Recommendations for rosacea diagnosis, classification and management: update from the global ROSacea COnsensus 2019 panel.

BACKGROUND: A transition from a subtyping to a phenotyping approach in rosacea is underway, allowing individual patient management according to presenting features instead of categorization by predefined subtypes. The ROSacea COnsensus (ROSCO) 2017 recommendations further support this transition and align with guidance from other working groups. OBJECTIVES: To update and extend previous global ROSCO recommendations in line with the latest research and continue supporting uptake of the phenotype approach in rosacea through clinical tool development. METHODS: Nineteen dermatologists and two ophthalmologists used a modified Delphi approach to reach consensus on statements pertaining to critical aspects of rosacea diagnosis, classification and management. Voting was electronic and blinded. RESULTS: Delphi statements on which the panel achieved consensus of ≥ 75% voting 'Agree' or 'Strongly agree' are presented. The panel recommends discussing disease burden with patients during consultations, using four questions to assist conversations. The primary treatment objective should be achievement of complete clearance, owing to previously established clinical benefits for patients. Cutaneous and ocular features are defined. Treatments have been reassessed in line with recent evidence and the prior treatment algorithm updated. Combination therapy is recommended to benefit patients with multiple features. Ongoing monitoring and dialogue should take place between physician and patients, covering defined factors to maximize outcomes. A prototype clinical tool (Rosacea Tracker) and patient case studies have been developed from consensus statements. CONCLUSIONS: The current survey updates previous recommendations as a basis for local guideline development and provides clinical tools to facilitate a phenotype approach in practice and improve rosacea patient management. What's already known about this topic? A transition to a phenotype approach in rosacea is underway and is being recommended by multiple working groups. New research has become available since the previous ROSCO consensus, necessitating an update and extension of recommendations. What does this study add? We offer updated global recommendations for clinical practice that account for recent research, to continue supporting the transition to a phenotype approach in rosacea. We present prototype clinical tools to facilitate use of the phenotype approach in practice and improve management of patients with rosacea.

Updating the diagnosis, classification and assessment of rosacea: recommendations from the global ROSacea COnsensus (ROSCO) panel.

BACKGROUND: Rosacea is currently diagnosed by consensus-defined primary and secondary features and managed by subtype. However, individual features (phenotypes) can span multiple subtypes, which has implications for clinical practice and research. Adopting a phenotype-led approach may facilitate patient-centred management. OBJECTIVES: To advance clinical practice by obtaining international consensus to establish a phenotype-led rosacea diagnosis and classification scheme with global representation. METHODS: Seventeen dermatologists and three ophthalmologists used a modified Delphi approach to reach consensus on statements pertaining to critical aspects of rosacea diagnosis, classification and severity evaluation. All voting was electronic and blinded. RESULTS: Consensus was achieved for transitioning to a phenotype-based approach to rosacea diagnosis and classification. The following two features were independently considered diagnostic for rosacea: (i) persistent, centrofacial erythema associated with periodic intensification; and (ii) phymatous changes. Flushing, telangiectasia, inflammatory lesions and ocular manifestations were not considered to be individually diagnostic. The panel reached agreement on dimensions for phenotype severity measures and established the importance of assessing the patient burden of rosacea. CONCLUSIONS: The panel recommended an approach for diagnosis and classification of rosacea based on disease phenotype.

Validation of a dose warping algorithm using clinically realistic scenarios.

OBJECTIVE: Dose warping following deformable image registration (DIR) has been proposed for interfractional dose accumulation. Robust evaluation workflows are vital to clinically implement such procedures. This study demonstrates such a workflow and quantifies the accuracy of a commercial DIR algorithm for this purpose under clinically realistic scenarios. METHODS: 12 head and neck (H&N) patient data sets were used for this retrospective study. For each case, four clinically relevant anatomical changes have been manually generated. Dose distributions were then calculated on each artificially deformed image and warped back to the original anatomy following DIR by a commercial algorithm. Spatial registration was evaluated by quantitative comparison of the original and warped structure sets, using conformity index and mean distance to conformity (MDC) metrics. Dosimetric evaluation was performed by quantitative comparison of the dose-volume histograms generated for the calculated and warped dose distributions, which should be identical for the ideal "perfect" registration of mass-conserving deformations. RESULTS: Spatial registration of the artificially deformed image back to the planning CT was accurate (MDC range of 1-2 voxels or 1.2-2.4 mm). Dosimetric discrepancies introduced by the DIR were low (0.02 ± 0.03 Gy per fraction in clinically relevant dose metrics) with no statistically significant difference found (Wilcoxon test, 0.6 ≥ p ≥ 0.2). CONCLUSION: The reliability of CT-to-CT DIR-based dose warping and image registration was demonstrated for a commercial algorithm with H&N patient data. ADVANCES IN KNOWLEDGE: This study demonstrates a workflow for validation of dose warping following DIR that could assist physicists and physicians in quantifying the uncertainties associated with dose accumulation in clinical scenarios.

