 0.21 higher (95% CI 0.29 lower to 0.71 higher). The estimated effect size for the 6MWD  was an MD of 81.0 m longer (95% CI 7.01 m longer to 154.99 m longer). For the MRC-SS , the estimated effect size was an MD of 0.47 points higher (95% CI 4.09 points lower to 5.04 points higher). The effect size for muscle mass  was an SMD of 0.39 higher (95% CI 0.13 higher to 0.65 higher). The estimated effect size for duration of mechanical ventilation  was an MD of 0 days shorter (95% CI 0.25 days shorter to 0.25 days longer). For length of hospital stays , the estimated effect size was an MD of 1.96 days shorter (95% CI 3.32 days shorter to 0.6 days shorter). The intervention group was found to be superior in most outcomes, and the desirable effect was assessed as “moderate”. The estimated effect size for all adverse events  was 10 fewer events per 1000 individuals (95% CI 60 fewer to 30 more), indicating a “trivial” undesirable effect. Given the moderate desirable effect and trivial undesirable effect, we determined “favors the intervention”.For use of both neuromuscular electrical stimulation and in-bed cycle ergometer, the estimated effect sizes for ADL (Katz Index and Barthel Index) .In critically ill patients, swallowing function is often impaired due to interventions, such as the placement of a tracheal tube, tracheostomy, and surgical procedures. In particular, in older adults, pre-existing dysphagia may be present due to comorbidities and aging. Therefore, it is important to understand the frequency of dysphagia in critically ill patients. Dysphagia can also impact restrictions in oral intake, changes in dietary methods, decisions regarding discharge to home, and prognosis. Therefore, swallowing function should be evaluated at an appropriate time during ICU admission. Swallowing function assessment consists of screening to identify dysphagia and diagnostic swallowing function tests. However, the optimal screening methods and timing of tests for swallowing function in critically ill patients remain unknown. Various methods for evaluating swallowing function exist, but ICU patients are often attached to multiple medical devices and have limited mobility, which restricts the swallowing function tests that can be performed in the ICU setting. Given the above, dysphagia should not be overlooked in critically ill patients and the appropriate screening methods and timing of tests for this purpose should be clarified. Therefore, these issues were addressed as a CQ in this guideline.The frequency of dysphagia among critically ill patients in the ICU varies widely, due to the lack of standardized evaluation methods and diagnostic criteria, differences in study populations in previous studies, and variations in the timing of assessments. In recent years, various systematic reviews and cohort studies on dysphagia in the intensive care setting have been reported. An endoscopic evaluation of swallowing function in patients aged 65 years and older, who underwent more than 48 h of mechanical ventilation and subsequent extubation revealed dysphagia in 52% of the participants  . Among tDysphagia in critically ill patients admitted to the ICU is associated with outcomes, such as the development of pneumonia, reintubation, length of hospital stays, home discharge rates, swallowing function at discharge, ability to resume oral intake, and in-hospital mortality rates . TherefoPrior to conducting various screening methods, an assessment of the oral and pharyngeal morphology and function, as well as a neurological examination, should be performed. First, during observation of autonomous opening and closing movements, the oral cavity should be checked for contamination and tongue coating, and oral care should be provided. Next, the remaining teeth, loose teeth, and dental caries should be identified to assess chewing function. Swallowing function can be inferred by examining tongue movement, tongue deviation and atrophy during tongue protrusion, soft palate elevation, and the curtain sign. Facial nerve function, including the depth of the nasolabial groove, pursing of the lips, and corner of the mouth retraction, can affect the intraoral retention of the food bolus. In the evaluation of voice quality and articulation, breathy voice and reduced volume may suggest impaired glottal closure and possible nerve paralysis should be considered. In addition, wet hoarseness can be caused by the presence of airway secretions adhering to the vocal folds, but caution should be exercised, as this can also occur due to the pooling of saliva in the vallecula epiglottic and pyriform sinuses or due to penetration into the larynx.Answer: We suggest against managing critically ill ICU patients based on VE (GRADE 2D: Certainty of evidence = “Very low”).Critically ill patients in the ICU often experience dysphagia due to factors, such as prolonged inability to take food orally, resulting in oral functional decline, the presence of an oral endotracheal tube, and systemic catabolism due to invasive procedures . SwallowIn the SR, only one RCT that met the PICO criteria was identified . No repoN = 70), the estimated effect size for reintubation was 24 more cases per 1000 people (ranging from 25 fewer to 539 more). The occurrence of pneumonia was set as a desirable effect, but based on one RCT (N = 70), the estimated effect size for pneumonia was 75 more cases per 1000 people (ranging from 33 fewer to 590 more), an undesirable effect suggesting an increase with the intervention. Therefore, the undesirable effect was considered to be “small” in magnitude.In the identified RCT  only. Since the intervention tended to increase harm, the control treatment was considered to be superior.Answer: We suggested that rehabilitation therapy related to swallowing function should be provided for critically ill patients (GRADE 2C: Certainty of evidence = “Low”).In critically ill patients in the ICU, swallowing function can be compromised due to factors, such as oral functional decline, placement of an oral endotracheal tube, tracheostomy, and a history of highly invasive procedures. Compromised swallowing function increases the risk of aspiration pneumonia and necessitates changes in the method of food intake in daily life, resulting in a deterioration of the patient's QOL. Rehabilitation therapy targeting oral and swallowing function is provided with the aim of improving swallowing function in these critically ill patients. However, the effectiveness of such rehabilitation interventions remains unclear.N = 591) was 1 event fewer per 1000 individuals (ranging from 55 fewer to 95 more), but differences were not statistically significant. The estimated effect size for the incidence of pneumonia  was 145 events fewer per 1000 individuals (ranging from 196 to 80 fewer), suggesting a clinically significant effect. No reports addressed QOL or ADL. The estimated effect size for eating status   showed an MD of 0.79 higher (ranging from 0.21 lower to 1.79 higher), indicating a beneficial direction of the effect of the intervention. While a reduction in pneumonia incidence was observed, no clear effects were demonstrated for other outcomes, leading to the judgment of a “small” desirable effect.In the SR, we identified 11 RCTs that met PICO criteria, which were included in a meta-analysis –83. The N = 419) showed an estimated effect size of 13 fewer events per 1000 individuals (ranging from 263 fewer to 574 more). Although the outcome was set as a harmful effect, a beneficial direction of the effect was observed, although without statistical significance, leading to a judgment of a “trivial” undesirable effect.The outcomes related to adverse events .Previously, the target energy intake for critically ill patients has been recommended as 25–30 kcal/kg/day . HoweverN = 192), the estimated effect size, measured as the MD, was 0.58 higher (ranging from 4.77 lower to 5.92 higher). For health-related QOL (HRQOL) scores , the estimated effect size was 0.01 higher (ranging from 0.03 lower to 0.05 higher). While a trend for intervention showing superiority was found in terms of physical function and QOL outcomes, the effect sizes were small, indicating only trivial desirable effects. Regarding adverse events, the estimated effect size for diarrhea  was 36 more cases per 1000 individuals (ranging from 9 fewer to 93 more). Considering the occurrence of adverse events, the undesirable effects were also considered to be trivial. Therefore, neither the intervention nor the control was deemed superior.Based on our SR, 15 RCTs that matched the PICO criteria were identified from 18 published papers –106, andAnswer: We suggest administering protein of 1 g/kg/day or more to critically ill patients on days 4–10 of treatment (GRADE 2D: Certainty of evidence “Very low”).Similar to energy requirement, the optimal amount of protein to provide critically ill patients has not yet been clearly established. Protein is necessary for immune function  and tissN = 236), the estimated effect size was an MD of 21.55 higher (ranging from 1.3 lower to 44.4 higher). For physical function outcomes , the estimated effect size was an MD of 1 lower (ranging from 5.79 lower to 3.79 higher). For muscle mass changes , the estimated effect size was an SMD of 0.47 higher (ranging from 0.24 higher to 0.71 higher). Finally, for HRQOL scores , the estimated effect size was an SMD of 0.13 points lower (ranging from 0.31 points lower to 0.06 points higher). The estimated effect size for the adverse event of diarrhea  was 45 fewer events per 1000 individuals (ranging from 176 fewer to 140 more cases). The outcomes of ADL, muscle mass changes, and adverse events favored the intervention group, while the outcomes of physical function and HRQOL favored the control group. However, considering the low importance level assigned to these outcomes, the desirable effects were judged to be “small.” No significant increase in the occurrence of undesirable effects was observed, and therefore, the undesirable