Spinal stenosis is a common condition in elderly individuals. Many patients are unresponsive to the conventional treatment. If the transforaminal epidural block does not exert a sufficient treatment effect, percutaneous transforaminal epidural adhesiolysis (PTFA) through the safe-triangle approach using an inflatable balloon catheter can reduce the patients’ pain and improve their functional capacity. We aimed to evaluate the safety and efficacy of the Kambin’s-triangle approach for PTFA using an inflatable balloon catheter and compare this approach to the traditional safe-triangle approach. Thirty patients with chronic unilateral L5 radiculopathy were divided into two groups: the safe-triangle-approach and Kambin’s-triangle-approach groups, with 15 patients each. The success rate of the procedure was assessed. Pain and dysfunction were assessed using the Numerical Rating Scale and Oswestry Disability Index, respectively, before the procedure and at 1 and 3 months after the procedure. The success rate of the procedure was high in both the groups, with no significant difference between the groups. The Numerical Rating Scale and Oswestry Disability Index scores significantly decreased 3 months after the procedure in both the groups, with no significant difference between the groups. For patients in whom the safe-triangle approach for PTFA is difficult, the Kambin’s-triangle approach could be an alternative. Spinal stenosis is a common condition in elderly individuals, causing lower back and radicular pain. Many of these patients are unresponsive to conservative treatment, such as physical therapy, non-steroidal anti-inflammatory drugs, and muscle relaxants ,2. For tPercutaneous epidural adhesiolysis (PEA) is a minimally invasive procedure in which a catheter is placed directly into the adhesions or scar tissue compressing the nerve root. PEA can eliminate the effects of adhesions and ensure the delivery of high concentrations of injected drugs to target areas . A high-Recently, a randomized controlled trial involving cases of unsuccessful resolution of adhesions or insufficient relief of stenosis with conventional methods demonstrated that PEA using an inflatable balloon catheter resulted in significantly higher pain reduction and functional improvement for 6 months compared with PEA using the Racz catheter , for back pain −2.02 −3.58 to −0.45), for leg pain −1.88 (−3.15 to −0.61), and for Oswestry Disability Index (ODI) −13.74 (−22.18 to −5.30)) [ to −0.45Efficacy of the transforaminal approach has been shown in patients refractory to conventional PEA using the caudal approach . The traHowever, the safe-triangle approach may cause irritation of the spinal nerve root during the injection in cases of severe spinal stenosis, epidural fibrosis, and intervertebral disk degeneration. An alternative transforaminal approach is the Kambin’s-triangle approach, in which the needle is located in the inferior–posterior or lateral view, reducing the risk of irritation of the spinal nerve root. The safety and efficacy of the Kambin’s-triangle approach for transforaminal epidural injection have been demonstrated .In this study, we aimed to investigate the safety and efficacy of the Kambin’s-triangle approach for PTFA using an inflatable balloon catheter and compare this approach to the traditional safe-triangle approach.This was a prospective, randomized, controlled study. This study was approved by the Institutional Review Board of Seoul National University Bundang Hospital (No. B-1708/415-304) in September 2019. Patient recruitment and data collection were performed from September 28, 2017 to March 28, 2018. All participants were provided with written and verbal information on the trial before obtaining their written consent. The inclusion criteria were as follows: (1) age 20–80 years; (2) unilateral L5 radiculopathy for more than 3 months; (3) no symptom improvement or continuation of pain relief for more than 1 month after physical therapy and medication; and (4) no or <50% pain reduction in response to transforaminal epidural injection. The exclusion criteria were as follows: (1) unilateral L5 radiculopathy for less than 3 months; (2) prior lumbar surgery; (3) occurrence of adverse effects due to local anesthetics, contrast medium, or steroids; (4) hemostatic disorders; (5) infections, cancer, severe neurological defects, or cauda equina syndrome; and (6) uncontrollable medical or psychiatric illness.A total of 30 patients with lumbar spinal stenosis were included in this study; the safe-triangle-approach and Kambin’s-triangle-approach groups comprised 15 patients each. Two patients from each group dropped out. Two patients in the safe-triangle-approach group were excluded: one decided to opt out of the study, and the other was lost to follow-up. Two patients from the Kambin’s-triangle-approach group were excluded as they were lost to follow-up .A random allocation software was used to randomly allocate patients into two groups. Ultimately, the safe-triangle-approach and Kambin’s-triangle-approach groups comprised 15 patients each. This was a double-blinded study in which the experimenters and participants were blinded to the group allocation. All patients underwent PTFA using an inflatable balloon catheter.PTFA was performed using an inflatable balloon catheter with the safe-triangle approach or Kambin’s-triangle approach under fluoroscopy, by an experienced pain physician, who was blinded to the purpose and design of this study. In the traditional safe-triangle approach, a 16-gauge Tuohy needle  was inserted in the intervertebral foramen between L5 and S1 (just below the L5 pedicle). Fluoroscopy and contrast medium injection were used to check that the end of the needle had entered the anterior epidural space. In the Kambin’s-triangle approach, a 16-gauge Tuohy needle  was inserted just above the superior articular process of L5 under oblique fluoroscopy . In bothThe success of the procedure, pre- and post-procedure pain, and the degree of dysfunction were evaluated by an independent physician who was blinded to the study design and group assignment. The success of the procedure was assessed using three categories : in category B , the device entered the target area, and the contrast medium diffusion was successful after balloon inflation; in category D (dye spread), balloon inflation failed, but contrast medium diffusion and adhesiolysis were successful; and in category F (fail), balloon inflation and adhesiolysis failed, so contrast medium diffusion could not be confirmed.Patients’ degree of pain was measured using a standardized 11-point (0–10) Numerical Rating Scale (NRS) and evaluated by a well-trained physician at baseline and 1 and 3 months after the procedure. The severity of pain was scored from 0 to 10, where “0” represented no pain at all, and “10” represented the worst possible pain. The patients were encouraged to express their feelings regarding the pain.The ODI was used to assess the patients’ degree of dysfunction. ODI assessments were performed at baseline and 1 and 3 months after the procedure. ODI is a 10-item questionnaire used globally to functionally assess patients with low back pain . Howeverp-value < 0.05 was considered statistically significant.All statistical analyses were performed using the SPSS Statistics program, version 21.0 . Demographic data of the patients were analyzed using the chi-squared test and Fisher’s exact test. The success or failure of the procedure was analyzed using the Fisher’s exact test. In addition, a linear mixed model analysis was used to determine the differences in NRS and ODI scores at the following time points: before the procedure and immediately and 1 and 3 months after the procedure. A p = 0.593, Fisher’s exact test)  .Changes in the NRS score were analyzed using a linear mixed model. In both the groups, 1 month after the procedure, the NRS score decreased compared to that before the procedure, although without statistical significance. Furthermore, in both the groups, the NRS score significantly decreased 3 months after the procedure compared to that before the procedure, with no significant difference between the groups .Changes in the ODI score were also analyzed using a linear mixed model. Similarly, in both the groups, the ODI score decreased 1 month after the procedure compared to that before the procedure, although without statistical significance. Furthermore, in both the groups, the ODI score significantly decreased 3 months after the procedure compared to that before the procedure, with no significant difference between the groups , Table 4p = 0.782). There were no significant differences between the two groups in the number of cases of severe neurostimulation requiring cessation of the procedure or number of cases requiring needle readjustment because of injection of the contrast medium into a blood vessel.The severity of pain during the procedure, which was assessed using NRS, was comparable between the two groups and did not differ significantly . PEA performed with a wire-type catheter, such as the Racz catheter, is based on the concept of chemical adhesiolysis through the administration of medications to the target site. In contrast, a steerable catheter enables the physician to place the catheter tip near the nerve root for precise delivery of medications. Furthermore, it can facilitate mechanical adhesiolysis . In addiAlthough the aforementioned conventional PEA is frequently applied, in patients with pain refractory to conventional PEA, a procedure for more effective and safer PEA is needed. Therefore, PTFA was introduced, which demonstrated good results . AdditioThe safe triangle is formed by the diagonal path of the nerve, base of the vertebral pedicle, and outer boundary of the vertebral body . This trThe Kambin’s triangle is formed by the path of the spinal nerve, upper border of the lower vertebral body, and inner boundary of the upper vertebral pedicle . The KamEither the safe-triangle or the Kambin’s-triangle approach may be used for transforaminal ESIs; both approaches showed similar effects on pain reduction at 2 months . HoweverSeveral factors may contribute to pain relief and functional improvement noted after PEA using an inflatable balloon catheter. First, expansion of the epidural space by the balloon catheter may lead to effective mechanical adhesiolysis of perineural adhesions. Moreover, breaking or lengthening the thin transforaminal ligament can lead to expansion of the marginal space in the intervertebral foramen ,30. SecoThere are several limitations of this study. First, the total number of patients included in this study was relatively small, so a definitive conclusion could not be drawn. Second, the type and severity of stenosis, which may affect the success rate of the procedure, were not evaluated on imaging. Furthermore, the effect of the procedure may vary depending on whether the main cause of pain is the intervertebral disc or the bony intervertebral foramen. Third, there were a number of confounding variables, including the patient’s pain duration and functional status. We suspect that the age distribution of in our study showed a large variation and influenced the results, such as ODI. Fourth, this is not a double-blind study. This bias may affect the results; double-blind studies are needed in the future. Fifth, the patients were followed-up only for 3 months after the procedure; hence, only the short-term results were evaluated.Further studies should be conducted to overcome the aforementioned limitations. These studies should include more patients, use detailed inclusion and exclusion criteria, include a wide variety of third variables, and have a long observation period.In summary, as in the case of transforaminal ESIs, the Kambin’s-triangle approach could be an alternative for patients in whom the safe-triangle approach for PTFA is difficult. A randomized, controlled, double-blind, multi-center study should be conducted to support the findings of this study


