The effect of parenting type on anxiety level of hospitalised children: A cross-sectional study.

OBJECTIVE: To determine the influence of parenting type on the anxiety level of hospitalised children. METHODS: The cross-sectional, observational study was conducted in June 2021 at the paediatric ward of Arifin Ahmad General Hospital, Pekanbaru, Riau, Indonesia, and comprised inpatients and their parents. The Data analyses was performed with SPSS 16.0. Statistical test results were considered significant at a p <0.05 level when 95% confidence intervals did not include zero. A personal Chi-Square test was applied to determine the influence of parenting type on the anxiety level of hospitalised children. RESULTS: There were 25 children with mean age 4.04±4.84 years, while the mean age of 25 parents was 34.87±36.89 years. Among the parents, 15(60%) were mothers. A significant influence was found between the type of parenting and the anxiety levels in hospitalised children (p=0.037; odds ratio:2.750; 95% confidence interval: 1.33-18.89). CONCLUSIONS: Good parenting patterns during treatment could reduce anxiety levels in hospitalised children.

Relationships Between Meaning in Life and Positive and Negative Spirituality in a Field Setting in Japan.

This study examined the relationships between positive/negative spirituality and meaning in life at two religious sites in Japan. Participants reported greater sadness and less meaning in life at Koyasan Okunoin, a temple with graves surrounded by nature, than at Nachi Kumano Taisha, a shrine with a waterfall. However, greater feelings of happiness protected meaning in life in the presence of sadness at Koyasan. Additionally, participants who felt a sense of awe reported greater meaning in life through self-liberation, regardless of the sites. The results provide new insights into meaning in life from the two sides of spirituality.

Testing the Associations Between State and Trait Anxiety, Anger, Sadness, and Ambulatory Blood Pressure and Whether Race Impacts These Relationships.

BACKGROUND: Anxiety, anger, and sadness are related to elevated ambulatory blood pressure (ABP), yet it is unclear whether each emotion exerts unique effects. Moreover, an understanding of who might be most susceptible to the negative effects of these emotions is limited, with the trait tendency to experience them or one's race as potential moderators. PURPOSE: The study examined the potential for differential effects of momentary anxiety, anger, and sadness on ABP. The study assessed whether a trait tendency to experience these negative emotions and/or race (Black vs. non-Black) would moderate these relationships. METHODS: Participants (n = 153) completed trait anxiety, anger, and depressive symptoms measures at baseline. ABP was collected over two 24-hour periods 3-4 months apart. Momentary measures of anxiety, anger, and sadness were assessed via ecological momentary assessment (EMA) after each ABP reading. RESULTS: Momentary anxiety consistently predicted diastolic blood pressure but not systolic blood pressure. Momentary anger and sadness did not predict blood pressure (BP). Conditional effects were found with momentary anxiety and anger predicting elevated BP in those individuals with trait anxiety/anger at its mean. Trait anxiety and depression consistently predicted heightened BP in Black participants. Trait anger did not moderate the relationships between negative emotions and ABP. CONCLUSIONS: Findings suggest that momentary anxiety and anger should be given attention as potential risk factors for hypertension and highlight the unique perspective of EMA methods. Black participants who were more anxious and depressed experienced heightened BP, with anxiety and depression providing possible intervention targets in improving racial disparities in cardiovascular health.

CROWD-5e: A Croatian psycholinguistic database of affective norms for five discrete emotions.

The present study introduces affective norms for a set of 3022 Croatian words on five discrete emotions: happiness, anger, sadness, fear, and disgust. The words were rated by 1239 Croatian native speakers. Each participant rated 251 or 252 words for one discrete emotion on a five-point Likert scale. The analyses revealed a significant relationship between discrete emotions, emotional dimensions (valence and arousal), and other psycholinguistic properties of words. In addition, small sex differences in discrete emotion ratings were found. Finally, the analysis of the distribution of words among discrete emotions allowed a distinction between "pure" words (i.e., those mostly related to a single emotion) and "mixed" words (i.e., those related to more than one emotion). The new database extends the existing Croatian affective norms collected from a dimensional conception of emotions, providing the necessary resource for future experimental investigation in Croatian within the theoretical framework of discrete emotions.

"The many faces of sorrow": An empirical exploration of the psychological plurality of sadness.