effects were judged to be “trivial.” With desirable effects being “small” and undesirable effects being “trivial,” the intervention was deemed to be likely to be superior.Based on the SR, 15 RCTs from 16 papers that met the PICO criteria were identified , 111–125Answer: We suggest an early physical rehabilitation protocol be introduced for critically ill children (GRADE 2D: Certainty of evidence = “Very low”).In the field of pediatric intensive care, knowledge is lacking regarding the effectiveness and safety of implementation of a physical rehabilitation protocol soon after ICU admission, with the goals of early mobilization and muscle strength preservation. However, similar to the adult settings, some pediatric patients struggle with mobilization and muscle recovery, even during the convalescence phase. Such patients may benefit from early physical rehabilitation after admission, leading to reduced risk of mortality and shorter hospital stays. On the other hand, concerns such as unplanned removal of various tubes and a lack of understanding among the healthcare staff may create hesitation regarding implementation of physical rehabilitation during the acute phase in critically ill children. Therefore, we considered that it would be important to investigate the effectiveness and safety of early physical rehabilitation in this CQ.N = 58) was a mean difference (MD) of 0 days (95% CI 4.98 days shorter to 4.98 days longer), while the estimated effect size for length of ICU stay  was an MD of 1.5 days longer (95% CI 2.63 days shorter to 5.63 days longer). No RCTs reporting on mortality were identified. Based on the above, even though the length of ICU stay was prolonged; because of the limited sample size and the inability to evaluate the outcome of mortality, the desirable effects of early physical rehabilitation were considered “unknown.” On the other hand, the estimated effect size for adverse events requiring therapeutic intervention  was 66 fewer events per 1000 individuals (95% CI 91 fewer to 151 more). Consequently, the intervention does not appear to increase adverse events, and therefore, the undesirable effects of early physical rehabilitation were considered “trivial.” In this CQ, while the undesirable effects were “trivial,” the desirable effects could not be determined. Therefore, the judgment of superiority between the intervention and control is “unknown” in this CQ. Nevertheless, considering that early physical rehabilitation protocols have already been implemented without additional resources in many hospitals and that adverse events are unlikely to increase, we decided to emphasize potential desirable effects of early physical rehabilitation protocols for critically ill children.The results of the SR identified two relevant RCTs meeting the PICO criteria , 127, anIt should be kept in mind, however, that the effectiveness of implementing an early physical rehabilitation protocol for critically ill children could not be clearly determined in this study. Therefore, the effects should be evaluated individually for each patient.Answer: We suggest performing respiratory physiotherapy to mechanically ventilated children from the acute phase. (GRADE 2D: Certainty of evidence = “Very low”).Children, particularly infants, are prone to developing atelectasis, because their high lung chest wall compliance is not elastic enough to counteract the recoil of the lungs, and also because their airways are narrow. Therefore, it has been reported that respiratory physiotherapy is actively performed in the acute phase of mechanical ventilation management . HoweverN = 143) was a risk difference (RD) of 107 fewer events per 1000 people (95% CI 178 fewer to 64 more), while the estimated effect size for duration of mechanical ventilation  was a mean difference (MD) of 10.1 h longer (95% CI 37.57 h shorter to 57.77 h longer). No RCTs regarding lengths of hospital stay or ICU stay were identified. Based on these results, the desirable effect of respiratory physiotherapy was judged to be “moderate.” On the other hand, the estimated effect size for adverse events requiring therapeutic intervention  was an RD of 22 fewer events per 1000 patients (95% CI 78 fewer to 175 more). Based on these results, it was considered that the intervention did not lead to an increase in adverse events, and therefore, the undesirable effect of respiratory physiotherapy was judged to be “trivial.” Considering the moderate desirable effect and the trivial undesirable effect in this CQ, the balance of effects is likely to favor the intervention.The results of the SR identified two RCTs meeting the PICO criteria , 130, anIt would be important to evaluate the effects of the intervention on individual patients carefully, keeping in mind that the two selected RCTs evaluated the effects of prone positioning management specifically, and no RCTs evaluating other interventions in respiratory physiotherapy were obtained.Answer: We suggest providing enhanced rehabilitation to critically ill patients after ICU discharge. (GRADE 2D: Certainty of evidence = “Very low”).N = 807) was an SMD of 0.10 higher (95% CI 0.06 lower to 0.25 higher). For QOL  , the estimated effect size was an SMD of 0.19 higher (95% CI 0.03 lower to 0.42 higher), and for QOL  , the estimated effect size was an SMD of 0.22 higher (95% CI 0.09 lower to 0.54 higher). For ADL , the estimated effect size was an SMD of 0.41 lower (95% CI 1.28 lower to 0.46 higher). No RCTs reported on the effect of enhanced rehabilitation on return to work. Among the outcomes, the three clinically important QOL measures favored enhanced rehabilitation, while ADL favored comparison. With lower importance assigned to ADL than to QOL, the desirable effect was considered “small.” For all adverse events , the estimated effect size was 49 more events per 1000 individuals (95% CI 8 fewer to 310 more), with 0 events reported in both the intervention and comparison groups in three of four RCTs. Regarding the initially anticipated beneficial outcome on mortality , the estimated effect size was 22 more events per 1000 individuals (95% CI 31 fewer to 218 more), indicating a “small” undesirable effect. Considering that the importance assigned to mortality and all adverse events was lower than that assigned to QOL, the judgment was that “probably favors the intervention”.The objective of rehabilitation for critically ill patients is to maintain and improve ADL and to enhance QOL. Similar to rehabilitation in ICU, enhanced rehabilitation after ICU discharge is also performed with the goal of improving ADL, enhancing QOL, and facilitating social reintegration. However, no definitive consensus on the effects and adverse events associated with enhanced rehabilitation after ICU discharge has been established to date. It has been observed that physical, cognitive, and psychological impairments in critically ill patients persist for a long time, even after ICU discharge. Therefore, clarifying the effectiveness of enhanced rehabilitation after ICU discharge for critically ill patients is important, to develop appropriate rehabilitation plans for them. Our SR identified 20 RCTs that met the PICO criteria –150, whiAnswer: The involvement of family in the rehabilitation of critically ill patients includes direct participation and assistance in actual rehabilitation activities, such as mobilization, providing encouragement by holding hands, assisting with ADLs and contributing to the patient’s comfort. By involving family members, the patient’s motivation for rehabilitation can be maintained, and is likely to have positive effects, such as reducing anxiety, discomfort, and post-rehabilitation fatigue. In addition, it can satisfy the needs of family members who wish to help the patient and can potentially improve negative beliefs, feelings of futility, and powerlessness. However, family involvement in rehabilitation may also impose psychological burdens on both the patient and the family. It is necessary to provide sufficient explanation and education to the family before suggesting their participation (Provision of information for background question).Critically ill patients are in a severe physical and mental condition, and the presence of family is crucial. Strategies commonly used in the routine care of critically ill patients, such as the ABCDEF bundle, incorporate elements of early rehabilitation and family involvement, which are considered important throughout the recovery process . PreviouFamily-centered care is an approach to healthcare that respects the individual needs and values of each family and involves providing information, involving them in care, and supporting their decision-making processes . In the Although intervention studies examining the effects of family participation in rehabilitation for critically ill patients are limited, it has been shown to help maintain the patient’s motivation for rehabilitation and to reduce anxiety, discomfort, and post-rehabilitation fatigue , 153. InOn the other hand, family participation may potentially cause psychological distress for both patients and family members. Some patients may wish to maintain their self-image or feel embarrassed about their appearance, while others may have concerns about the safety of family participation, questioning whether family members are skilled in providing care; hence, it is necessary to consider the patients’ emotions and social backgrounds when making these choices. Family members also express concerns about the potential negative impact on the patient's health or about interfering with healthcare professionals’ work . In partWhile the involvement of family members in the rehabilitation of critically ill patients has not been verified sufficiently, it is anticipated that future research will shed light on its effectiveness.Additional file 1. Financial and academic COIs and roles of committee members.Additional file 2. Supplementary materials associated with the clinical practice guidelines.