Chest tube removal is considered a painful technique, which may not respond well to palliative therapies. There are no standard procedures or guidelines to manage the pain associated with chest tube removal. This study aimed to examine the effects of cold application on pain reduction during and after chest tube removal.This randomized controlled trial was conducted on 90 hospitalized patients, undergoing heart bypass surgery at the intensive care units where at least a pleural chest tube was inserted. The patients were randomly divided into two groups (45 samples per group). In the cold application group, an ice bag was placed at the designated point for 20 minutes before chest tube removal, while only routine interventions were applied for chest tube removal in the control group. Pain severity was measured in the groups before, during, and 15 minutes after chest tube removal, using the visual analogue scale. Repeated measures ANOVA test was applied for data analysis.There was no significant difference in the baseline pain score between the groups (P= 0.18). However, there was a significant difference in terms of pain severity score between the cold application (3.58±1.09) and control (4.73±0.86) groups during chest tube removal (P< 0.001). On the other hand, there was no significant difference between the groups regarding the score of pain severity at 15 minutes after chest tube removal (P= 0.38).Cold application, as a nonpharmacological intervention, may contribute to the alleviation of cryotherapy-related pain. Cardiovascular diseases (CVDs) are among the most debilitating diseases, accounting for the highest rate of mortality worldwide. According to statistics, CVDs lead to death in more than 16 million people annually . CardiacIt is necessary to insert a chest tube in all types of heart surgeries in order to maintain the function of the heart and lungs and prevent pneumothorax, hemothorax, and pleural effusion. A chest tube is generally removed within 24 to 48 hours after cardiac surgery when the volume of secretion is less than 100–150 cc, and respiratory sounds are normal . RemovalMedium to severe pain has been reported by patients during cryotherapy (CTR), while there are no standard procedures or guidelines to manage CTR-related pain , 7. NursToday, many efforts are being made to reduce pain severity and dosage of narcotic medications, using nonpharmacological methods . Pain-reCold application is an efficient technique for pain relief. This technique reduces the speed of nervous conductance and pain. Similarly, based on the gate control theory of pain, stimulation of thick fibers through methods such as cooling may close the gate and reduce pain . Cold apPrevious studies have investigated the effect of cold application on reducing pain owing to CTR. While cold application was reported to be effective in a study by Hassanzadeh et al. , Sauls rAccordingly, this study aimed to clarify the effects of cold application on relieving pain owing to CTR. In this study, effects of cold application on pain relief were examined during and after CTR in patients with at least a pleural chest tube. The study hypothesis was that pain severity scores would be lower in the cold application group, compared to the controls.This randomized controlled trial was conducted from February 2016 to August 2016. The study was carried out in a single center, affiliated to the Cardiac Surgery Intensive Care Unit (CSICU) of Shahid Madani Hospital, Khorramabad, Iran. It is a specialized referral hospital for various types of cardiac surgeries, equipped with 100 beds and different departments, including echocardiography, angiography, angioplasty, electrophysiology, coronary care unit, and CSICU for men and women.Ethical approval was obtained from the Ethics Committee of Iran University of Medical Sciences, Tehran, Iran. The study was also registered in the Iranian Registry of Clinical Trials (IRCT) under the code, IRCT2016012626217N1. The study sample comprised of all patients, who had undergone heart bypass surgery at Shahid Madani Hospital. Before enrollment in the study, an informed consent was obtained from each participant.2; 7) no use of narcotic or sedative medications one hour before CTR; and 8) lack of supportive mechanical ventilation.The inclusion criteria were as follows: 1) age range of 18–65 years; 2) having at least one pleural chest tube (not less than 24 hours or more than 120 hours should pass since insertion); 3) absence of vision problems or inability to give proper responses to the researcher’s questions; 4) no history of mental disorders; 5) lack of drug abuse or alcohol addiction; 6) body mass index (BMI) < 30 kg/mOn the other hand, the exclusion criteria were as follows: 1) pain score above seven; 2) unwillingness to continue cooperation; 3) dissatisfaction during cold application; 4) use of narcotic or sedative medications during the intervention; and 5) sudden changes in the vital signs. The sample size was calculated based on a previous study by Mazloum et al. , which iBased on the mentioned study , the number of samples was estimated at 41 per group. However, we recruited 45 patients in each group to compensate for probable attrition and obtain more reliable results. The final sample size included 90 patients, who were admitted to CSICU for post-heart bypass surgeries. Ninety eligible patients were randomly allocated to either cold application or control group, using randomized fixed quadripartite blocks. Convenience sampling method was applied to assign samples to the groups; the participants had an equal chance of assignment to each of the groups. A data recording checklist, consisting of two parts, was used for data collection. The first part was used to record demographic data (10 questions). Also, a checklist was developed to review relevant literature; its content validity was confirmed by 10 faculty members from Iran University of Medical Sciences. The second part of the checklist evaluated pain severity, using a visual analogue scale (VAS). In this tool, a score of zero indicates no pain, while a score of 10 presents the worst pain imaginable. Accordingly, the participants indicated the severity of pain on VAS. Overall, numerous studies have used this scale to measure pain severity in heart surgery patients , 14–16. Surgery was performed by one surgeon, and surgical methods were similar for all patients. Anesthesia was subsequently induced in both groups, based on the standard protocol for heart surgery. The diameter of chest tubes was also similar in both groups (F= 14–16). Before the intervention, the participants were given some information about cold application. The chest tubes were removed using a similar technique under the clinical supervision of five experienced CSICU nurses. Data were collected by another nurse, who was not a member of the research team to prevent any possible bias in data collection.The patients were placed in the semifowler position with a pillow under their head and shoulder to achieve more comfort during the intervention; their rough cloths were also removed. In the cold application group, a 9-inch ice bag  was placed over the chest tube at −5°C; it remained in contact with the patient’s skin for 20 minutes. A layer of sterile gauze was then placed over the chest tube and skin to prevent direct contact with the ice bag. The chest tube was removed maximally two minutes after lifting the ice bag. On the other hand, the control group did not receive cold therapy, and routine interventions were applied according to the ward policies. The pain score was measured by VAS in the two groups before, during, and 15 minutes after CTR.t test were also used to compare demographic data. Repeated measures ANOVA was applied to compare pain scores between the groups at different intervals. In addition, ANOVA test was applied for comparing pain scores between the groups at any time interval. P-value less than 0.05 was considered statistically significant.The collected data were analyzed using descriptive tests in SPSS version 21. Descriptive statistics were used to summarize the demographic information. Chi square and In the present study, 90 eligible subjects were divided into the cold application and control groups. The cold application group received cold therapy before CTR, while the control group received routine interventions according to the ward policies. In a total of 90 participants, two patients from the cold application group and one patient from the control group were excluded for having a pain score above seven. After excluding these cases from the survey, data from 87 patients were finally analyzed.P> 0.05)  (79.3%). There was no significant difference between the groups with regard to the baseline characteristics, including gender, BMI, education, occupation, marital status, type of surgery, history of chronic pain before surgery, history of regular sedative drug use before surgery, or history of chest tube insertion before surgery (P> 0.05) .P> 0.05). The mean pain severity scores of the groups are presented in P= 0.18). In addition, the mean pain severity scores were compared between the groups immediately after CTR, and the difference (1.15) was found to be significant (P< 0.001). However, the difference (0.17) in the mean pain severity score was not significant between the groups at 15 minutes after CTR (P= 0.38).Based on the findings, gender, age, BMI, history of chronic pain, history of analgesic use, and chest tube insertion had no effects on pain due to CTR in the cold application and control groups (Chest tube removal is considered a painful and debilitating experience for all patients . HoweverDespite the promising results of different studies on the effects of cold application on reducing pain caused by CTR, other clinical trials have reported conflicting results , 14, 15.In line with the present study, several investigations have shown that cold application is effective in relieving pain during CTR , 18, 19.On the other hand, Sauls reported cold application to be ineffective in reducing pain caused by CTR . This diThe results of the present study showed that cold application has no effects on reducing pain severity at 15 minutes after CTR. This finding is not consistent with the results of previous research , 16, 18 In a study by Mazloum et al., no sedative treatment was applied for patients on the day of intervention. Unlike our study, the results indicated that cold therapy was effective in pain relief at 15 minutes after CTR . In addiThe present study was carried out with an open-label design, as the nature of intervention made it impossible to integrate a proper placebo. The limitations of this study include execution of CTR by five different individuals. Of course, we tried to reduce the effect of this factor by providing training on a single CTR technique. Finally, the patients might express different responses to pain with respect to the subjective nature of pain and their physical, emotional, and cultural status. This limitation can create some bias in the results, although such potential biases were minimized by means of randomization.It is hoped that the present findings promote future studies in this area. It is recommended to conduct a study with a larger sample size on CTR-associated pain in non-heart bypass surgery patients in order to confirm the present findings.The results of this randomized controlled trial suggest that cold application, as a nonpharmacological intervention, may temporarily contribute to the alleviation of pain caused by CTR.