Sadness has typically been associated with failure, defeat and loss, but it has also been suggested that sadness facilitates positive and restructuring emotional changes. This suggests that sadness is a multi-faceted emotion. This supports the idea that there might in fact be different facets of sadness that can be distinguished psychologically and physiologically. In the current set of studies, we explored this hypothesis. In a first stage, participants were asked to select sad emotional faces and scene stimuli either characterized or not by a key suggested sadness-related characteristic: loneliness or melancholy or misery or bereavement or despair. In a second stage, another set of participants was presented with the selected emotional faces and scene stimuli. They were assessed for differences in emotional, physiological and facial-expressive responses. The results showed that sad faces involving melancholy, misery, bereavement and despair were experienced as conferring dissociable physiological characteristics. Critical findings, in a final exploratory design, in a third stage, showed that a new set of participants could match emotional scenes to emotional faces with the same sadness-related characteristic with close to perfect precision performance. These findings suggest that melancholy, misery, bereavement and despair can be distinguishable emotional states associated with sadness.

Hostility bias or sadness bias in excluded individuals: does anodal transcranial direct current stimulation of right VLPFC vs. left DLPFC have a mitigating effect?

Exclusion has multiple adverse effects on individual's well-being. It induces anger and hostile cognitions leading to aggressive behavior. The purpose of this study was to test whether exclusion would affect recognition of anger on ambivalent faces of the excluders. We hypothesized that exclusion would elicit more anger encoding (hostility bias) than inclusion, but this effect would be mitigated by anodal tDCS of right VLPFC or left DLPFC-regions engaged in negative affect regulation. Participants (N = 96) were recognizing emotions (anger, sadness, happiness) on ambiguous faces of individuals who-as they were told-liked them or not. Results showed that exclusion induced more sadness bias. tDCS to VLPFC decreased anger and increased sadness recognition on excluders' faces compared with includers' faces, expressing a mixture of these two emotions. Additionally, stimulation to VLPFC and DLPFC decreased latencies for faces expressing sadness (sad-angry and happy-sad) but increased for happy-angry faces. Stimulation to VLPFC also increased reaction time to excluders faces while stimulation of DLPFC decreased reaction latency to includers faces. Results were discussed with the reference to the form of exclusion, motivational mechanism affected by disliking but also to lateralization (valence vs. arousal theory) and cortical regions engaged in encoding sadness after a threat to belonging.

Mother- and Father-Child Reminiscing About Past Events Involving Pain, Fear, and Sadness: Observational Cohort Study.

OBJECTIVE: Pain in childhood is prevalent and is associated with fear, particularly in the context of injuries or procedural pain, and negative emotions (e.g., sadness). Pain and fear share a bidirectional relationship, wherein fear exacerbates the experience of pain and pain increases subsequent anticipatory fear. The existing research has focused primarily on children's immediate experience of pain and fear. Research on how children remember or talk about past painful, fearful, or sad events is lacking. Parent-child reminiscing about past pain has been demonstrated to differ from reminiscing about other past negative emotional events (i.e., those involving sadness, but not fear). The present study aimed to examine differences in how parent-child dyads reminisce about past pain, fear, and sadness. METHODS: One hundred and three 4-year-old children (55% girls) and their parents (52% fathers) engaged in a narrative elicitation task in which they reminisced about unique past events involving pain, fear, and sadness. Parent-child narratives were coded using established coding schemes based on the developmental psychology literature. RESULTS: Parent-child narratives about pain were characterized by fewer emotion-laden words and explanations, as well as more pain-related words compared to sadness or fearful narratives. Mothers and fathers reminisced with sons and daughters in a similar way across all types of events. CONCLUSIONS: Parent-children reminiscing about past painful events differs from reminiscing about other types of distressing events (e.g., involving sadness or fear). This highlights a possibility of differential socialization of pain versus fear. Potential clinical implications of the findings are discussed.

Experiences in elderly people with chronic obstructive pulmonary disease in relation to the use of long-term home oxygen therapy: a qualitative study about feelings attributed to therapy.