Return-to-work (RTW) process often includes many phases. Still, multi-state analyses that follow relevant labour market states after a long-term sickness absence (LTSA), and include a comprehensive set of covariates, are scarce. The goal of this study was to follow employment, unemployment, sickness absence, rehabilitation, and disability pension spells using sequence analysis among all-cause LTSA absentees.Register data covered full-time and partial sickness allowance, rehabilitation, employment, unemployment benefits, and permanent and temporary disability pension (DP), retrieved for a 30% representative random sample of Finnish 18–59 years old persons with a LTSA in 2016 . LTSA was defined as a ≥ 30-day-long full-time sickness absence spell. Eight mutually exclusive states were constructed for each person and for 36 months after the LTSA. Sequence analysis and clustering were used to identify groups with different labour market pathways. In addition, demographic, socioeconomic, and disability-related covariates of these clusters were examined using multinomial regressions.We identified five clusters with emphases on the different states: (1) rapid RTW cluster (62% of the sample); (2) rapid unemployment cluster (9%); (3) DP after a prolonged sickness absence cluster (11%); (4) immediate or late rehabilitation cluster (6%); (5) other states cluster (6%). Persons with a rapid RTW (cluster 1) had a more advantaged background than other clusters, such as a higher frequency of employment and less chronic diseases before LTSA. Cluster 2 associated especially with pre-LTSA unemployment and lower pre-LTSA earnings. Cluster 3 was associated especially with having a chronic illness before LTSA. Those in cluster 4 were on average younger and had a higher educational level than others. Especially clusters 3 and 4 were associated with a LTSA based on mental disorders.Among long-term sickness absentees, clear groups can be identified with both differing labour market pathways after LTSA and differing backgrounds. Lower socioeconomic background, pre-LTSA chronic diseases and LTSA caused by mental disorders increase the likelihood for pathways dominated by long-term unemployment, disability pensioning and rehabilitation rather than rapid RTW. LTSA based on a mental disorder can especially increase the likelihood for entering rehabilitation or disability pension.The online version contains supplementary material available at 10.1186/s12889-023-15895-2. With high financial and human costs, occupational disability is a major challenge for today’s societies. Numerous studies have shown that tackling disability as early as possible is essential. The longer the sickness absence period continues, the lower is the probability for returning to sustained full-time work, and the higher the chance for a disability pension transition –3.Once a long-term sickness absence (LTSA) occurs, personal characteristics such as younger age, higher education and higher socioeconomic position are known to enhance the chances for return-to-work (RTW) and decrease the risk for prolonged or permanent disability –6. HowevSequence analysis has proven to be a valuable method in capturing the different phases and transitions involved in the RTW process , 5, 9–12Knowledge on the frequency and timing of rehabilitation is a central issue associated with early support and RTW. However, the timing of rehabilitation has often been lacking in multi-state models identifying post-LTSA labour market transitions. Madsen’s  and PedeIn addition, the pathways after LTSA can depend on a wide range of personal demographic and socioeconomic characteristics, and baseline labour market position , 11, 12.The aim of this study was to follow the alteration between employment, unemployment, further sickness absence spells, rehabilitation, and disability pension after LTSA, using sequence analysis and objective register data. We aimed to identify clusters based on the individual sequences, and to examine covariates of these clusters using a wide range of background characteristics.All persons who started a full-time sickness absence spell lasting at least 30 days during 2016 were first retrieved from a fully representative random sample of the Finnish population, including 30% of all working-age persons. LTSA was thus defined as a ≥ 30-day-long full-time sickness absence spell.The study sample was then restricted to 18–59 years old persons with no sickness absence days during 12 months prior to that spell . The age limits were set so that all the subjects would be of adult age and would not reach the lowest limit of old-age pension in Finland (63 years) during the follow-up. Subjects were followed for 36 months (three years) from the first day exceeding 30 LTSA days.Data on full-time and partial sickness allowance spells, demographics and the existence of chronic or severe diseases were retrieved from registers of the Social Insurance Institution of Finland (Kela). Data on socioeconomic status was obtained from Statistics Finland. Employment and unemployment benefit spells, and annual earned incomes were retrieved from registers of the Finnish Centre for Pensions. Rehabilitation spells and benefits were retrieved from Kela and the Finnish Centre for Pensions. Rehabilitation included vocational rehabilitation , medical rehabilitation , discretionary rehabilitation  and rehabilitative psychotherapy. All data on benefit and employment spells included start and end dates. Data on temporary and permanent disability pensions was derived from registers of Kela and the Finnish Center for Pensions, including the start dates of DP.Sickness absence was measured through compensated sickness allowance days. Kela can pay sickness allowance to non-retired persons aged 16–67 as compensation for loss of income due to sickness or impairment. The allowance can be paid when the sickness absence exceeds 10 working days, covered by the employer. A physician’s sickness certificate is needed for the allowance. Based on a certain diagnosis, the allowance can generally be paid up to twelve months during two years’ time. Partial sickness allowance can be granted if work ability is reduced but the beneficiary is able to continue working part-time.A disability pension may mainly be granted after the statutory maximum period of full-time sickness allowance. A temporary disability pension can be granted to compensate earnings loss during rehabilitation or treatment. Also the rehabilitation benefit is meant for securing income during vocational or medical rehabilitation that is already realizing or secured.Register data on sickness allowance spells included the start and end dates and diagnoses of the spells. Persons with full-time sickness absence spells at least 30 days long were studied, as longer sickness absence both signals the need for care or rehabilitation and are a more significant risk for permanent disability –3, 16. AEight mutually exclusive states were constructed for each person and for each of the 36 months of the follow-up. The possible states in each month were permanent disability pension, rehabilitation, temporary disability pension, full sickness allowance, partial sickness allowance, unemployment or employment. If none these sources of income could be found for a 1-month unit, the state of that month was recorded as other/unknown. These other states included those who either died during the follow-up  or exited the Finnish population .In the case of overlap, the state mentioned earlier in the above list dominated over the states listed later. An exception was made in the case where there was both unemployment and employment ‒ and no states “above” them ‒ during a 1-month unit. In that case the state was defined based on which of the two states had more registered days.The nine covariates were mostly measured in the start of 2016. Age was classified into four groups .In general, the average number of transitions between states during the 36-month follow-up was 4.0 (standard deviation [SD] 1.9). While only one transition was most typical in all sequences (25.4% of the study sample), 45.9% had four or more transitions during the follow-up. The average number of Table Examining the average total durations of each state, employment covered on average the most, 20.0 months of the follow-up. Full sickness absence (mean 4.5 months), unemployment (mean 3.6 months) and other states (mean 3.1) were the next most frequent states, with rehabilitation (mean 1.9 months), temporary DP (mean 1.3 months), and permanent DP (mean 1.3 months) coming next. Respectively, the average number of episodes was also highest for employment (mean 1.7) and full sickness absence (mean 1.6).Out of four cluster-stopping indexes, three supported a five-cluster solution  and higher average number of employment episodes (2.1). The cluster also depicted RTW with little rehabilitation or temporary DP (table Cluster 1 (67.7%), the largest one, was dominated by DP table . For a lDP table .rapid unemployment. Many faced prolonged unemployment that lasted on average 24.6 months of the whole 36 month follow-up time (S2). A significant proportion of persons in this cluster had a long unemployment period right after the initial 30-day