Gastrointestinal toxicity due to chemotherapeutic drugs is a common problem in cancer patients. Chemotherapy-related diarrhea is most commonly described with fluoropyrimidines (fluorouracil and capecitabine) and irinotecan. Fluoropyrimidines are widely used for the treatment of gastrointestinal (GI) tract tumors and also in other solid malignancies such as breast and head and neck cancers ,2 and arThe DPD is a rate-limiting enzyme out of three enzymes in fluoropyrimidine metabolic pathways. The partial or complete deficiency of DPD activity has been shown to increase severe or fatal toxicity. To date, over 128 mutations and polymorphisms in DPD encoding gene (DPYD) has been reported ,5. AmongThe correlation between DPYD*9A c.85T>C) genotype and DPD deficiency clinical phenotype is controversial 5T>C geno,11. OtheRecently, our group has reported that DPYD*9A c.85T>C) variant was the most common variant diagnosed in our cohort and a genotype-clinical phenotype correlation was noticeable. All patients who received full dose fluoropyrimidines experienced grade 3-4 diarrhea ,16. Othe5T>C variFluoropyrimifines-related toxicity not only results in treatment interruption but also sometimes discontinuation, adversely affecting the quality of life and an increase in health care cost. Up front screening of DPD deficiency through genotyping for high-risk DPYD variants  only is suboptimal to predict fluoropyrimidine-related toxicity. Genotyping for DPYD*9A in addition to the high-risk DPYD variants represents a more comprehensive approach. Diagnosing of DPD deficiency upfront provide the treating oncologist the opportunity to avoid fluoropyrimifines-related toxicity. In patients who are heterozygous, oncologists are advised to start their patients on a reduced dose with subsequent titration or choosing an alternative regimen. In patients who are homozygous, fluoropyrimidines-based regimen should be avoided.


There is an emergent body of evidence supporting exercise therapy and physical activity in the management of musculoskeletal pain. The purpose of this study was to explore potential barriers and facilitators with patients and physiotherapists with patellofemoral pain involved in a feasibility randomised controlled trial (RCT) study. The trial investigated a loaded self-managed exercise intervention, which included education and advice on physical activity versus usual physiotherapy as the control.Qualitative study, embedded within a mixed-methods design, using semi-structured interviews.A UK National Health Service physiotherapy clinic in a large teaching hospital.Purposively sampled 20 participants within a feasibility RCT study; 10 patients with a diagnosis of patellofemoral pain, aged between 18 and 40 years, and 10 physiotherapists delivering the interventions.In respect to barriers and facilitators, the five overlapping themes that emerged from the data were: (1) locus of control; (2) belief and attitude to pain; (3) treatment expectations and preference; (4) participants’ engagement with the loaded self-managed exercises and (5) physiotherapists’ clinical development. Locus of control was one overarching theme that was evident throughout. Contrary to popular concerns relating to painful exercises, all participants in the intervention group reported positive engagement. Both physiotherapists and patients, in the intervention group, viewed the single exercise approach in a positive manner. Participants within the intervention group described narratives demonstrating self-efficacy, with greater internal locus of control compared with those who received usual physiotherapy, particularly in relation to physical activity.Implementation, delivery and evaluation of the intervention in clinical settings may be challenging, but feasible with the appropriate training for physiotherapists. Participants’ improvements in pain and function may have been mediated, in some part, by greater self-efficacy and locus of control.ISRCTN35272486; Pre-results. This paper identified, through interviews, key barriers and facilitators to implementation of a loaded self-managed exercise programme, with education and advice on physical activity.Two authors independently coded all transcripts, and a clear, transparent and reproducible methodological approach was used in the analysis.The main limitations of this study were the difficulty in interviewing patients lost to follow-up (from both groups) and finding patients classed as ‘non-responders’ in the loaded self-managed group.The study population comprised a single clinical setting, where the researcher was also a clinician.Patellofemoral pain (PFP) is one of the most common forms of knee pain in adults under the age of 40 years, with an estimated prevalence of 23% in the general population.This research was undertaken within a framework of mixed-methods, embedded within a feasibility study comparing a loaded self-managed exercise protocol with usual physiotherapy for people with PFP.The loaded self-managed exercise programme does not align with current UK physiotherapists’ preferred treatment approach for PFP.Therefore, this qualitative investigation aimed to explore potential barriers and facilitators to implementation of the intervention with participants with PFP involved in a feasibility randomised controlled trial (RCT),a priori.A qualitative study was conducted embedded within a mixed-methods feasibility study. To avoid cross-contamination between the two groups, the intervention group was treated by different qualified physiotherapists, who received the intervention training package, to the usual physiotherapy group. To fully explore the aims of this study, patients and physiotherapists receiving and delivering both the intervention and usual physiotherapy were interviewed.This study has been reported in line with the COnsolidated criteria for REporting Qualitative research checklist.This study did not set out to prove or disprove a hypothesis, it set out to generate new data from which an understanding of barriers and facilitators to the intervention and study design might be developed. The authors took an epistemological position described as ‘contextualist’ by Braun and Clarke that sits central on the spectrum of realism and constructivism.A purposive sample of 10 patients with PFP were recruited from the 60 patients who were recruited to a feasibility study, this included patients in the intervention group and those receiving usual physiotherapy. International consensus has defined PFP symptoms as typically developing insidiously with retropatellar pain or diffuse peripatellar pain, aggravated by activities that ‘load the joint’, such as climbing and descending stairs, squatting, running or jumping.Initial recruitment to the feasibility study included gaining written consent for taking part in future qualitative investigations with consent to audio-recording and to publication of anonymised quotations. Participants were initially followed up by a telephone call. If they agreed, a convenient time was arranged to complete an interview. Participants were given the opportunity to discuss any concerns before the interviews started.Ten physiotherapists were purposively sampled, this included those delivering the intervention and those delivering usual physiotherapy. Based on similar studies, we anticipated this sample size would be sufficient to reach data saturation.All participants were interviewed at a convenient time in the hospital-based physiotherapy department. The researcher (BES) introduced himself as a physiotherapist working in that department, and as a researcher conducting a PhD. The researcher explained the aims of the study. Verbal consent was taken to start recording.Semi-structured interviews were designed by the researchers (BES and FM) using topic guidelines with prompts to explore barriers and facilitators to taking part in a loaded self-managed exercise intervention. Patients from both treatment groups were asked about response to treatment, belief and attitude to pain, belief and attitude to physical activity, treatment expectations and protocol parameters. Only those in the intervention group were asked about their engagement with the loaded self-managed intervention. All physiotherapists were asked about their usual practice, personal development, belief and attitude to pain, belief and attitude to physical activity and protocol parameters. Only those delivering the intervention were asked about their engagement with the loaded self-managed intervention, including the training package. The interviews ranged from 5 to 21 min (mean time 11 min) in duration.The interview guide was not piloted, however the researcher maintained a reflective journal, noting down initial thoughts and ideas after each interview.All audio files were collected and transcribed verbatim.The data were analysed using a thematic Framework Method,Data were organised and analysed using QSR International’s NVivo V.11. After 10 interviews per group, it was determined by the researchers that data saturation had occurred as no new thoughts or concepts were generated in the later interviews.This research project has been driven by the views of people suffering from PFP. Patients were consulted for their views, including patient members of the Steering Group Committee. Thoughts and preferences to current programmes of therapy and treatment were requested, and these views have been incorporated into the planning, design, application and dissemination of this study.The 10 patients included 3 men and 7 women, aged between 26 and 37 years (mean: 30.6 years), with a diagnosis of PFP for a mean duration of 25 months (range: 3 months to 10 years). The 10 physiotherapists included 2 men and 8 women, aged between 24 and 58 years (mean age 39.4 years), with a mean of 16 years qualified (range: 3–37 years). Full patient and physiotherapist characteristics are presented in In respect to barriers and facilitators, the five major overlapping themes that emerged from the data were: (1) locus of control; (2) belief and attitude to pain; (3) treatment expectations and preference; (4) participants’ engagement with the loaded self-managed exercises and (5) physiotherapists’ clinical development. Locus of control was one overarching theme that was evident throughout. The findings are presented in relation to existing literature.Locus of control is a psychological construct about the degree people believe they have control over their actions and outcomes.R: And how did you feel about being in charge of that (the exercise)?P8: Yeah. I think it was empowering in a way. (Loaded self-managed)Early interviews raised matters relating to whose authority it was to give the ‘permission’ to return to, or increase, physical activity; including when and how this should be done. Again, clear differences between usual physiotherapy and the intervention could be seen, particularly in relation to physiotherapists’ management approach to physical activity.Ultimately up to the patient really. They should feel in charge of what they do. They need to have control of the situation. If they’re just waiting for somebody else to dictate that, then they haven’t got very good control. But they might need some encouragement or reassurance that it’s okay to actually, if you want to get back to these activities you can. You don’t need to ask me permission really. (T2—loaded self-managed)I would usually kind of bat it back to them and say, ‘Well, what do you think you can do?’ And using the same principles as with the exercises, if you’re getting some discomfort at the time, it doesn’t mean to say you then stop. And just see how it is afterwards, and then modify how much you’re doing in response to how much pain you’re experiencing afterwards. (T4—loaded self-managed)Contrasting the push for an internal locus of control with the intervention was a narrative discussed by some patients receiving usual physiotherapy. For example, participant 4 had indicated she was ‘strongly recovered’, had minimal pain and had returned to almost all of her usual activity. However, she had not returned to the gym yet, and had booked a follow-up appointment with the treating physiotherapist for after the interviews where she hoped to receive the ‘go-ahead’ to return.And this patient narrative was reinforced by the treating physiotherapists’ understanding of their role:I’d assess them functionally. So you kind of break down that hobby or that activity into sections. So if it’s a sport, look at part of it… and if you can’t do two or three of them, it’s not just your knee that’s letting you down. Generally, you’re not quite ready for that. A few of the physiotherapists within the usual physiotherapy group viewed their role more of a partnership with the patient, where decisions about return to activity were agreed mutually.Well, it’d be a mutual thing. A lot of them weren’t sporty, but they would ask and we discussed the suitability. Locus of control is inter-related to the psychological construct of self-efficacy, where it relates to the power of thinking in achieving treatment outcomes.That sense of just you know how much progress you made. A week ago you did 20, and now you did 30 or 40. (P9—loaded self-managed)When I hit the target and I then thought, ‘Oh, I can actually do a few more’, and it’s comfortable to do, I did do that. (P5—loaded self-managed)Previous qualitative work has identified unmet treatment expectation as a potential barrier to treatment adherence,A small number of patients discussed an expectation of hands-on passive treatment.I was more expecting sort of a hands-on approach, more like physio massage when I came. (P8—loaded self-managed)Furthermore, in keeping with themes found in other PFP qualitative work,For me, I wanted answers on why my knee was painful. Because I think, going back 10 years ago, when I first went to my doctor’s, I was told it was ligament damage. And it didn’t clear up, and when I went back, it was like, ‘Well, the waiting list for physio is so long, by the time you get there, you’ll be recovered’. And then, when I went back again, it was like, ‘Well, you’re too young to have steroid injections’. And then, I just always felt I was like, in a sense, sent packing without any answers. And then, I wanted some answers as to why it’s hurting so I could understand it. (P10—loaded self-managed group)Previous qualitative work in patients with PFP found a dominant negative view of physiotherapy,The physio—I don’t know, I was a bit sceptical, to be honest. But yeah, it has given me the result I wanted. (P10—loaded self-managed)All physiotherapists reported that their current practice and preference for treating PFP included an exercise programme. However, in contrast to the majority of UK physiotherapists,But if you think about a VAS or something like that … probably you wouldn’t want your pain to be greater than maybe a 3 or a 4 out of 10. Quite often I tell people to do reps to kind of fatigue, but not to pain. So people are getting a bit of a niggle, if they can manage it, and they can bring the pain level back down quite quickly afterwards. So if they can do exercises, it aggravates it, but within about a half an hour symptoms have settled, then that’s fine. Dissonance between the single exercise approach used in the intervention and treating physiotherapists’ preference was evident. The single exercise approach was not favoured by any of the physiotherapists interviewed:I think possibly the intervention was simpler to do in the fact that it was geared, sort of guided around one exercise. And probably, what I would have done before is perhaps give more exercises and chop and change them maybe a bit more frequently. (T7—loaded self-managed)Additionally, some physiotherapists were very prescriptive with their exercise dosage.Initially I might start with them with 15 repetitions and work to three sets, 2 min break in between. Again, in contrast to the majority of UK physiotherapists,I’m a little less strict on sets and reps. I’m more do what you feel you can. If you’re happier, push on a little bit more. (T3—loaded self-managed)As identified above, most patients were content with the anticipation that exercises would be painful, and indeed this matched current clinical practice with the physiotherapists interviewed, despite not aligning with UK wide current practice.Interlinked to the all themes, particularly locus of control were patients’ and physiotherapists’ beliefs and attitudes to pain. There is a growing body of evidence suggesting that health practitioners with a biomedical orientation to pain are more likely to advise patients to limit their physical activity due to painShe (the physiotherapist) gave me exercises to do. I’ve always been keen on the gym. I go to the gym. I was a doing a lot of the stuff she’s asking me to do, anyway. Or it’s probably more about my technique. I was maybe not doing it as well as I could have done. So I fell back. …So she referred me for scans on both knees—well, referred me back to my doctor. My doctor referred me to an orthopaedist. They referred me for a scan on both knees. The MRI scan showed this knee’s absolutely fine—which it’s not. R: So if they’re not achieving that, would you advise them not to run then?P10: Probably. Yes. I’d probably have a look at them, and if they were really antalgic on their gait, then yeah, tell them not to bother, to work on their weaknesses, and then reassess it a bit later down the line. Because otherwise, they might just end up making their knee 10 times worse because they’re running on a weakened, less controlled knee. Of interest is that the physiotherapist delivering the usual physiotherapy, as described in theme 2, did describe treatment preference not fully aligned with the majority of UK physiotherapists,I think it was sometimes a bit hard to stick to usual physio, because we still keep reading. We try to keep up with what’s happening… So it’s just a bit of reading and then I change ‘usual physio’, it keeps developing as you work. Yet despite this, there was marked differences in the patients’ and physiotherapists’ beliefs and attitudes to pain in the intervention group, compared with usual physiotherapy, demonstrating some reconceptualisation of pain. This suggests the training programme did improve contemporary knowledge of pain science.Yeah, the pain wasn’t excruciating or anything. At no point did I think, ‘I can’t keep doing this’. It was a fairly normal level, I’d say. It wasn’t anything that would make me come back, and say, ‘I’m worried that I’m doing something wrong’, or anything like that. It was fairly normal. I wouldn’t say it was too bad. (P1—loaded self-managed)P7: The physiotherapist said to go ahead and run if it wasn’t going to do any damage. Yes, if it’s painful, stop. My own thoughts have been, I think, changed definitely with this intervention. I think exercise is—I’ve always said to patients that if it’s painful, they can still carry on. But again, like I said, I gave that arbitrary figure. If it goes above this, then maybe taper down… But actually, maybe educating them and telling them, ’Pain isn’t an indicator of damage. You can push through into it a little bit, but it just has to be something that you’re comfortable with'. And I think the thing that changed with me saying that to patients was I am not the one that’s going to dictate that. You’re the one has to go through this. (T3—loaded self-managed)There was one example of mixed messages from the patient, with regard to acceptable and appropriate levels of pain during exercise and physical activity. This may suggest the heterogeneity in physiotherapy advice, as previously discussed in the second theme with physiotherapists, may have a negative effect with increasing levels of uncertainty. This is in keeping with previous research suggesting an iatrogenic effect with physiotherapy treatment for PFP relating to diagnosis uncertainty and fear-avoidance behaviour.He (the physiotherapist) recommend that I didn’t run, which is probably the only thing I don’t do now. I think it was the impact. Like, my knee with my cartilage. That’s why he didn’t recommend it at that point. (P10—loaded self-managed)Only patients and physiotherapists receiving or delivering the intervention were asked to discuss their thoughts about it. Both patients and physiotherapists reported several different ways in which they interacted and connected with the intervention. First, the intervention laid the foundation of reconceptualisation of pain-related fear where the physiotherapist spent a period of time educating the patient about pain mechanisms.Once you’d explained—all the key is in the explanation about pain and how pain works and explaining why they’re doing it from that. And in fact, sort of the particular girl I’m thinking about, she’d stopped going downstairs because of the pain. When I reviewed her last time, she said, ‘Well, I haven’t been avoiding the stairs’ (with no increase in pain levels). So it’s good stuff. (T7—loaded self-managed)Other critical aspects of the intervention discussed by the participants were the self-dosage of the exercise, based on the symptomatic response, rather than being prescribed by the physiotherapist. These aspects were all discussed positively, with no negative features identified.I think for me I’ve got results a lot quicker, so because I was kind of going through the pain with all that. And I definitely stuck with the exercise more, because when I first started with one exercise I might get a bit bored. But I’ve definitely stuck to it more. (P9—loaded self-managed)The simplicity of a single exercise approach was discussed by all the interviewees, predominantly in a positive manner.So I think it’s quite simple, so if I do ever get—the problem starts to occur again, it’s no real problem to just start. (P1—loaded self-managed)However, one physiotherapist admitted to being initially sceptical that one exercise would be enough.And using that single exercise as that treatment. So in terms of my thoughts before, would that be enough for my patients? And the ones I’ve seen, have seemingly done well with just one exercise, rather than having four or five different exercises to do. (T3—loaded self-managed)The key feature of patients self-dosing their exercise, based on the symptomatic response, is an understanding of when and how to progress or regress the exercise. Patients recognised the role of ‘trial and error’ in this process, and the relevance of the pain education prior to the exercise programme being implemented.I do remember, initially, there being kind of a week or two, maybe, where I was kind of finding kind of the right amount (of the exercise to do). (P9—loaded self-managed)I think what you tend to do as physios, we very often tend to be quite prescriptive. And patients do ask that. They want to know how many they should do, how many times a day, whereas this is actually giving them much more their own power of making them decide what they’re going to do. So actually, hopefully, then they’re going to carry on with it in the future. (T7—loaded self-managed)Interlinked to self-dosing was the expected pain flare-ups, when patients overdosed their exercise or physical activity. The physiotherapists’ training programme at the start of the feasibility study covered this topic, with physiotherapists aiming to discuss self-management approaches at preventing and dealing with flare-ups. Despite this, flare-ups remained common place, and were a cause of concern for several patients; suggesting this topic needs additional emphasis in any future training programme.R: Did it worry you when you had those flare-ups?P1: Yeah. There were kind of back-of-your-head thoughts, like, ’What if this time I have done it a bit too far? If it lasts a bit longer, am I going to have to go back in case I’ve damaged it a bit?’ or anything like that. But most of the time, again, was 2 days tops. So I did have kind of a little niggling worry, but nothing to kind of cause me to do anything or anything like that. (Loaded self-managed)Both patients and physiotherapists were asked to reflect on the intervention and their clinical response. For patients, quantitatively, the global rating of change at follow-up  was used to identify responders and non-responders. The scale was dichotomised so that responders were defined as ‘completely recovered’ or ‘strongly recovered’,Yeah. I’m playing football again. Yeah. I’m just kind of—sometimes I can tell I’ve got a little bit of tension there. But I’m not getting pain. It’s not stopping me doing nothing at all. So yeah. (P9—loaded self-managed)And this corresponded from the feedback from the treating physiotherapists, with all physiotherapists reporting favourable outcomes with the intervention.The main emphasis of patients’ and physiotherapists’ narrative was the simplicity of the exercise, the loaded element of the exercise and the self-dosage of the exercise.It is thought that difficulties accessing and understanding research, and professional isolation may act as barriers to implementation of research into practice.I don’t think I ever would have said to people, ‘Don’t push into any pain'. I think over the years I’ve probably got—as research projects and things we’ve done where we’re kind of talking more about it being okay to push into pain, I’ve got more relaxed with it… I think maybe as a junior I might have done, to be honest. So probably when I did my first rotation, I might have been saying more, ‘Very, very low’, or, ‘It needs to be virtually pain free’. But as the years have gone on, probably got more and more relaxed with saying it’s okay, on the back of, I suppose, of the things that have happened in our department and changes in practice generally. I think from when I first started practice, it would have been different. So when I first started, I would often tape the knee, or if they came back and said