BACKGROUND: Elderly people are more likely to suffer severe chronic obstructive pulmonary disease (COPD) and require long-term home oxygen therapy (LTOT) as part of their treatment. LTOT has advantages such as improvement in symptoms, but there are also disadvantages such as physical barriers, psychosocial barriers and emotional challenges. The aim of this study is to understand the experiences of elderly people with COPD using LTOT with respect to their feelings attributed to therapy. METHODS: Qualitative study. Seven semidirected interviews were conducted with patients with a confirmed COPD diagnosis who used LTOT and were treated at an outpatient service. The content analysis technique was applied with the support of WebQDA software 2.0. RESULTS: Three categories emerged that were associated with the use of LTOT: (1) poor self-image; (2) feelings of sadness and (3) the impact of LTOT on others such as family and friends. CONCLUSIONS: LTOT in elderly people with COPD was associated with a poor self-image, feelings of sadness and impacted on others apart from the patient. When LTOT is prescribed, healthcare practitioners should proactively address these concerns to minimise the negative biopsychosocial experiences caused by LTOT.

Are music listening strategies associated with reduced food consumption following negative mood inductions; a series of three exploratory experimental studies.

Emotions play an important role in overeating, yet there is little research looking at practical strategies to reduce overeating in response to a negative mood. In three different experimental studies, we tested if exposure to music can reduce food consumption in a negative mood. Female undergraduates (N = 120-121 in each study) completed a measure of emotional eating and reported baseline hunger. Mood ratings were taken at baseline, post-mood induction and post-eating. All participants were given a mood induction (sadness for study 1, stress for studies 2 and 3) and allocated to one of three music conditions (self-chosen in study 3) or a silent (control) condition. Music was selected from three pieces reported by each participant as being listened to regularly when experiencing the negative mood being examined (sadness or stress) in order to provide solace (comforting music), diversion (distracting positive music), or discharge (angry and/or sad music). Participants were provided with several snack foods to consume whilst completing a mock taste test and intake (in grams) was compared between conditions. In study 1 participants in the music for discharge condition consumed less than those in the control condition. Moreover, participants with high levels of self-reported EE ate more crisps in the control than in the distraction condition. In study 2 participants in the solace condition consumed less than those in the control and discharge conditions. In study 3 most participants chose music for diversion; this did not, however, lead to lower consumption, despite a reduction in reported stress. Overall, the results of these studies indicate that listening to certain types of music might reduce emotion-related eating after controlling for hunger using a standardized pre-session snack.

Differences in genetic counseling student responses to intense patient affect: A study of students in North American programs.

Research indicates genetic counseling patients often experience intense emotions. No studies, however, have investigated how genetic counseling students respond to patient affect. This survey study investigated student responses to patient emotions and select factors affecting their responses. One-hundred fifty-one genetic counseling students in North American programs wrote a response to each of three hypothetical prenatal scenarios, identical except for the patient affect expressed (anger, fear, or sadness). They also completed measures of empathy tendency and tolerance of negative affect and demographic questions. Multivariate analysis of covariance (MANCOVA), used to analyze the effects of major study variables on the types of responses given by participants, was significant. Follow-up univariate ANCOVAs indicated small to moderate effect sizes for student clinical experience, race/ethnicity, and relationship status within and across scenarios. For example, as number of patients counseled increased, participants used more feeling reflections and fewer self-involving statements. There were no significant differences in responses due to empathy tendency or affect tolerance. Most common responses were information provision and feeling reflections for the Anger scenario, information provision for the Fear scenario, and influencing responses for the Sadness scenario. Responses to each scenario typically involved multiple thoughts (range: 1-14; means ranged from 3.25 in the Sadness scenario to 3.62 in the Fear scenario). Most students (82%) reported the Anger scenario was the most difficult. Thematic analysis of reasons a scenario was difficult yielded four themes: Discomfort with situation/emotion, Positive countertransference, Uncertain how to respond, and Negative countertransference. Findings that clinical experience affects how participants responded to patient affect support the essential role of applied experience. Findings also support training and supervision to help genetic counseling students in North America learn ways to respond to strong patient emotions and recognize and manage countertransference.

Exploring the Impact of Maternal and Paternal Acceptance on Adolescent Girls' Emotion Regulation.