LTSA, and 15% were only unemployed alter LTSA for the whole follow-up (table Cluster 2 (8.7%) included persons with emphasis on up table . Howeverup table .disability pension after a prolonged sickness absence spell  consisted mostly of individuals transferring to either permanent or temporary ell Fig. . The aveell Fig. . Respectell Fig. . For manell Fig. . Overallell Fig. . For 19.immediate or late rehabilitation. The average overall duration of rehabilitation during the follow-up was 21.6 months (table S2). Although for many, the rehabilitation started early in the follow-up, the proportion of persons in rehabilitation was most frequent around the 24th follow-up month , a rather small one, included persons with other states during the follow-up, i.e. unknown states that were not captured by the variables available in this data set. Of the measured states, employment, unemployment and new full sickness absence spells altered most often with the unknown states , included persons with a lot of months in tes Fig. .Besides forming its own cluster, the states not captured by our study design were present in other clusters. They were usually placed between full sickness absence and the next states, especially before unemployment cluster 2), DP (cluster 3) or rehabilitation (cluster 4), as seen in Fig. , DP  spell at least 30 days long. By using sequence analysis, the primary goal was to identify groups with different emphases on these states, different transitions between states and unique covariates.rapid RTW cluster as the largest in size, covering 62% of all subjects. Notably, this group mostly returned directly to work, with few records of other states or rehabilitation periods in between. Interestingly, while the rapid RTW group had the lowest average number of sickness absence months in total after the initial 30-day LTSA, they had the highest amount of separate full sickness absence spells during the follow-up. This shows that for many the fast RTW can still include new sickness absence spells before a more stable RTW. The rapid RTW group had a better socioeconomic background, i.e. a higher employment frequency, and a lower frequency of chronic diseases before LTSA than members of other clusters. Such an advantaged background naturally aids in restoring the work ability and returning to work. In addition, in Finland those employed usually have access to free-of-charge Occupational Health Services, specialized in work ability issues [Based on sequence analysis, we found five clusters with clear identities and emphases on the labour market states examined. As in previous studies , 9, mosty issues , aiding In contrast to the rapid RTW group, cluster 2 identified those with a quite rapid transition to unemployment after LTSA (9% of the subjects). This group had relatively scattered paths, with the second most transitions between different states, typically between unemployment and new full sickness absence spells or employment. The alteration between states and difficulty of work attachment is not surprising as unemployment or lower socioeconomic status intertwine with disability in many ways , 33, makThe third cluster identified persons transitioning to permanent or temporary disability pension 11%). They were characterized especially by older age, having a chronic illness before the initial LTSA, but also by a lower socioeconomic status as shown also in previous studies , 34, 35.1%. They The fourth cluster identified persons with immediate or late rehabilitation, whether medical or occupational (6%). Rehabilitation spells covered on average two years of the three-year follow-up. The recurrence of rehabilitation was frequent and there was a high number of transitions between different states, for example between employment and rehabilitation. It is understandable that if work disability is severe enough to require rehabilitation, the RTW process can be incoherent. Especially vocational rehabilitation spells can be long, and recurrent rehabilitation periods common , 41. ForFinally, there was a fifth group (6%) whose paths after the initial 30-day LTSA were mostly unknown, i.e. dominated by states or sources of income not captured by our study. This group may include persons living on other social security benefits that our data did not capture, such as family benefits or students’ benefits. Other possibilities are living on other household members’ income, on their own savings, or on capital income. Interestingly, when examining the other clusters with more distinct identities, the unknown other state was usually placed between full sickness absence and the next state. This can reflect the difficulty to stabilize the labour market position and secure income during or after work disability. As it also may indicate a break in income, future studies could shed more light on this observation.Sickness absentees’ background factors such as higher age and lower socioeconomic on RTW processes are well known to predict future sickness absences and disability and a lower likelihood for RTW , 11, 12.Unlike in many previous studies, we were also able to control for the pre-LTSA chronic diseases. Unsurprisingly, having at least one chronic disease before the LTSA increased especially the risk of being in the cluster of persons that transferred to disability pensions. This background factor can reflect general morbidity, and in some cases a lengthy or severe condition behind the sickness absence. A higher number of diseases, and comorbidity of somatic or psychiatric conditions increase the risk for long occupational disability , 50. In Unlike many previous multi-state studies, we were able to study multiple relevant labour market states reflecting the RTW process after long-term work disability, and to utilize register data on all states. Furthermore, unlike many sequence analyses or other multi-state analyses on long-term sickness absence, we included a comprehensive set of register-based demographic, socioeconomic, and disability-related covariates. Registers are deemed to be highly reliable and objective, with no self-report bias and no loss to follow-up. However, the time-span is a limitation in our study. Like RTW in general, rehabilitation can be a long process, and our three-year follow-up may not have been totally sufficient to show more steady benefits from the rehabilitation spells. Our rehabilitation cluster showed persons that were in rehabilitation for the most of the three-year follow-up. As Madsen’s study has shown, it may require a long follow-up setting to distinguish between early, late or successful rehabilitation groups. In addition, our proxy measure for chronic disease was not ideal. While information in the register for special entitlements for medicine expenses has been considered to be a good proxy for morbidity , these eWe identified distinct groups among long-term sickness absentees, with both differing labour market pathways after a 30-day LTSA and differing backgrounds. A lower socioeconomic background, pre-LTSA chronic diseases and mental disorders increase the likelihood for long-term unemployment, disability pensioning and rehabilitation spells rather than rapid RTW. LTSA based on a mental disorder can especially increase the likelihood for rehabilitation or disability pension. Future multi-state studies could build on our observations by analyzing rehabilitation processes related to successful RTW and income gaps in RTW pathways.Below is the link to the electronic supplementary material.Supplementary Material 1


This study aimed to explore whether there is an association between androgen receptor (AR) expression and ultrasound, clinicopathological features and prognosis of breast cancer.A total of 141 breast cancer patients were included in this retrospective study. AR expression was analyzed by immunohistochemistry. The images of B-mode, color Doppler and strain elastography from 104 patients were collected continuously, and the corresponding ultrasound characteristics were obtained. The differences in ultrasound and clinicopathological features in different AR status were analyzed. Progression-free survival (PFS) of patients was obtained through up to 90 months of follow-up; then, the effect of AR on PFS was analyzed. Subsequently, a nomogram was constructed to predict the AR status. The predictive accuracy was calculated using C-index.p = 0.034) and lower Ki-67 level (p = 0.029). Triple-negative breast cancer (TNBC) had the lowest probability of AR + (p < 0.001). The AR + group mostly showed unsmooth margin (p < 0.001), posterior acoustic shadowing (p = 0.002) and higher elasticity score (p = 0.022) on ultrasound. The echo pattern of most tumors with AR + was heterogeneous (p = 0.024) in Luminal A subtype. AR + could be a sign of a better prognosis in overall breast cancer (p < 0.001), as well as in human epidermal growth factor receptor 2 (HER2) overexpression and Luminal B subtypes (p = 0.001 and 0.025). The nomogram showed relatively reliable performance with a C-index of 0.799.The positive expression of AR (AR +) was associated with lower histological grade (Our research demonstrated that AR expression was closely related to ultrasound, clinicopathological features and prognosis of breast