that it was painful, I asked them to kind of back off. Almost think about off-loading the knee if it was painful. So trying to reduce activity if it was sore. And then I think just as I became more experienced and read more about that type of thing, I got more confident in not using adjunct and trying to use loaded exercise and reassurance about pain. So I think it fits more with my current practice, and I don’t think it was that different. Obviously, I do a lot of pain education with back patients, so I think that was quite easily transferable. (T8—loaded self-managed)Department culture has been identified in previous qualitative work as a facilitator or barrier to change, over and above research evidence and clinical guidelines,I guess in this department we’re quite used to doing that sort of intervention for these patients, so it wasn’t particularly ground-breaking to me, in a nice way (laughter). It’s your (the researcher’s) fault. (T2—loaded self-managed)Oh, it is working in a different environment as well. So when I was in ** I was most of the time by myself in a GP clinic. And you don’t get a lot of interaction. That influence, when you actually have a bigger (department). We talk about loading as well. So we talk about Achilles or tendons and we just keep talking about how everything changes and you just do your own research and you think, ‘Okay’. How to make it better. Two physiotherapists discussed how being part of the research challenged their current practice and resulted in clinical development to both patients with and without PFP. One physiotherapist conferred how the training package and personal reflection of treating study patients challenged him; the second from sparking an interest in research.I think if you tell them, ‘Actually, how do you feel about it. You’re in control’, gives them the onus to take what they do. That’s definitely changed massively. And I kind of do that with other patients now as well, not just the knee patients. I’m a little less strict on sets and reps. I’m more do what you feel you can. If you’re happier, push on a little bit more. (T3—loaded self-managed)In respect to barriers and facilitators, the five major overlapping themes that emerged from the data were: (1) locus of control; (2) belief and attitude to pain; (3) treatment expectations and preference; (4) participants’ engagement with the loaded self-managed exercises and (5) physiotherapists’ clinical development. Locus of control was one overarching theme that was evident throughout.The aim of this qualitative study was to identify barriers and facilitators to the implementation of a loaded self-management exercise programme, which included education and advice on physical activity. Contrary to popular concerns relating to adherence of painful exercises,A key aspect of the loaded self-managed exercise programme is the single exercise method. Previous research with a similar approach in patients with shoulder pain identified this as a potential barrier to implementation, with physiotherapists and patients viewing this with a degree of uncertainty and scepticism.Locus of control is thought to predict health-related behaviours and physical activity,Previous qualitative work has suggested that department culture is a key driver or barrier to change.Implementation fidelity refers to the degree by which the delivery of an intervention adheres to the protocol and description.This research demonstrates that even though physiotherapists have certain expectations around management and exercise prescription, their approach was adaptable to the intervention with only two, 2-hour training sessions; enabling patients to self-manage and make sensible decisions about their own treatment and return to physical activity. The results of this study establish a skill set needed to deliver the intervention, including: complex musculoskeletal assessment; anatomy; tissue healing and remodelling; pain biology; peripheral and central sensitisation; psychological and social factors that might affect pain perception; self-management strategies and education skills. Currently, in the UK, these skills form part of the degree training programme for physiotherapy, further supplemented by the research training package.Two authors independently coded all transcripts, and used a clear, transparent and reproducible methodological approach to data analysis. The author’s clinical and research experience lie within the biopsychosocial framework of musculoskeletal pain. It is worth noting that the interviewer made it explicit to the participants that he was a physiotherapist working in the department conducting the research.Despite efforts to the contrary, the main limitations of this study were the difficulty in interviewing patients lost to follow-up (from both treatment groups) and those classed as non-responders in the experimental intervention group. Four patients were contacted who failed to return any outcome measures, and initially agreed to be interviewed; unfortunately, they failed to attend.The study population comprised a single clinical setting, where the researcher was also a clinician and where clinical trials are often undertaken; it is unknown how transferable the intervention is without the relevant physiotherapy training package.It is possible that the patient sample may differ from other samples within the UK, and how representative these findings are to other populations with PFP is unknown.This qualitative paper has identified some of the barriers and facilitators with participants (physiotherapists and patients) with the delivery of a loaded self-managed exercise programme, with education and advice on physical activity.From the patients’ perspective, facilitators to engagement included effective education around: self-management on exercise dosage; physical activity and flare-ups. This facilitation may have been mediated, in some part, to enhancements of self-efficacy and internalised locus of control. From the physiotherapists’ perspective, these results highlight the importance of ‘control’ and self-management during their assessment and management of patients with PFP.In the context of the UK’s usual management approach for PFP, which showed that a large proportion of practising physiotherapists would advise a patient to cease exercise or physical activity if they experience pain, implementation into general clinical practice may be challenging, but, ultimately feasible.


In addition to allergen-specific IgE (sIgE), allergen-specific IgG4 (sIgG4) antibodies are also involved in the immune response resulting from an allergen exposure. The aim of our study was to analyze sIgE and sIgG4 patterns in the most common allergic disorders: bronchial asthma, upper airway disorders and atopic dermatitis.In this study a screening analysis of blood serum samples from 673 patients aged from 6 months to 17 years with different allergic entities was performed on microarrays. sIgE and sIgG4 levels to the most common allergens were estimated.sIgE response to most pollen allergens is more strongly associated with respiratory diseases than with atopic dermatitis, while sIgE responses to cat and dog dander are more strongly associated with bronchial asthma than with atopic dermatitis and upper airway disorders such as rhinosinusitis and allergic rhinitis. A lower prevalence of sIgG4 to pollen allergens in cases of atopic dermatitis is observed compared with that in cases of asthma and upper airway disorders. Analyzing all the allergic disorders, one can see that sIgG4 response to inhalant allergens is strongly associated with sensitization to the corresponding allergen.Allergen-specific IgE and IgG4 patterns that are relevant to concrete allergic diseases differ by sIgE and sIgG4 prevalences to defined allergens.The online version of this article (10.1186/s40413-018-0220-5) contains supplementary material, which is available to authorized users. Bronchial asthma, allergic rhinitis and atopic dermatitis are the most common allergic reactions. The pathologies individually and their comorbidities are often diagnosed among many atopic patients in different periods of life . Along wCurrently, allergen-specific IgE is considered the only notable serological marker of type 1 hypersensitivity. A number of studies , 6 have Allergen-specific IgG, including subclass G4, participates in the development of allergic reactions. The analysis of allergen-specific IgG4 is mainly performed in studies that are related to allergen-specific immunotherapy (ASIT) , and a cThe aim of our study was to analyze the sIgE and sIgG4 responses to allergens that are most relevant to the chosen allergic pathologies. We determined sIgE and sIgG4 levels in blood serum samples from 673 patients diagnosed with bronchial asthma, upper airway disorders or atopic dermatitis using microarrays with immobilized protein extracts of 31 allergens. Profiles of the groups with different allergic pathologies were defined, and the correlation between sIgE and sIgG4 occurrence was evaluated.Patients from the Filatov Moscow City Pediatric Clinic No. 13 aged from 6 months to 17 years were enrolled in the study  had not demonstrated symptoms of allergic skin reaction for a period of 1 year before the study. The patients in the group with atopic dermatitis had not demonstrated symptoms of allergic airway diseases for a period of 1 year before the study. The children with well controlled and/or well-medicated asthma were not included in the group with atopic dermatitis.Surplus blood serum samples that remained after routine diagnostic procedures were analyzed. Additional blood draws were not performed. The study was approved by the local ethics committee of the Filatov Moscow City Pediatric Clinic No. 13.Microarray design and manufacturing technologies were described in full in the previous works , 14. BriConcentrations of the allergens were chosen in such a way that the results obtained from the microarrays most accurately coincided with the results obtained by the reference methods (Specific IgE REAST (ALLERG-O-LIQ) and Specific IgG4 ELISA ) . The sIgThe analysis of sIgE and sIgG4 on the microarrays includes 4 stages: 1) incubation of the microarray with the serum sample; 2) washing with a washing buffer containing detergent; 3) incubation with the developing antibodies, a mixture of anti-human IgE and anti-human IgG4 antibodies conjugated with Cy5 and Cy3, respectively; 4) washing with a washing buffer containing detergent .After the analysis, fluorescent signals from the gel pads with immobilized allergens are detected using a microarray analyzer with laser illumination and a device for speckle suppression . FluoresPatients were considered sensitized to the allergen if the sIgE level for the allergen exceeded the minimum cutoff of 0.35 IU/ml. Nonsensitized, monosensitized and polysensitized patients were enrolled in the study.sIgE prevalence was determined as the ratio of patients who exhibit sIgE above the cutoff of 0.35 IU/ml to the total number of patients in the group of interest. sIgG4 prevalence was determined as the ratio of patients who exhibit sIgG4 above the value of 100 ng/ml to the total number of patients in the group of interest.sIgE prevalence and sIgG4 prevalence were adjusted by age with the average population as a standard  using thp < 0.05.The statistical significance of the differences in sIgG4 response for sensitized and non-sensitized patients was estimated according to the results of the Fisher’s exact test calculated by MedCalc. The differences were considered statistically significant for pairwise comparisons with The diagrams were plotted using Microsoft Excel 2010.In the current study, sIgE and sIgG4 levels of 673 blood serum samples from patients aged from 6 months to 17 years with allergic reactions  were obtained.Results of the determination of allergen-specific IgE and IgG4 as well as sIgE and sIgG4 prevalence for different allergens in different age groups are presented in Additional file Patients with airway disorders  are mostly sensitized to pollen allergens. Notably, the adjusted sIgE prevalence for most pollen allergens distinguishes less than 10% for the patients with asthma and with upper airway disorders Fig. .Indoor allergens also have a significant impact, especially the animal epithelium allergens of cat dander and dog dander. sIgE sensitization to these allergens is more common for patients with bronchial asthma than for patients affected by only upper airway disorders or atopic dermatitis Fig. . For theThe adjusted prevalence of sensitization to food allergens of animal origin is higher in asthma and atopic dermatitis patients than in patients with upper airway disorders. However, this difference is most commonly not statistically significant  and food allergens Tables  and 3.This study is aimed at the sIgE and sIgG4 responses among atopic patients from 6 months to 17 years of age with allergic diseases: bronchial asthma, upper airway disorders or atopic dermatitis. The age range was chosen as 0 to 17 years because it is known that there are noticeable changes in immunoglobulin patterns among allergic patients during this period of life , 22. AftAlthough genetic predispositions to asthma and upper airway disorders are associated with different genetic polymorphisms, both diseases have common profiles of inflammatory mediators and cell-mediated responses involving eosinophils in the allergic inflammation . SubsequFor all explored allergens, with few exceptions, namely, cat and dog dander, considerable differences between sIgE profiles for patients with asthma and upper airway disorders are not observed Fig. . Daniel Our data on sIgE sensitization partly coincides with the results observed among adult population (22–86 years old) in the study : there wUnlike upper airway disorders, atopic dermatitis and bronchial asthma have a strong connection with food allergens , 28, whiAs the study has not included healthy controls, we have compared sIgE prevalence in our study with the sIgE prevalence in random population from Russian Karelia, that was analyzed in the study of Ruokolainen L et al.  Additional file 2:Comparison of age-adjusted sIgE prevalences among the patients diagnosed with bronchial asthma, upper airway disorders (such as rhinosinusitis and rhinitis) or atopic dermatitis involved in the study with the sIgE prevalences of the random population from Russian Karelia . (TIF 96 kb)