[ICD-10 adaptation of 15 Agency for Healthcare Research and Quality patient safety indicators]. / Adaptation au codage CIM-10 de 15 indicateurs de la sécurité des patients proposés par l'Agence étasunienne pour la recherche et la qualité des soins de santé (AHRQ).

BACKGROUND: In the United States, the Agency for Healthcare Research and Quality (AHRQ) has developed 20 Patient Safety Indicators (PSIs) to measure the occurrence of hospital adverse events from medico-administrative data coded according to the ninth revision of the international classification of disease (ICD-9-CM). The adaptation of these PSIs to the WHO version of ICD-10 was carried out by an international consortium. METHODS: Two independent teams transcoded ICD-9-CM diagnosis codes proposed by the AHRQ into ICD-10-WHO. Using a Delphi process, experts from six countries evaluated each code independently, stating whether it was "included", "excluded" or "uncertain". During a two-day meeting, the experts then discussed the codes that had not obtained a consensus, and the additional codes proposed. RESULTS: Fifteen PSIs were adapted. Among the 2569 proposed diagnosis codes, 1775 were unanimously adopted straightaway. The 794 remaining codes and 2541 additional codes were discussed. Three documents were prepared: (1) a list of ICD-10-WHO codes for the 15 adapted PSIs; (2) recommendations to the AHRQ for the improvement of the nosological frame and the coding of PSI with ICD-9-CM; (3) recommendations to the WHO to improve ICD-10. CONCLUSIONS: This work allows international comparisons of PSIs among the countries using ICD-10. Nevertheless, these PSIs must still be evaluated further before being broadly used.

Trends and variations in perinatal mortality and low birthweight: the contribution of socio-economic factors.

OBJECTIVE: To examine trends and regional variations in perinatal mortality and low birthweight (LBW) and regional variations in socio-economic risk factors. METHODS: Population-based study of Central West Region of Ontario with approximately 28,000 births annually during the period 1988-1995 using vital statistics records and Census data. RESULTS AND CONCLUSIONS: There was no significant change in the perinatal mortality rate averaging 9.4 per 1,000 births per year. The LBW rate increased from 49.7 to 54.8 per 1,000, while the prematurity rate increased from 56.1 to 75.8 per 1,000. Significant variation occurred in outcomes among different regions, which was partially explained by socio-economic factors. The increases in LBW and prematurity rate emphasize the need for effective targeted services and programs. In their planning and implementation, regional variations in socio-economic factors, and other factors such as: the availability and utilization of services and barriers to access in services, require further evaluation and consideration.

Assessment of residual gastric volume and thirst in patients who drink before gastroscopy.

BACKGROUND: Before endoscopy patients undergo an uncomfortable fluid fast to reduce the risk of gastric acid aspiration and to ensure good endoscopic views are obtained. However, fluids rapidly leave the stomach and thus a long fluid fast before endoscopy may not be required. AIMS: The object of this study was to establish whether drinking before endoscopy is safe and relieves patients' symptoms of thirst. PATIENTS AND METHODS: 88 patients with American Society of Anaesthesiologists classification of physical status grades I and II were recruited in a controlled randomised single blind trial. The volume and pH of gastric aspirate obtained at gastroscopy was assessed in patients who drank 330 ml of water a minimum 90 minutes before their endoscopy and compared with values in patients who starved overnight. RESULTS: 44 patients who drank ('drinkers') 330 ml of water a mean 117 minutes before their morning gastroscopy had a similar volume and pH of gastric aspirate compared with 44 patients starved overnight ('starvers'); median volume 12.5 ml versus 10 ml, median pH 2.0 versus 2.0; 'drinkers' versus 'starvers' (NS). Before endoscopy patients were asked to score their thirst and hunger ratings as either none, mild, moderate or severe. Ratings for moderate and severe thirst were grouped together for analysis. The percentage of drinkers compared with starvers in each group with no thirst, mild thirst, and moderate severe thirst was 63%, 46%, and 37% respectively (chi 2 test for trend p < 0.05). Hunger ratings were similar in the two groups. CONCLUSIONS: It is safe for elective day cases to drink a significant volume of water two hours before endoscopy and this alleviates symptoms of thirst.

Impotence following pelvic fracture urethral injury: incidence, aetiology and management.