cancer.The online version contains supplementary material available at 10.1186/s13244-023-01387-9. In terms of clinicopathology, the probability of AR expression in different subtypes of breast cancer was various, and the positive expression of AR was associated with lower histological grade and lower Ki-67 level.In terms of ultrasound, the positive expression of AR was associated with unsmooth margin, posterior acoustic shadowing and stiffer on strain elastography, and AR + and AR– tumors performed differently when analyzed separately according to different molecular subtypes.The positive expression of AR could be a sign of a better prognosis in breast cancer.The online version contains supplementary material available at 10.1186/s13244-023-01387-9. Breast cancer, with a global incidence of approximately 2.26 million new cases each year, has overtaken lung cancer to become the most commonly diagnosed cancer globally, which seriously threatens women's health and life . MeanwhiThe expression of molecular markers affects the biological and histological behavior of breast cancer and then affects the imaging appearances; they are inextricably related , 9. UltrBae et al.  suggesteThis is a retrospective study of case information collated from June 2013 to September 2016. A total of 151 breast cancer patients underwent ultrasound examination before the operation and obtained pathological sections postoperatively. However, 7 of these patients lacked clinicopathological information and the other 3 patients had poor quality of pathological sections, which led to the exclusion of these 10 patients. Finally, 141 patients were included in the study. This study was approved by the institutional ethics committee of Harbin medical university . We reviewed the clinical data and the ultrasound images of these patients during the study period. The process of selecting patients for data analysis is presented in Fig. We reviewed the following data from the 141 patients’ medical records: age, tumor size, menopausal status (non-menopause and menopause), lymph node metastasis (absent and present), distant metastasis (absent and present), histological type , histological grade   and clinThe ultrasound images of breast masses in 104 patients were scanned by a radiologist with 5 years of experience in breast ultrasound using a HITACHI Vision 500 system  equipped with a linear probe of 5–13 MHz. In real-time scanning, the static images of the maximum diameter of the mass during transverse and longitudinal cutting, and the dynamic images of the standard sections of B-mode, color Doppler and ultrasound strain elastography were preserved. These ultrasound images were reviewed independently by two breast radiologists with the wealth of experience of 8 and 10 years, respectively, while ignoring the IHC results. Where differences occurred, a consensus was reached. Feature extraction of B-mode ultrasound images was based on the Breast Imaging Reporting and Data System (BI-RADS) lexicon . The ultThe expression of AR was analyzed by IHC based on tissue microarray (TMA), which was evaluated by two pathologists with > 10 years of breast pathology experience. The TMA section was stained with AR antibody . Normal breast tissue on TMA was used for internal control. We choose known positive breast cancer tissues as positive controls. Negative controls were prepared by omitting the primary antibody. False negatives and false positives were avoided by this approach, similar to ER and PR. AR positivity is defined as ≥ 10% of tumor cells with positive nuclear staining . AccordiOf the 141 patients, 103 were followed up in multiple methods. We gave priority to collecting as much detailed as possible through outpatient review information, inpatient treatment records, followed by telephone follow-ups. These patients were followed up twice a year with a 6-month cycle. Patients without recurrence were followed for at least 60 months, and those with recurrence were followed until the time of recurrence. Progression-free survival (PFS) was used as the study endpoint and was defined as the time from the operation date to tumor recurrence and death or the last follow-up date.http://www.R-project.org) were used for statistical analysis. The relationship between clinicopathological features and AR status was analyzed by univariate and multivariate logistic regression analysis; the odds ratio (OR) and 95% confidence interval (95% CI) were calculated, and the differences in ultrasound characteristics between AR + and AR– groups were evaluated using the Chi-square test or Fisher's exact test. A nomogram based on the logistic regression analysis model was constructed to predict AR status. The efficiency of the logistic regression model was calculated by receiver operating characteristic curve (ROC) and area under curve (AUC). Additionally, the performance of the nomogram was measured by C-index and calibration curve. Moreover, the Kaplan–Meier method was used to evaluate PFS. Multivariate Cox proportional hazards model was used to analyze prognostic factors. For all the analysis p values < 0.05 were considered statistically significant.IBM SPSS Statistics, Version 26.0, and R Version 4.1.1 (p = 0.001), histological grade , p = 0.011) and Ki-67 level , p = 0.027) were significantly different between the two groups by univariate logistic regression analysis ; further, AR + was related to lower histological grade , p = 0.034) and lower Ki-67 level , p = 0.029) by multivariate logistic regression analysis.As presented in Table  0.404 0.00, 0.816p < 0.001). Compared with AR– breast cancer, AR + was more likely to be posterior acoustic shadowing . The elasticity score of AR + breast cancer was mostly concentrated in 4  . The internal echo pattern in AR + group was more heterogeneous. However, in our study, perhaps because the sample size was not large enough, no significant differences were found in ultrasound characteristics when AR expression differed in the other three subtypes  of AR + breast cancer showed unsmooth margin on ultrasound; however, that of AR– was 72.73% 24/33). Only 1 of 71 cases of AR + breast cancer showed smooth margin ( of AR + /33. Onlyp = 0.011), posterior acoustic pattern , p = 0.019) and margin , p = 0.017) were positively correlated with the expression of AR, while menopausal status , p = 0.011) was negatively correlated. This meant that the probability of AR positive expression was higher in patients who were older, with posterior acoustic shadowing, with unsmooth margins, and non-menopause. Based on the statistically significant variables of multivariate regression, the final logistic model was established to predict the AR status. The model showed excellent diagnostic efficiency with the Hosmer-Lemeshow goodness of fit test for AR , and AUC of 0.799  and statistically significant ultrasound features  in the multivariate logistic regression analysis Table . The res.984 1.62, 138.161Subsequently, the nomogram was constructed according to the logistic regression model. In the nomogram, the menopausal status, age, margin and posterior acoustic pattern were distributed according to their risk coefficient. Each patient can calculate the total points by accumulating the corresponding points of each feature according to their conditions to evaluate the AR status Fig. a. There 2 = 16.895, p < 0.001). According to AR status, the Kaplan–Meier plot of PFS for the entire study cohort is presented in Fig. p = 0.014) and tumor size , p < 0.001) were independent prognostic factors for breast cancer by multivariate Cox regression analysis. In the survival analysis of different subtypes, it was found that the clinical outcomes of Luminal B (p = 0.025) and HER2 overexpression subtypes (p = 0.001) were consistent with that of the entire study cohort; the patients with AR + had favorably clinical outcomes  were followed up from 1 to 90 months median, 63 months). Of the 103 patients, 11 cases experienced disease progression. Only 2 patients  in the AR + group experienced disease recurrence, compared with 9  in the AR– group. The 5-year survival rate of AR + and AR– groups was 97.22% and 70.97% for PFS, respectively. After the Log-rank test, there was a statistically significant difference between the two groups  on ultrasound. Ultrasound elastography can semi-quantitatively measure the hardness of tumor in a routine examination . The harWe initially constructed a simple nomogram to predict the AR status based on our findings that AR is indeed related to ultrasound and clinicopathological features. Nomogram is a model that can reflect the evaluation value intuitively, and contains various characteristics. It can not only be used to the prediction, but also to verify the correlation . Our nomSurvival analysis showed that AR status and tumor size were independent prognostic factors of PFS. Besides, in the entire study cohort, the clinical outcomes of AR + patients were significantly better than that of AR–. Moreover, we analyzed the effect of the AR status on prognosis in different subtypes and found that the results in HER2 overexpression and Luminal B subtypes were consistent with the overall results, which were in accordance with the results of Jiang et al.. Given