The aim was to study the level of satisfaction with an emergency department and to identify the factors associated with satisfaction.This research consisted of a descriptive, cross‐sectional study.The study population was composed of patients and companions who visited the emergency department during a three‐month period. The patients were selected randomly from the register of visits to the emergency department during the period of study. Sociodemographic variables and variables related to the attention received were studied through questionnaires (response rate 33%).p = 0.002), as was female sex (p = 0.013) and greater optimism (p < 0.001). Greater control of pain was a factor associated with satisfaction (p = 0.033), as was the perception of a shorter waiting time before the medical visit (p < 0.001).Older age was associated with greater satisfaction ( Additionally, the perceived level of optimism was studied .To study the factors associated with satisfaction, the numerical global satisfaction variable was recoded into two categories: “less satisfied,” which included those users who gave a score of between 0–7 and “more satisfied,” which included those who gave a score of between 8–10 points. The pain control variable was also recoded as “pain controlled,” for those who had referred to their pain being sufficiently or completely controlled and “pain not controlled” for those referred to their pain having been little or not controlled.The satisfaction questionnaire validated by González et al.  was admiData from the clinical history were also gathered to perform analysis with the responses of the patients and companions: date of birth, date of the visit, time of arrival at the emergency department, electronically recorded time of the nursing triage and electronically recorded time at which the doctor assigned the date and time of release from the department. In the case of companions, data related to the patient's visit were used.2.5® SPSS Statistics® version 19 was used to analyse the data.IBMt test was used to compare quantitative and categorical variables, the Pearson's correlation was used to compare quantitative variables and the chi‐squared test was used for categorical variables. For variables that did not meet the criteria of normality, the Mann–Whitney U test and the Kruskal–Wallis non‐parametric test were used to compare quantitative and categorical variables and the Spearman's rho test was used for quantitative variables. A binary regression model was run from factors associated with patients' and companions' satisfaction with the emergency department adjusting for age, sex and level of optimism. The level of significance was taken as p < 0.05.The numerical variables are described by mean and standard deviation or by median and interquartile range. To study the association between the variables that met the criteria of normality, Student's 2.6All the participants who responded to the questionnaire also returned the signed informed consent. This project respects the Helsinki Declaration of the World Medical Association. The study was approved on 1 August 2012 by the ethical committee of the hospital before beginning the study.3SD = 18.3), and 53.6% were women. The sociodemographic data of the patients and companions are presented in Table A total of 15,273 patients were attended to, from whom, 1,526 patients were randomly selected (864 patients were included and 662 were excluded). A total of 285 responses were received (response rate 33.0%); of which, 221 (77.5%) corresponded to patients, 62 (21.8%) to companions and 2 (0.7%) to respondents who failed to identify themselves as either a patient or companion. The mean age of the respondents was 54.6 years (N = 273) was 7.6 (SD = 2.2) . The patients (N = 214) and companions (N = 57) assigned a mean satisfaction score of 7.6 (SD = 2.2)  and 7.5 (SD = 2.1) , respectively, without significant differences between the two scores .For patients and companions, the mean score for subjective overall satisfaction with the visit (SD = 17.2) , for nursing care 79.7 (SD = 19.9) , for comfort in the department 65.7 (SD = 19.1) , for visiting 78.3 (SD = 11.7) , for privacy 79.6 (SD = 30.3)  and for cleanliness 91.3 (SD = 14.1) .The results of the individual dimensions of the satisfaction scale taken separately were as follows: for the dimension of medical care, a mean score of 84  (Pearson's correlation).Analysing the association between subjective overall satisfaction and the age of the participants shows that older patients scored higher than younger patients with respect to overall satisfaction with the visit (SD = 2.3) , whereas those who were not in pain gave a mean score of 7.8 (SD = 1.6)  . On the other hand, studying the association of control of pain and overall satisfaction shows that people whose pain was better controlled gave higher scores for overall satisfaction with the visit .The presence of pain was compared with overall satisfaction. Patients with pain gave a mean satisfaction score of 7.5 (p < 0.001). The relationship between the perceived waiting time for the medical visit and subjective overall satisfaction was also studied; patients who had the perception of having waited for a short or for a very short period of time gave higher scores for subjective satisfaction than did those who had the perception of having waited for a long time or for an extremely long time .The perceived waiting time for nursing triage was compared with subjective overall satisfaction. It was found that patients who perceived that they had waited for a very short or short period of time gave higher scores for subjective satisfaction than did those who perceived that they had waited a long or extremely long time  , whereas those who were not informed gave a mean score of 7.4 (SD = 2.2) , .Furthermore, the association between information about the waiting time and satisfaction was analysed. Patients and companions who were informed about the waiting time gave a mean score of 8.4 (SD = 1.7)  for overall satisfaction and that those who would not recommend it gave a mean of 4.6 (SD = 2.9) , .A total of 88.8% of the respondents would recommend the emergency department to a family member or friend. Analysing the possibility of recommending the department via subjective overall satisfaction shows that those who would recommend the department gave a mean score of 8.0 (SD = 2.0) .The level of perceived optimism of patients and companions had a mean score of 7.2 .Analysing the relationship between the level of optimism and subjective satisfaction with the visit shows a positive correlation between the two variables, with greater levels of optimism being found to correspond to greater overall satisfaction  than the less satisfied users, and women were found to be in more satisfied group . Observably, people who scored better in optimism were in the most satisfied group . Furthermore, people who had better controlled pain were found to be in the group of the most satisfied users (80.9% vs. 57%) .Table χ2 = 28.87; p < 0.001); the same occurred with the perceived waiting time for the medical visit, where those who considered this time to be very short or short were also among the group of the most satisfied users (38.3% vs. 16.8%) . People who were not informed about the approximate waiting time for the medical visit were among the least satisfied (86.9% vs. 75.6%) , and people who would recommend the emergency department to a family member or friend were among the group of the most satisfied users (95.7% vs. 77%) .Regarding the perceived waiting times, people who perceived that the waiting time for the visit of the triage nurse was very short or short were found to be in the group of the most satisfied users (49.4% vs. 23.4%) (p = 0.002), as was the female sex . The level of optimism was also associated with user satisfaction, with the most optimistic people being the most satisfied .Table p = 0.033). The perceived waiting time was also associated with satisfaction, with those who perceived that the waiting time for the medical visit was very short being among the most satisfied .Control of pain was a factor associated with satisfaction and greater control of pain was associated with greater satisfaction (OR = 0.418; CI 95% [0.19–0.93]; 4The present study has identified the factors associated with the patients' and companions' satisfaction with the emergency department of a Spanish general hospital.The chosen method for the questionnaire, a mailing with a pre‐paid envelope, achieved a 33% response rate, which was similar to that of other studies (González‐Valentín, Padín López, & de Ramón Garrido, Subjective overall satisfaction with the visit to the emergency department was high, with a mean score of 7.6, which is in line with the scores obtained in similar studies (Gea, Hernán‐García, Jiménez‐Martín, & Cabrera, Older patients were found to be more satisfied, coinciding with other authors (Crow et al., In our study, more than eight out of ten of the patients surveyed referred to pain when they visited the emergency department and in most cases, the pain was controlled completely or sufficiently. This result is similar to Kamali, Jain, Jain, and Schneider , who fouIn our study, the perception of the waiting time was one of the factors that most influenced the subjective overall satisfaction of users in terms of both nursing care and the medical visit. Similarly, in a study undertaken in an emergency department, patients who referred to having waited less time were more satisfied than those who had waited longer (Mercer, Hernandez‐Boussard, Mahadevan, & Strehlow, Being informed of the approximate waiting time also influences users’ satisfaction. The present results show that users who were informed about the approximate waiting time gave better scores for satisfaction with the service. In an investigation in an emergency department, Kington and Short  observedPatient satisfaction must include, along with overall satisfaction with the service, the probability that the patient will recommend the service to others and the willingness to return to the service Welch, . As in eRegarding optimism, the most satisfied users scored higher for optimism. Costello et al.  observedIdentifying the factors associated with user satisfaction makes it possible to define strategies and actions to improve the quality of the emergency department. It is especially important to improve the control of pain in the emergency department and to reduce the real and perceived waiting times as well as to improve the supply of information about these times.4.1The possible limitations of the present study are related to the methodology employed; the cross‐sectional design does not allow causality to be established. Furthermore, we have no way of knowing the motivations of those who left the service without being visited and it is likely that these may include dissatisfaction with the service. One of the strengths of this investigation is the inclusion of companions in the patient satisfaction study.5The level of satisfaction with the emergency department was high, and the factors associated with the satisfaction of patients and companions were age, sex, optimism, control of pain and the perceived waiting time before the medical visit.The most satisfied users were those who were older, women, patients whose pain was better controlled and those who perceived shorter waiting times and who were informed of an approximate waiting time.