Maternal acceptance is associated with youth emotion regulation (a correlate of depression among adolescent girls); however, less is known about the impact of fathers. In this prospective study, we examined effects of maternal and paternal acceptance on youth sadness inhibition (a facet of emotion dysregulation) among adolescent girls (n = 82; Mage = 13.28; 43% from minoritized racial/ethnic groups) over 1 year. Youth varied on depression risk, which was assessed via clinical diagnostic interviews. Bivariate results showed that maternal acceptance was associated with lower youth sadness inhibition at baseline and 1-year follow-up, while paternal acceptance was only associated with lower youth sadness inhibition at 1-year follow-up. Step-wise regressions showed that paternal acceptance was inversely associated with youth sadness inhibition over time, above and beyond effects of youth age, baseline sadness inhibition, depression risk, and maternal acceptance. Findings highlight the importance of examining both mothers' and fathers' impact on adolescent girls' development of emotion regulation.

Affective Dynamics and Mean Levels of Preschool Irritability and Sadness: Predictors of Children's Psychological Functioning Two Years Later.

Although irritability and sadness are cardinal symptoms of depression, they are also common in preschoolers. The daily experiences of these emotions are not well-understood during early childhood, yet may provide insight into identification of early depressive symptoms. The current longitudinal study examined daily mean levels and emotion dynamics of preschool-aged children's irritability and sadness and psychiatric outcomes in early school-age. Parents (n = 291) completed 14 consecutive daily diaries about their preschoolers' emotions. Two years later, parents (n = 164) completed a semi-structured clinical interview and questionnaires about their children's psychological functioning. Strong correlations between mean and dynamic measures (rs = 0.65-0.91) were identified. Preschoolers' mean daily levels and dynamics of irritability (variability, instability, inertia) and sadness (instability, inertia) predicted symptoms and impairment 2 years later. Sadness instability and inertia continued to predict difficulties after adjusting for mean daily sadness. Fine-grained daily measures of preschoolers' affect may be help identify children at-risk for psychological problems.

Interactive Effects of Coping Strategies and Emotion Dysregulation on Risk for Peer Victimization.

The aim of the current longitudinal study was to examine the interactive effects of six common coping strategies (i.e., adult support seeking, friend support seeking, problem solving, humor, passive coping, and cognitive distancing) and emotion (i.e., anger and sadness) dysregulation on concurrent levels and subsequent trajectories of peer victimization over a 2-year period. Participants were 287 predominantly Caucasian students (53.7% boys; ages 6-9) from an elementary school located in the Midwestern United States. Self-reported coping strategies and emotion dysregulation were assessed at baseline; children also provided ratings of peer victimization annually over a 2-year period. Results indicated that the effectiveness of particular coping strategies may depend on children's overt, undercontrolled displays of anger and sadness. Consistent with recent recommendations, these findings suggest that some youth may require interventions that focus on both enhancing emotion regulation skills and teaching strategies for responding to peer victimization in a more adaptive manner.

PDSTD - The Portsmouth Dynamic Spontaneous Tears Database.

The vast majority of research on human emotional tears has relied on posed and static stimulus materials. In this paper, we introduce the Portsmouth Dynamic Spontaneous Tears Database (PDSTD), a free resource comprising video recordings of 24 female encoders depicting a balanced representation of sadness stimuli with and without tears. Encoders watched a neutral film and a self-selected sad film and reported their emotional experience for 9 emotions. Extending this initial validation, we obtained norming data from an independent sample of naïve observers (N = 91, 45 females) who watched videos of the encoders during three time phases (neutral, pre-sadness, sadness), yielding a total of 72 validated recordings. Observers rated the expressions during each phase on 7 discrete emotions, negative and positive valence, arousal, and genuineness. All data were analyzed by means of general linear mixed modelling (GLMM) to account for sources of random variance. Our results confirm the successful elicitation of sadness, and demonstrate the presence of a tear effect, i.e., a substantial increase in perceived sadness for spontaneous dynamic weeping. To our knowledge, the PDSTD is the first database of spontaneously elicited dynamic tears and sadness that is openly available to researchers. The stimuli can be accessed free of charge via OSF from https://osf.io/uyjeg/?view_only=24474ec8d75949ccb9a8243651db0abf .

Sports- or Physical Activity-Related Concussions and Feelings of Sadness or Hopelessness Among U.S. High School Students: Results From the 2017 Youth Behavior Risk Survey.