eAltogether, we studied the correlation between AR status and ultrasound, clinicopathological features and clinical outcomes in breast cancer, although our research still has some limitations. First, the sample size is not large enough, which might lead to bias in the results. Our study can be regarded as the initial exploration, and the sample size should continue to be expanded to analyze different results caused by the expression of AR in different subtypes. In order to explore whether AR is related to more detailed categorization of BI-RADS, it is also necessary to expand the sample size. Second, we did not include more features, such as the number of lymph node metastasis, peritumoral vascular invasion and blood flow resistance index, among others. And we only included strain elastography, without evaluating shear wave elastography. Additionally, mammogram, MRI and other imaging features were not included in this study. Then, we did not evaluate the diagnostic differences between radiologists. Finally, the simple nomogram was mainly used to verify the correlation, and the subsequent research will improve it for better prediction.In conclusion, AR is closely related to the clinicopathological features and prognosis of breast cancer. Moreover, the ultrasound findings of breast cancer with different expression of AR are also different. As a new molecular marker of breast cancer and an important prognostic factor, AR will play an increasingly important role in diagnosing and treating breast cancer. The above results will help to better understand various biological functions of AR and provide more information for the treatment of breast cancer.Additional file 1. Fig. S1. Examples of ultrasound and IHC images of two patients with breast cancer.


Practitioners have a clinical, ethical, academic, and economic responsibility to dispassionately consider how effective their services are. Approaches to measure how “good” or “bad” healthcare is include clinical audit, satisfaction surveys, and routine outcome measurement. However, the process of comparing the clinical outcomes of a specific service against the ‘best’ services in the same specialism, also known as benchmarking, remains challenging, and it is unclear how it affects quality improvement. This paper piloted and compared two different approaches to benchmarking to assess clinical outcomes in neurorehabilitation. Norming involved comparing routine measures of clinical outcome with external validators. Stacking involved pooling and comparing internal data across several years. The analyses of routine clinical outcome data from 167 patients revealed significant differences in the patient characteristics of those admitted to the same service provider over time, but no differences in outcomes achieved when comparing with historical data or with external reference data. These findings illustrate the potential advantages and limitations of using stacking and norming to benchmark clinical outcomes, and how the results from each approach might be used to evaluate service effectiveness and inform quality improvement within the field of brain injury rehabilitation. No matter who provides or funds the care and rehabilitation of patients with acquired brain injury, service providers have a clinical, ethical, scientific, and economic responsibility to dispassionately consider how effective their services are . At the It is not always straightforward to measure how good (or bad) the healthcare provided by an organisation is. Some approaches include clinical audit, routine outcome measurement, and patient satisfaction surveys. Clinical audit requires comparison to an agreed standard, which is often difficult to establish in the field of brain injury rehabilitation due to methodological limitations , whereasBesides the lack of studies explicitly using benchmarking as the main approach to assessing effectiveness of service delivery, there is also the question of which measures would be most suitable to use. In this regard, Alderman and colleagues  analysedBenchmarking considering outcome data from the same service or service provider over time periods is still in the early stages of widespread adoption in healthcare  but coulThe alternative to stacking is norming, which consists of reviewing the most up-to-date research literature produced in the field and using that as a reference group. There are several advantages to stacking over norming: it provides an opportunity for time trend analyses, it should provide a (relatively) large sample, against which detection of any cross-sectional change should be possible, and it arguably provides the closest clinical reference group . However, the use of stacked data also has limitations, such as high data homogeneity, which may obscure actual change . Put difIn this study, we compared stacking with norming to provide a practical illustration of how the use of these two methods can add an external check and balance to the internal approach of stacking in the analysis of the clinical outcome data from services operated by Brainkind , a UK-based not-for-profit provider of post-acute brain injury rehabilitation. The aim is to compare how these approaches might reduce some of the technical challenges to benchmarking seen in brain injury rehabilitation, and to identify whether the findings arising from the different techniques increase transparency and inform service improvement and development.The collection of clinical outcome measures on admission and discharge from rehabilitation within the services provided by Brainkind is part of the standard evaluation policies and procedures, which have been reviewed and approved by Brainkind’s clinical and governance teams. The present work did not raise any of the ethical issues considered within the Health Quality Improvement Partnership Guidance  and, in This study uses a mixed design, combining paired comparisons of routine clinical outcome within individuals over time (between admission and discharge from rehabilitation), cohort comparisons within a single rehabilitation provider over epochs, and cross-sectional comparisons of the present data with published results from other similar patient cohorts.Routine clinical outcome data of 167 patients discharged from post-acute brain injury rehabilitation between 1 June 2021 and 31 May 2022 were included in this study. Data were only excluded if the rehabilitation programme had not been completed as planned . Pairwise deletion was used to deal with missing data. The rehabilitation services evaluated in this study were provided by Brainkind’s  network, which follows a neurobehavioural therapy approach to rehabilitation described by Coetzer and Ramos [Brainkind’s network of services provides rehabilitation and support to people with an acquired brain injury. Rehabilitation services are indicated for people who are medically stable and within two years post-injury, but who require further assessment and rehabilitation before they are able to return home or live more independently after discharge from hospital. Rehabilitation programmes are tailored to individual needs, after a comprehensive assessment by a transdisciplinary team comprising clinical psychologists, neuropsychologists, occupational therapists, physiotherapists, speech and language therapists, a team of rehabilitation support workers, and neuropsychiatrists and nurses . The team works through a neuropsychology-informed approach to deliver individual programmes which vary in content and intensity of sessions on the basis of each individual’s presentation and goals. For example, people who have good self-awareness into their condition and do not experience barriers to rehabilitation, such as severe fatigue or behaviours that challenge, are offered 45 min of the relevant therapies at least five days a week . ProgramWe compared outcomes at admission and discharge from rehabilitation, on measures of supervision , impairN = 214—Last), and with historical results . Additional comparisons were made (1) between the data from the Current cohort and published reference data and (2) for all three cohorts across three clinical streams [p < 0.01.Data from the present cohort (Current) were compared with the data gathered within the same services in the previous year , which showed a higher proportion of women admitted in the current cohort ; older age in the current cohort than historically  = 6.11, p < 0.001); a higher proportion of people admitted with stroke in the current cohort than historically ; and a difference in the prevalence of certain comorbidities , which were less prevalent in the current cohort. There was also a difference in time since injury, indicating that people have been admitted on average two months sooner currently than historically . An overview of the patient characteristics across the different stacking groups is shown on W = 36,114, p = 0.001). Overall, the results show positive change, with significant reductions in the levels of supervision between admission and discharge, and reduction in global disability, impairment, and participation across all epochs . However, in the current cohort, the difference between admission and discharge for Adjustment was marginal (p = 0.06). In