Chronic pain, such as low-back pain, can be a highly disabling condition degrading people’s quality of life (QoL). Not every patient responds to pharmacological therapies, thus alternative treatments have to be developed. The chronicity of pain can lead to a somatic dysperception, meaning a mismatch between patients’ own body perception and its actual physical state. Since clinical evaluation of pain relies on patients’ subjective reports, a body image disruption can be associated with an incorrect pain rating inducing incorrect treatment and a possible risk of drug abuse. Our aim was to reduce chronic low-back pain through a multimodal neurorehabilitative strategy using innovative technologies to help patients regain a correct body image.Twenty patients with chronic low-back pain were included. Before and after treatment, patients underwent: a neurological exam; a neuro-psychological evaluation testing cognitive functions  and personality traits, QoL and mood; pain ratings; sensorimotor functional abilities’ testing. Patients underwent a 6 week-neurorehabilitative treatment  using virtual reality . Treatment consisted on teaching patients to execute correct movements with the painful body parts to regain a correct body image, based on the augmented multisensory feedback  provided by the VRRS.Our data showed significant reductions in all pain rating scale scores (p<0.05); significant improvements of QoL in the domains of physical functioning, physical role functioning, bodily pain, vitality, and social role functioning; improvements in cognitive functions (p<0.05); improvements in functional scales (p<0.05) and mood (p = 0.04).This non-pharmacological approach was able to act on the multi-dimensional aspects of pain and improved patients’ QoL, pain intensity, mood and patient’s functional abilities. Chronic pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage that has been lasting for at least twelve weeks . ChronicIt has also been demonstrated that chronic pain can lead to a somatic disperception, meaning a substantial mismatch between the sensation of the affected body part and its actual physical state –15. DistDistortion of body image has been demonstrated in a majority of patients presenting with CRPS and low-back pain. Förderreuther and colleagues  studied Sensorimotor cortical reorganization has been demonstrated in chronic pain due to deafferentation , but alsSeveral non-pharmacological approaches can be administered to reduce chronic low-back pain, such as massage, exercise, spinal manipulation, cognitive-behavioral therapy, acupuncture, yoga or functional restoration. These cognitive-behavioral, sensory or motor strategies aim particularly at reducing pain through cortical plasticity due to sensorimotor or cognitive stimulation. Most of these approaches aim to teach patients the best techniques to lead them to a self-management of their pain experience, through a manipulation of their thoughts, their feelings and their behavior. Such techniques have been demonstrated as moderately effective to reduce chronic low-back pain .Virtual reality (VR) is a technological rehabilitation tool that allows the user to experience the interaction with a computer-generated environment . It may Thus, VR may be considered a good candidate to help patients in improving their own movements and body position perception  in orderIn this proof-of-concept study, we treated chronic low back pain with a non-immersive virtual reality training starting from the working hypothesis that this treatment might contribute to restore a correct body image, improve QoL (primary outcome measure), reduce pain sensations, act positively on mood, and recover sensorimotor abilities.The study was conducted in the Neurorehabilitation and Functional Recovery Department of the San Raffaele Hospital . In this single-armed study, 20 patients  presenting with chronic low back pain were included  and all participants signed an informed consent according to the Declaration of Helsinki before entering the survey.Before and after treatment, subjects underwent a comprehensive neuropsychological assessment and a physical therapy examination.In the neuropsychological assessment, the following tests for different cognitive domains and questionnaires for daily living activities were administered: (1) Activities of Daily Living (ADL) , (2) InsIn the physical therapy exam, the functional and pain assessment included: (1) an 11-point numeric rating scale (NRS) , (2) theRight rotation: IR+ = avg(Mn+)/max(Mn+)Left rotation: IR- = avg(Mn-)/min(Mn-),The Repetition Index was calculated as follows:Mn+ is defined as the Maximum Value of the all Positive Values of -n repetitions of the movement (right rotation) and Mn- is defined as the Minimum Value of all Negative Values of -n repetitions of the movement (left rotation).Then, the total Repetition Index (IR) consisted on the average of IR+ and IR-.After treatment, patients were also asked to report their Global Impression of Change (GIC) on a 7-point categorical scale .Patients underwent 12 rehabilitative sessions of 1 hour each, over a period of 4 to 6 weeks. Treatments consisted in virtual reality-based sensorimotor rehabilitation provided by the Virtual Reality Rehabilitation System (VRRS) of the Khymeia group . The technological equipment included a computer workstation connected to a 6 degrees of freedom (DOF) motion-tracking system , a high-resolution LCD displaying the virtual scenarios on a large screen and a software processing the motion data. These data are issued by the receiver of the end-effector placed on the sternum or the hips.The VRRS allows the participant to perform the requested motor tasks, while the movement of the system’s end-effector is simultaneously represented in a virtual scenario. In this scenario, an avatar reproduces online the performance of the patient who also gets an immediate visual and acoustic feedback on his/her performance. Indeed, for each exercise, the patient has to reach a certain result. The performance of the patient is immediately codified in terms of score, color code and acoustic feedback so that the patient always has a knowledge of performance and result. The aim of the exercises was to regain a correct body image by improving the control of single movements of the trunk. Patients underwent a series of exercises consisting mainly in trunk rotation, flexion and extension realized in various positions  as displayed in Power size calculation was done on primary outcome: QoL, measured with the SF36—Short Form Health Survey. Considering a SF36 post-treatment change of 7.7 points and a standard deviation of 10.7, a 5% tyData were considered significant when p<0.05. The commercially available software IBM SPSS Statistics v.23 (IBM Corp.) was used for all statistical tests.Every patient completed the sessions of virtual reality rehabilitation without side effects and with a good compliance (no dropouts during treatment). Seven out of the twenty patients refused to take part to some of the post-treatment neuropsychological evaluation. Thus, analyses of neuropsychological data are presented with n = 13 .Eighteen out of the twenty patients reported an improvement on the NRS pain scale . Indeed,Results are displayed in Lastly, a significant post-treatment improvement of the Beck Depression Inventory-II scores was found (p = 0.04).Neuropsychological evaluations did not show clinically significant abnormalities in patients’ cognitive functions. The statistical analyses revealed some significant improvements after treatment at the following tests see : naming The descriptive analysis of the psychological profile of patients (MMPI-2) showed that 63.2% of patients presented with scores above normal for hypochondriasis. Scores above normal were also observed for lie (42.1%), health concern (36.8%), hysteria (31.6%), addictions acknowledgement scale (26.3%) and depression (26.3%). Detailed results of psychological profile are displayed in Results are exposed in The improvements in participation (RMDQ) correlated with the improvements reported by the patients on the GIC scale , NRS , MPQ PRI-TOT  and MPQ NWC .In this proof-of-concept study, we were able to show that VR-based rehabilitation could have significant impact on chronic low-back pain. Indeed, after six weeks of treatment, significant decreases were observed for all pain scores, some of which overstepping the MCID reported in the literature. This decreased pain sensation was also accompanied by improvements in QoL, in some cognitive functions and sensorimotor output. Although such results need to be reproduced in a larger, controlled, randomized study, we believe these data bring evidence on the fact that virtual reality can be efficient in helping chronic low-back pain patients in regaining better motor function together with a reduced pain sensation and improvement in their quality of life.Our treatment was based on the hypothesis that helping patients to regain a correct body perception would help them improve their functional abilities, improve their QoL and reduce pain sensations. The fact that patients improved significantly in movement reproducibility and amplitude with training seems to indicate that VR-based rehabilitation produced significant proprioceptive and functional improvements. Previous studies also showed that VR could improve movement and body position perception . In chroAlthough further studies will need to investigate the corticospinal mechanisms induced by VR-based rehabilitation, we could hypothesize that such effects might have been due to corticospinal reorganization. Indeed, VR training has influences on various cortical and subcortical neuronal circuits, particularly related to learning. First, in some simple motor rehabilitation exercises, the motor copy strategies use mirror neurons system to improve learning . MoreoveOther non-pharmacological therapies have been shown to improve chronic pain. In their review, Chou and Huffman found good evidence that psychological interventions , exercise, interdisciplinary rehabilitation, functional restoration and spinal manipulation were effective for chronic low-back pain. These interventions were associated with moderate effects such as 10 to 20 points difference on a 100-point visual analogue pain scale or 2 to 4 points on the RMDQ . InteresCognitive-behavioral treatments for chronic pain aim to reduce feelings of helplessness and uncontrollability and instate behaviors that limit the impact of pain on QoL. Cognitive-behavioral approaches also focus on extinguishing pain behaviors and acquiring healthy ones. Such treatments can modulate brain activity related to pain. Indeed, it has been shown that exposure therapy can alter brain processes related to stimuli that are relevant for the disorder. Sensory approaches can also modulate cortical organization. This has been shown in phantom limb pain which was decreased by somatosensory training acuity. Motor strategies, such as mirror therapy and virtual limbs for neuropathic pain might correct cortical body maps to remove the incongruence between motor commands and sensory feedback (for review see ).The chronic pain state can trigger a cascade of changes in psychological processes  that seeIn line with previous reports, our patients presented with abnormal levels of hypochondria, depression, hysteria and health concerns, as shown by the MMPI analyses –9. The MChronic pain has become a major health concern worldwide. Pharmaceutical companies are currently addressing the crisis of prescription drug abuse or misuse through the development of abuse-deterrent formulations of opioid analgesics, addiction treatments, medication to treat opioids overdoses, and non-opioid drugs . The devOur results open thus new study perspective and further randomized studies are necessary to define: (1) treatment effectiveness; (2) the best treatment duration; (3) in which manner might these improvements affect patients’ motor and functional activities; (4) how such VR treatments can reduce analgesic drug intake; (5) what are the benefits of this kind of treatment with respect to the traditional ones. We acknowledge the absence of a control group in this study, the heterogeneity in patients’ profile, as well as an absence of correction for multiple hypothesis testing.Our study showed that a virtual reality-based motor training was able to reduce chronic pain and act on the multidimensional aspects of pain, such as pain sensation itself, quality of life, sensory and motor sensations as well as cognitive functions. These data serve as a proof-of-concept study that should lead to larger, controlled, randomized clinical trials to better investigate the potential of virtual reality to act on body perception to treat chronic pain.