For this study, we explored the association between high school students' reported history of sport- or physical activity-related concussions and persistent feelings of sadness or hopelessness. Data from the 2017 national Youth Risk Behavior Survey (YRBS; N = 14,765) was used for this analysis. YRBS is administered to high school students throughout the country every 2 years. Findings from this study demonstrate that the prevalence of persistent feelings of sadness or hopelessness was 36.4% among students who reported sustaining one or more concussions. Compared to students who did not report having sustained a concussion, the odds of persistent feelings of sadness or hopelessness were significantly higher among students who had sustained one or more concussions (AOR = 1.41). These findings support the need for continued efforts by school nurses and other health care providers to identify students with a history of concussion and assess their mental health needs.

Children experiencing sadness: Coping strategies and attachment relationships.

This study aimed to explore the events which are sources of sadness for children, and their coping strategies for overcoming their sadness according to their attachment security. We expected that distinct clusters would emerge, with securely attached children more likely showing constructive and successful coping strategies than insecurely attached children. Middle-class children (N = 191) aged 7-11 years old from four private elementary schools were asked to talk about a sad event they experienced using open-ended questions from the Sadness Interview. The answers were coded into different categories of sad events and associated coping strategies. Finally, children were assessed on their security attachment using the Security Scale. Cluster analyses identified a four-cluster solution. Children in the Clusters 1 and 2 were characterized by a perceived successful constructive coping strategy while describing minor events (in the first Cluster), and very painful events (in the second). Furthermore, in the third Cluster children overcame sad events using a perceived successful disengagement coping strategy, whereas children in the fourth Cluster are characterized by perceived unresolved sadness. ANCOVA testing showed that children in the first cluster had significantly higher attachment security compared to Clusters 3 and 4, which did not significantly differ from each other. The study of sadness in children may be particularly informative for clinicians and educators for understanding and supporting children's strategies of sadness management while considering the influence of their attachment relationships on their ability to cope with sadness.

The physiological signature of sadness: A comparison between text, film and virtual reality.

Studies focused on the ubiquitous emotion of sadness demonstrate substantial variability in physiological responses during sadness elicitation, with no consensus regarding the physiological pattern of sadness. Variability in findings could be attributed to (a) the use of different induction techniques across studies or (b) the existence of subtypes of sadness with distinct physiological activation patterns. Typically, studies have used text and film to elicit sadness. However, virtual reality (VR) confers advantages over more traditional methods by allowing individuals a subjective sense of "being there" or presence. We compared participants' physiological responses to the same narrative presented via VR, Film and Story (n = 20 each) and collected their subjective responses to the stimuli. Results confirmed that participants in all conditions experienced the discrete emotion of sadness. Moreover, participants in the VR condition experienced the highest degree of presence. Regarding psychophysiological responses, participants in the VR condition had the lowest degree of baseline-adjusted parasympathetic activation in comparison to participants in the Film condition. Furthermore, while participants in the VR group showed diminished baseline-adjusted respiration rate and parasympathetic activation with an increase in presence, the opposite pattern was true for participants in the other conditions. The data suggest that the VR condition may elicit an activating pattern of sadness; whereas Film and Story conditions may elicit a deactivating pattern of sadness. Our results have implications for research using the discrete model of emotion, highlighting that different emotion elicitation techniques may result in differing expressions of what is considered a unitary emotion.

Do emotions predict eating? The role of previous experiences in emotional eating in the lab and in daily life.

Emotional eating is defined as an increase in eating following negative emotion. Self-reported emotional eating has been associated with physical health concerns. However, experimental and daily diary studies indicate that induced or naturally experienced negative emotions do not reliably lead to increased eating behavior in people without eating disorders, not even among self-professed emotional eaters. Emotional eating may depend on associations people have made between specific emotions and eating. We describe a set of studies with the overarching goal of determining whether accounting for the variation in people's associations between eating and different discrete emotions is the key to observing emotional eating. In both Study 1 (N = 118) and 2 (N = 111), we asked people to report on their tendency to eat following sadness and anxiety and determined how much they ate when induced to feel sad or anxious in the lab (Study 1) or experiencing these emotions in daily life (Study 2). We found no support for our hypotheses in either study; self-professed sad- or anxious-eaters did not eat more when induced to experience these emotions in the lab, or when experiencing these emotions in daily life. Thus, accounting for the variation in people's associations between eating and two discrete emotions, sadness and anxiety, is not the key to observing sad or anxious eating behavior in the lab or in daily life. Preregistration, materials, data, and code: https://osf.io/kcqej/ (Study 1) and https://osf.io/3euvg/ (Study 2).