addition, a comparison of the proportion of individuals showing clinically significant change on the MPAI-4 indicated that these improvements had marginally decreased in the current cohort for global disability, and in the last two years for participation. W = 51,755, p < 0.001) and Support streams  compared to those discharged from the Restoration stream. But stays in the Compensation stream were also significantly shorter than those in the Support stream . However, there were significant changes between admission and discharge across the three clinical streams for all variables . It is also apparent that the scores of those in the Support stream both on admission and on discharge reveal more severe disability compared to those in the Restoration and Compensation streams. Therefore, while there were significant improvements across the three groups, the level of functioning for people discharged from the Support stream was lower. This study presents a novel approach set out to compare different methods of benchmarking, including using stacking of internal data, and comparisons with published reference data. We found minor differences in the stacking comparisons, which indicated a shift in the characteristics of people being admitted to rehabilitation in the last two years from those admitted historically. The main differences were on time since injury, which has become shorter; primary diagnosis, which now includes a higher proportion of people with stroke, and older age. Over time, there has also been an increase in the proportion of women admitted and a reduction in specific comorbidities. These do not appear to have influenced outcomes, which were, by and large, comparable across epochs. However, other studies have found that characteristics such as age, stroke severity , and levComparisons with reference data demonstrated that the target services described in this study are currently achieving outcomes which are at least equivalent to those observed in other national and international services in most areas. However, the area within which the target services performed more modestly, was adjustment and, to a lesser extent, participation. The two cohorts which performed better in these areas were described by Alderman et al.  and JackThe patterns of change observed across the three clinical streams reflect what would be expected given the nature of the problems presented and stage of recovery. Following the neurobehavioural therapy model described in Coetzer and Ramos , outcomeBrainkind has developed and maintained an outcome measures system and has regularly reported outcome data for many years ,30,31. WFinding a genuinely “equivalent” group to measure outcome data against is fraught with difficulty. The present study illustrated the use of two broad approaches to benchmarking in brain injury rehabilitation settings. The main findings indicate that comparing outcomes internally and externally can provide some indication as to the level of effectiveness in a particular service, but it may also reveal areas that need investigation and development. For example, we found that the characteristics of the patients admitted to our services have changed over time, reflecting evolving national commissioning and funding patterns. At present, the outcomes appear to be comparable over time, with some differences more attributable to clinical characteristics, such as time since injury and barriers to engagement in rehabilitation. Equally, the comparisons across clinical streams illustrate how different needs and presentations have some influence on the outcomes achieved, providing some indication on required dose and optimal timing for intervention. Where our results more closely matched those of published studies, the global characteristics of the samples were also more comparable. The stacking approach, however, revealed more differences on characteristics on admission than on outcomes achieved, which suggests that those differences alone are unlikely to significantly influence the outcomes of an approach to rehabilitation that strives to closely match the interventions to individual needs. The main limitation of this study is that it did not carry out a systematic review and meta-analysis of the literature to use as a normative comparator. However, that is an investigation in its own right and is beyond the scope of this paper. Instead, we aimed to present a practical illustration of different benchmarking methods for evaluating routine clinical outcome data in brain injury rehabilitation. It is also acknowledged that the outcome measures selected may not cover all relevant areas in sufficient detail, or that the introduction of other existing or emerging measures, such as a forthcoming adaptation of the Adaptive Behaviour and Community Competency Scale  for neurThe present results suggest that there is no “best” method for benchmarking services, and that the answers we get, and areas for further exploration we uncover, may differ depending on the method selected. Nevertheless, using two different approaches within a benchmarking initiative in a service, is likely to provide a robust system of evaluating results from multiple angles and enable the identification of areas where services excel or can improve.


Few population‐based studies have described allergic rhinitis (AR) according to the Allergic Rhinitis and its Impact on Asthma (ARIA) classification, and none have assessed the impact of asthma on this classification. Our aims were to 1) describe AR according to four ARIA classes and 2) within each of the four ARIA classes, compare participants with AR alone versus those with AR and asthma.Cross‐sectional analyses were performed using data from the 2014 annual follow‐up questionnaire of the French adult population‐based cohort Constances. Current AR was defined by the report of sneezing, runny, or blocked nose in the last 12 months and the report of nasal allergies. Following ARIA recommendations, rhinitis was classified according to its severity (mild or moderate‐severe) and duration (intermittent or persistent). Ever asthma was also defined by a questionnaire.Among the 4675 participants with AR , 44% were classified as mild/intermittent, 16% mild/persistent, 25% moderate‐severe/intermittent, and 15% moderate‐severe/persistent. Within each of the four ARIA classes, compared to participants with rhinitis alone, participants with rhinitis and asthma had significantly more severe symptoms, more conjunctivitis, a higher mean eosinophil count and more treatments with intra‐nasal corticosteroids and oral antihistamines co‐medication.This is a paradigm shift study as for the first time this large population‐based study in adults showed that asthma status has a profound effect on the ARIA classification. Rhinitis alone and rhinitis with asthma represent two distinct phenotypes. These results reinforce the need to include asthma status in the ARIA classification and guidelines. Our specific objectives were to 1) describe AR according to four ARIA classes and 2) within each of the four ARIA classes, compare participants with AR alone versus those with AR and asthma.22.1A cross‐sectional study was carried out with the data from the 2014 annual follow‐up questionnaire of the Constances cohort among participants reporting current AR. We first describe AR according to the two major criteria of ARIA that is, severity and duration and then we studied the impact of asthma on these ARIA classes concerning clinical features, eosinophils and medication needs.2.2https://www.constances.fr/index_EN.php). The participants were enrolled from 2012 to 2020 in 20 administrative districts. At inclusion, participants completed several standardized questionnaires and had a complete medical examination.Constances is a population‐based cohort of 220,000 adults aged 18–69 at inclusion, randomly selected from social security affiliates in France ), the National Council for Statistical Information , the National Medical Council , and the Institutional Review Board of the National Institute for Medical Research‐INSERM (authorisation no. 01–011). All participants signed a written informed consent.2.3During your lifetime, have you ever had a problem with sneezing, or a runny, or a blocked nose when you did not have a cold or the flu?”, to “Have you had these problems in the last 12 months?”, and to “Have you ever had nasal allergies in your lifetime, including hay fever?”