OBJECTIVE: To evaluate the potency status of patients undergoing delayed perineal repair following a pelvic fracture urethral injury to determine the incidence and aetiology of impotence. PATIENTS AND METHODS: Long-term potency (> 6 months post-operatively) was subjectively evaluated in 92 patients and correlated with their pre-operative and intra-operative findings. The management of their impotence was aso reviewed. Thirty original pelvic radiographs were assessed independently to determine if the pattern of bony injury was associated with the development of impotence. RESULTS: Fifty-seven patients (62%) remained impotent in the long term with a median follow-up of 48 months (range 12-128) and the operation did not render any potent patient impotent. Self-injection with vasoactive agents was successful in 24 of 27 (89%), suggesting a neurogenic aetiology in the majority. Bilateral pubic rami fracture was also associated with a high incidence of impotence. CONCLUSION: Disruption of the cavernosal nerves lateral to the prostatomembranous urethra behind the symphysis pubis is the most likely cause of impotence in this injury.

Relative importance of musculoskeletal disorders as a cause of chronic health problems, disability, and health care utilization: findings from the 1990 Ontario Health Survey.

OBJECTIVE: Musculoskeletal disorders (MSD) are a leading cause of morbidity in the population, yet their prominence seems to be insufficiently appreciated. We describe the ranking compared with other major body systems of the prevalence of MSD, including arthritis and rheumatism, and back/neck disorders, as a cause of chronic health problems, longterm disability, restricted activity days, consultation with health professionals, and use of both prescription and nonprescription drugs. METHODS: We analyzed data from the 1990 Ontario Health Survey, a stratified random sample of the household dwelling population in Ontario, based on 45,650 individuals aged 16 years and over. RESULTS: MSD ranked first in prevalence as the cause of chronic health problems, longterm disabilities, and consultations with a health professional and ranked 2nd for restricted activity days and use of both prescription and nonprescription drugs. No other body systems ranked invariably within the top 2 ranks for the morbidity indices examined. Even when compared to other major disease groups, arthritis and rheumatism ranked consistently in the top 3 and back/neck disorders also ranked high. MSD were mentioned as a reason for 40% of all chronic conditions, 54% of all longterm disability, 24% of restricted activity days and almost 20% of health care utilization. The impact of MSD was even greater in the 65 and over age group. CONCLUSIONS: MSD have a major role in the health profile of the population. This high burden of illness should be considered in planning health care services and setting research priorities.

Reliability, validity and efficiency of multiple choice question and patient management problem item formats in assessment of clinical competence.

Despite a lack of face validity, there continues to be heavy reliance on objective paper-and-pencil measures of clinical competence. Among these measures, the most common item formats are patient management problems (PMPs) and three types of multiple choice questions (MCQs): one-best-answer (A-types); matching questions (M-types); and multiple true/false questions (X-types). The purpose of this study is to compare the reliability, validity and efficiency of these item formats with particular focus on whether MCQs and PMPs measure different aspects of clinical competence. Analyses revealed reliabilities of 0.72 or better for all item formats; the MCQ formats were most reliable. Similarly, efficiency analyses (reliability per unit of testing time) demonstrated the superiority of MCQs. Evidence for validity obtained through correlations of both programme directors' ratings and criterion group membership with item format scores also favoured MCQs. More important, however, is whether MCQs and PMPs measure the same or different aspects of clinical competence. Regression analyses of the scores on the validity measures (programme directors' ratings and criterion group membership) indicated that MCQs and PMPs seem to be measuring predominantly the same thing. MCQs contribute a small unique variance component over and above PMPs, while PMPs make the smallest unique contribution. As a whole, these results indicate that MCQs are more efficient, reliable and valid than PMPs.

A comparison of knowledge, synthesis, and clinical judgment. Multiple-choice questions in the assessment of physician competence.

This study compares the reliability, validity, and efficiency of three multiple-choice question (MCQs) ability scales with patient management problems (PMPs). Data are from the 1980, 1981, and 1982 American Board of Internal Medicine Certifying Examinations. The MCQ ability scales were constructed by classifying the one best answer and multiple-true/false questions in each examination as measuring predominantly clinical judgment, synthesis, or knowledge. Clinical judgment items require prioritizing or weighing management decisions; synthesis items require the integration of findings into a diagnostic decision; and knowledge items stress recall of factual information. Analyses indicate that the MCQ ability scales are more reliable and valid per unit of testing time than are PMPs and that clinical judgment and synthesis scales are slightly more correlated with PMPs than is the knowledge scale. Additionally, all MCQ ability scales seem to be measuring the same aspects of competence as PMPs.