Delayed reduction of Anaplasma marginale parasitemia and packed cell volume normalization despite prolonged enrofloxacin treatment of cattle co-infected with Trypanosoma vivax.

Although co-infections of Trypanosoma vivax, Anaplasma spp., and Babesia spp. have been reported, knowledge gaps remain that need to be addressed. The present study evaluated the efficacy of enrofloxacin (7.5 mg/kg) against A. marginale in naturally infected cattle and cattle experimentally co-infected with T. vivax by observation of the variation in A. marginale parasitemia and packed cell volume (PCV) for 39 days. Bovines were distributed into two groups, each with six calves: T01 = animals immunosuppressed with dexamethasone and with latent anaplasmosis; T02 = animals immunosuppressed with dexamethasone, with latent anaplasmosis and experimentally co-infected with T. vivax on day 0 (D0). Animals of both groups were immunosuppressed with dexamethasone and received enrofloxacin (7.5 mg/kg) whenever mean values of parasitemia for A. marginale were ≥ 5% per group. Cattle of group T02 were also treated with isometamidium chloride (0.5 mg/kg) on D25. On D17 and D22 to D28 of the study, there was a higher (P ≤ 0.05) A. marginale parasitemia in animals of T02 than in those of T01. Animals of T01 required one enrofloxacin treatment to decrease A. marginale parasitemia, while those from T02 needed five treatments. From D5 to D37 of study, the mean values of PCV for calves from T02 were lower (P ≤ 0.05) than that for calves from T01. In conclusion, bovines co-infected T. vivax needed four more treatments with enrofloxacin to reduce A. marginale parasitemia and keep PCV values within reference standards.

Association of Spontaneous and Induced Self-Affirmation With Smoking Cessation in Users of a Mobile App: Randomized Controlled Trial.

BACKGROUND: Most smokers attempt to stop using cigarettes numerous times before successfully quitting. Cigarette cravings may undermine perceived competence to quit and thus constitute psychological threats to the individual's self-concept. Self-affirmation may promote smoking cessation by offsetting these threats. OBJECTIVE: This study examines whether self-affirmation is associated with smoking cessation in the context of a cessation app. Two types of self-affirmation are examined: tendency to spontaneously self-affirm, and self-affirmation inductions added to a publicly available smoking cessation app (Smoke-Free Quit Smoking Now). In addition, this study explores whether optimism and emotional states (happiness, anger, anxiousness, hopefulness, sadness) predict smoking cessation. METHODS: All users who met the inclusion criteria, provided consent to participate, and completed a baseline assessment, including all individual difference measures, were randomized to 1 of 4 conditions. Half of the participants were randomly assigned to complete a self-affirmation induction upon study entry. Orthogonally, half of the participants were randomly assigned to receive self-affirming text notifications during their quit attempt or to receive conventional notifications. The induction and the text notifications were fully automated, and all data were collected through self-assessments in the app. Self-reported smoking cessation was assessed 1 month and 3 months following study entry. RESULTS: The study enrolled 7899 participants; 647 completed the 1-month follow-up. Using an intent-to-treat analysis at the 1-month follow-up, 7.2% (569/7899) of participants self-reported not smoking in the previous week and 6.4% (503/7899) self-reported not smoking in the previous month. Greater tendency to spontaneously self-affirm predicted a greater likelihood of cessation (P<.001) at 1 month after controlling for smoking-related variables. Neither self-affirmation induction influenced cessation. In addition, spontaneous self-affirmation did not moderate the relationship between self-affirmation inductions and cessation. Greater baseline sadness was associated with a lower likelihood of reporting successful cessation. Optimism predicted past-week cessation at the 1-month follow-up, and both happiness and anger predicted past-month cessation at the 1-month follow-up; however, none of these potential predictors moderated the relationship between self-affirmation conditions and successful cessation. CONCLUSIONS: Spontaneous self-affirmation may be an important psychological resource for managing threats to self-concept during the smoking cessation process. Sadness may hinder quit attempts. Future research can explicate how spontaneous versus induced self-affirmation can promote smoking cessation and examine boundary conditions for the effectiveness of disseminated self-affirmation interventions. TRIAL REGISTRATION: ISRCTN Registry 56646695; https://www.isrctn.com/ISRCTN56646695.