Acute calcific periarthritis of the hand is a relatively uncommon painful condition involving juxta-articular deposits of amorphous calcium hydroxyapatite. Although conservative treatments have been generally considered effective, there is little evidence regarding how long they could remain effective.We retrospectively reviewed ten patients who were diagnosed with acute calcific periarthritis of the hand from January 2015 to June 2018. We recommended the use of warm baths, nonsteroidal anti-inflammatory drugs (NSAIDs), and limited activity as initial treatments. If the pain persisted despite at least 3 months of conservative treatment, we explained surgical treatment options. If the pain improved, we recommended gradual range-of-motion exercises with the continuation of daily NSAIDs use. The visual analogue scale (VAS) score for pain at each subsequent visit  was compared with that of the previous visit to investigate whether the pain had decreased during each time interval. Simple radiographs taken at each visit were compared with those taken at the previous visit to determine whether any significant changes in the amount of calcification had occurred during each time interval.P values = 0.004, 0.008, and 0.598, respectively). The simple radiographs also showed a significant reduction in the amount of calcification at 3 and 6 months, but not at 9 months .All 10 patients with 17 affected joints continued conservative treatments for an average of 11.1 months. The average VAS score for pain at the initial visit was 7, while that at 3, 6, and 9 months was 4.3, 3.3, and 2.9, respectively. There was a significant reduction in the VAS score at 3 and 6 months, but not at 9 months (Patients with acute calcific periarthritis of the hand exhibited residual pain and calcification for a relatively prolonged period. Those who continued conservative treatment, including NSAIDs, showed pain relief and reduced calcification for up to 6 months. These results suggest that conservative treatment could be tried for at least 6 months before considering the surgical treatment of calcific periarthritis of the hand. Acute calcific periarthritis is an unusual and painful condition associated with juxta-articular deposits of amorphous calcium hydroxyapatite . CalcifiAlthough common clinical manifestations of acute calcific periarthritis include the rapid onset of erythema, swelling, and restricted motion, patients generally suffer from the acute exacerbation of severe pain. As in other parts of the body, patients with acute calcific periarthritis of the hand typically complain of severe pain limited to the involved area of the hand. According to one previous report, over 25% of patients with acute calcific periarthritis of the hand visited the emergency department for intense pain .Conservative management strategies, including rest, splinting, and pain relievers, have been known to be effective for the treatment of acute calcific periarthritis . NonsterWe retrospectively reviewed patients who had visited the clinic and had been diagnosed with acute calcific periarthritis of the hand from January 2015 to June 2018. The diagnosis was made based on both the acute onset of periarticular pain within 1 month and periarticular calcific deposits visible on simple radiographs. Patients with calcific periarthritis of the MCP joint and IP joint were included, while those with calcific periarthritis of the radiocarpal, distal radioulnar, intercarpal, and carpometacarpal joints were excluded. Among the patients with acute calcific periarthritis of the hand, those with more than 6 months of follow-up were included. Ten patients were eligible for inclusion criteria. The mean patient age was 49.4 ± 9.2 years ; one (10%) patient was male and nine (90%) patients were females. Five patients showed the involvement of multiple joints, so a total of 17 joints were involved in 10 patients. Three (30%) patients recalled a previous minor trauma to the involved joints within the past 6 months. Five (50%) patients reported the current use of medications for other diseases: three (30%) patients were being treated with anti-hypertensive drugs, two (20%) with cholesterol-lowering agents, and two (20%) with oral hypoglycemic agents. There were no patients with underlying disease, such as end-stage renal disease or collagen vascular disease. Initial laboratory test results, including those of calcium, phosphorus, and alkaline phosphatase (ALP), showed no abnormalities, except in one patient, who had a high ALP level of approximately 205 IU/L  system. The VAS score at the 3, 6, and 9 month follow-up visits were compared with the VAS score at the previous  visit using a paired Simple radiographs of each affected joint were acquired at each follow-up visit. The amount of calcification at each visit was compared with that at the previous visit to determine whether any significant change had occurred. The radiographic change in the amount of calcification was categorized as follows: maintenance of complete resolution, decrease with complete resolution, decrease with residual calcification, no change with persistent calcification, and increase. All radiographs were assessed by two of the authors, who are orthopedic surgeons and were blinded to all other subject information. Intra-observer reliability was evaluated using a repeated assessment after 4 weeks. Inter-observer reliability was evaluated using the assessments of the two examiners. The intra-observer and inter-observer reliabilities were evaluated using kappa coefficients. We determined whether there had been a significant reduction in calcification during each time interval using the Wilcoxon signed-rank test. All statistical analyses were performed using SPSS ver. 20.0 .All ten patients continued the conservative treatments until the last visit Fig. . The aveP values = 0.004 and 0.008, respectively). However, there was no significant change in the VAS score between the 6- and 9-month follow-ups  , but not at the 9-month follow-up   out of the 17 joints, including 4 (24%) joints with complete resolution, 8 (47%) joints with no change, and 1 (6%) joint with increased calcification. The radiographic assessments performed at 6 months showed resolution maintenance in four (24%) joints and decreased calcification in seven (41%), including two (12%) with complete resolution, while no change was observed in five (29%) joints and increased calcification was observed in one (6%) joint. At 9 months, three (18%) joints were lost to follow-up, five (29%) joints showed maintenance resolution, and three (18%) joints showed decreased calcification, including two (12%) with complete resolution, while no change occurred in six (35%) joints. There was a significant reduction in the amount of calcification at the 3- and 6-month follow-ups  showed no reduction in the VAS score even after 6 months of conservative treatment. We could not identify any distinct clinical features from the medical records or simple radiographs of these two patients. The patients did not have any previous history of trauma, laboratory abnormalities, or current medications, except one patient was under treatment with anti-hypertensive drugs. Some authors have recommended other treatment modalities, such as local injections, ESWT, PRP therapy, and needling, for patients with residual or persistent pain after conservative treatment , 8. HoweSurgical treatments are usually indicated for calcific periarthritis with recurrent or persistent pain even after nonsurgical treatments , 8. HoweThe exact pathogenesis of calcific periarthritis remains controversial. In a relatively recent proposal by Uhthoff and colleagues, hypoxia in critical areas of the tendon initiates calcific periarthritis, followed by fibrocartilaginous metaplasia of the tendon . They diSeveral limitations of this study should be noted. First, above all, there was no control group. Thus, we cannot be sure whether the conservative treatments actually altered the natural course of calcific periarthritis. Second, this was a retrospective study with limited clinical data. There were no additional clinical data available during the 3-month intervals. With more weekly or at least monthly data, more details regarding reductions in pain and calcification might be elucidated. Third, the small sample size limits the generalizability of the results of this study. A comparative analysis, such as between a high- and low-response group and between a surgical and conservative treatment group in a relatively large cohort, may reveal significantly distinct clinical features, although such comparisons could not be performed in this study due to the small sample size.Patients with acute calcific periarthritis of the hand revealed residual pain and calcifications for a relatively prolonged period and those who continued conservative treatment, including NSAIDs, showed pain relief and reduced calcification up to the 6-month follow-up. These results suggest that conservative treatment could be tried for at least 6 months before considering surgical options for treatment of calcific periarthritis of the hand. Further studies with a prospective design, large sample size, and control group are required to clarify the optimal treatments for calcific periarthritis.