.As specific Immunoglobulin E (IgE) and Skin Prick Tests (SPTs) are not available in Constances, we used a definition of AR based on a questionnaire, as published previously.Following the ARIA recommendations,Allergic rhinitis was defined as persistent if symptoms occurred more than 4 days per week and more than four consecutive weeks. Otherwise, AR was defined as intermittent.Have you ever had asthma?” at inclusion or answered “asthma” to: “Here is a list of health problems. Indicate here the ones you have suffered from in the last 12 months ” at the 2014 follow‐up questionnaire.Participants were considered as having ever‐asthma if they answered yes to “Other variables of interest are described in the supplement.2.4Analysis in complete‐cases, that is, by excluding participants with missing data, was carried out, and no imputation was performed.We described AR according to the ARIA classification of severity (mild versus moderate‐severe) and duration (intermittent versus persistent) separately. The severity and duration of rhinitis were then combined into four classes according to the ARIA classification: mild/intermittent, mild/persistent, moderate‐severe/intermittent, and moderate‐severe/persistent. Then, we compared participants with AR and never asthma versus those with AR and ever asthma within each of the four ARIA classes.t test/analysis of variance comparison of variances for continuous variables were used. We computed effect size measures.Pearson Chi‐2 tests for categorical variables and Student All analyses were performed using SAS 9.4 software (SAS Institute).33.1n = 735) were excluded from the analyses. Among participants with current AR, participants with missing data regarding severity (n = 1031), duration (n = 100), or ever asthma (n = 91) were also excluded. Finally, 4584 participants with AR were included  of them completed the 2014 follow‐up questionnaire. Participants with missing data regarding the definition of AR . Participants with moderate‐severe AR had a higher mean eosinophil count  and a higher TNSS4 score  as well as an earlier age of onset of rhinitis symptoms  than those with mild AR. Compared to participants with mild AR, those with moderate‐severe AR reported more multi‐morbidities: ever asthma , ever conjunctivitis , and/or ever eczema . They also reported more nasal symptoms: rhinorrhea , nasal congestion/obstruction , nasal itching , sneezing  and associated‐eye symptoms . Participants with moderate‐severe AR reported more triggers of rhinitis symptoms: dust mites or house dust , animals , air pollution , change in weather , tobacco , pollens , cold air  or other triggers , and more persistent rhinitis  than those with mild AR. Regarding treatments, participants with moderate‐severe AR reported more co‐medication  + Intranasal Corticosteroids (INCS)) than those with mild AR . Large effect sizes were observed for TNSS4 as expected, medium effect sizes for the congestion/obstruction symptom and the number of reported symptoms and small effect sizes for asthma, duration, rhinorrhea, nasal itching, sneezing, associated‐eye symptoms, the number of reported triggers and co‐medication.The characteristics of participants with AR according to its severity are presented in Table 3.4p = 0.001), a higher TNSS4  and reported more moderate‐severe rhinitis  than those with intermittent AR. Participants with persistent AR also reported more ever asthma  and ever conjunctivitis . Regarding treatment, participants with persistent AR reported more co‐medication (OA + INCS) than those with intermittent AR . Small effect sizes were observed for TNSS4, severity, and co‐medication.The characteristics of participants with AR according to its duration are presented in Table 3.5The characteristics of participants with AR according to the four ARIA classes are presented in Table 3.6Eight sub‐classes were defined according to the ARIA classification and the ever asthma status in each subclass Table , with th3), but more marked differences between classes were observed in participants with ever asthma (range from 231 to 291 cells/mm3). The results of the multivariate logistic regressions after adjustment for age, gender, smoking, diploma, conjunctivitis and eczema are presented in the Table Whatever the ARIA subclass considered, within each ARIA subclass, asthma multimorbidity further separated participants, showing significant differences for most outcomes. In particular, ever conjunctivitis was higher by 10%–20% in AR and ever asthma in comparison to AR alone for all 4 ARIA classes . In each category, the largest effect size between participants without ever asthma and with ever asthma was for the age of onset of rhinitis. The age of onset of rhinitis ranged from 16.1 years (moderate‐severe/intermittent AR + ever asthma) to 26.0 years . Importantly, co‐medication (OA + INCS) was reported from 18.8%  to 64.1% (moderate‐severe AR + ever asthma). The prevalence of reported symptoms was always higher in the AR + ever asthma group regardless of the ARIA class. Reported triggers of rhinitis symptoms were far higher in AR + ever asthma than AR alone for mites or house dust and animals. Eosinophil counts were significantly higher for all ARIA classes in participants with asthma than in those with rhinitis alone . Of note, mean eosinophil counts varied little across the ARIA classes in participants without asthma  participants were randomly selected from the affiliated of the National Health Insurance Fund . In France, the General Health Insurance Fund administered by CNAM is compulsory for salaried workers, even during unemployed periods and their families; it covers about 85% of the population living in France. Individuals not covered by this scheme are those belonging to the agricultural scheme, which provides social protection for farmers and agricultural workers, the schemes for the liberal professions, and special schemes . As a result, some of the workers associated with these professions could not be included in Constances. 2) some geographical areas of France were not included. In addition, about 20% of participants had missing data for rhinitis severity. Compared to the participants included in the analysis population, the participants with missing data had a lower level of education and a higher average age, and we cannot exclude that they may have a particular rhinitis profile.As specific IgE and SPTs are not available in Constances, we used a definition of AR based on a questionnaire. We acknowledge that defining AR by questionnaire may be considered a limitation, even if we have used validated and standardized questions.4.2et al.,The percentage of patients with moderate‐severe rhinitis was lower in Constances than in the patient cohorts both in primarySeverity impacts more the characteristics of AR than duration, as shown by the higher effect sizes observed for severity than for duration. This was already observed in patients consulting for rhinitis in primary care.The ARIA classification has been criticized for only considering the severity of rhinitis in a dichotomous way: indeed, the large prevalence of moderate‐severe rhinitis found in patient cohorts suggests an important heterogeneity in this disease severity group.The major novel finding is the impact of asthma on rhinitis in all four ARIA classes. For most important outcomes, asthma has a significant impact . The effect size was often moderate, except for treatment (INCS + OA) and the age of onset where it was stronger, and the results persisted after adjusting for age, gender, smoking, diploma, conjunctivitis and eczema. An extremely important data is the treatments reported. For oral anti‐histamines, asthma does not make any difference. More patients without asthma reported intra‐nasal corticosteroids. On the other hand, there was a major impact on asthma by increasing the use of combined intra‐nasal corticosteroid and oral anti‐histamine by around 20% for the four ARIA classes. It has been found in real‐world data of over 10,000 patients that patients with rhinitis using this combination are less well controlled than those using intra‐nasal corticosteroids. These findings were observed in both cross‐sectional and longitudinal studies.In conclusion, for the first time in a large population‐based study in adults, the characteristics of AR according to the four ARIA classes were described. This result confirms what has been observed in clinical practice and highlights the interest of using the ARIA classification to define AR in the general population. Furthermore, asthma status added important information to the ARIA classification. These findings indicate that ARIA or other rhinitis guidelines should make a distinction between rhinitis alone and rhinitis with asthma for AR management. This critical information is already considered in the development of ARIA 2024.Marine Savouré: Conceptualization, methodology, formal analysis, writing – original draft, visualization. Jean Bousquet: Conceptualization, methodology, writing – review & editing. Bénédicte Leynaert: Review & editing. Céline Ribet: Resources, review & editing. Marcel Goldberg: Resources, review & editing. Marie Zins: Resources, review & editing. Bénédicte Jacquemin: Conceptualization, methodology, writing – review & editing, supervision. Rachel Nadif: Conceptualization, methodology, writing – review & editing, supervision.Dr. Bousquet reports personal fees from Cipla, Menarini, Mylan, Novartis, Purina, Sanofi‐Aventis, Teva, Uriach, other from KYomed‐Innov, and other from Mask‐air‐SAS, outside the submitted work. The other authors have nothing to disclose.Our findings strongly indicate for the first time that rhinitis guidelines should make a distinction between AR alone and AR with asthma for AR management.For the first time in a large population‐based study in adults, AR according to the four AR and Its Impact on Asthma classes was described. Asthma status added important information to the classification.Supplementary MaterialClick here for additional data file.