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At present time, on the basis of genome-wide association studies (GWAS), several authors found linkage of phobic disorders with certain regions of chromosomes – 3q26 (agoraphobia), 14q13 (specific phobias), 16q21 (social phobias), 16q22 (social phobias) and 4q31-q34 (phobic disorders). We propose 19 genes that are localized in these regions and are expressed in the brain: PRKCI, CLDN11, EIF5A2, TNIK, CLCN3, CPE, GLRB, GRIA2, NEK1, NPY2R, NPY5R, RAPGEF2, TRIM2, SMAD1, ADGRG1, BEAN1, CDH8, DOK4 and KATNB1. Therefore, these genes may be investigated as candidate genes of phobic disorders. Various sources propose 26 potential candidate genes of phobic disorders. Finnish geneticist J. Donner carries out a meta-analysis to study the 8 most probable among them and corroborates statistical validity only for 4 genes: ALAD, CDH2, EPB41L4A and GAD1. First three genes are involved in the social phobias, and fourth is involved in whole phobic disorders. Phobias are heterogeneous and multifactorial diseases. To understand the biological mechanisms of such disorders, to create effective methods for their prevention and treatment, there are needed further intensive molecular genetic studies of these disorders on sufficiently large samples and corroborating these results by other authors.

There is a growing concern amongst patients about topical corticosteroid (TCS) side effects, with increasing discussion of topical steroid addiction (TSA) and topical steroid withdrawal (TSW) particularly on social media platforms. However, the acceptance of TSA/TSW as a distinct condition remains controversial within the dermatological community. We conducted a literature search using PubMed, MEDLINE, Cochrane Library, Google Scholar, Embase and Web of Science to identify original articles addressing TSA/TSW. We described the definition and reported clinical features of TSA/TSW including its classification into erythemato-edematous and papulopustular subtype. To assess the validity of TSA/TSW, we summarised and objectively appraised the postulated mechanisms for this condition, including tachyphylaxis, dysregulation of glucocorticoid receptors, rebound vasodilation and impaired skin barrier leading to a cytokine cascade. Understanding the evidence including its limitations and uncertainties highlights areas for future research and helps medical practitioners better counsel and provide care to patients who may be experiencing or who have concerns about TSA/TSW.

Objectives To evaluate the influence of audio-guided self-hypnosis on claustrophobia in a high-risk cohort undergoing magnetic resonance (MR) imaging. Methods In this prospective observational 2-group study, 55 patients (69% female, mean age 53.6 ± 13.9) used self-hypnosis directly before imaging. Claustrophobia included premature termination, sedation, and coping actions. The claustrophobia questionnaire (CLQ) was completed before self-hypnosis and after MR imaging. Results were compared to a control cohort of 89 patients examined on the same open MR scanner using logistic regression for multivariate analysis. Furthermore, patients were asked about their preferences for future imaging. Results There was significantly fewer claustrophobia in the self-hypnosis group (16%; 9/55), compared with the control group (43%; 38/89; odds ratio .14; p = .001). Self-hypnosis patients also needed less sedation (2% vs 16%; 1/55 vs 14/89; odds ratio .1; p = .008) and non-sedation coping actions (13% vs 28%; 7/55 vs 25/89; odds ratio .3; p = .02). Self-hypnosis did not influence the CLQ results measured before and after MR imaging (p = .79). Self-hypnosis reduced the frequency of claustrophobia in the subgroup of patients above an established CLQ cut-off of .33 from 47% (37/78) to 18% (9/49; p = .002). In the subgroup below the CLQ cut-off of 0.33, there were no significant differences (0% vs 9%, 0/6 vs 1/11; p = 1.0). Most patients (67%; 35/52) preferred self-hypnosis for future MR examinations. Conclusions Self-hypnosis reduced claustrophobia in high-risk patients undergoing imaging in an open MR scanner and might reduce the need for sedation and non-sedation coping actions. Key Points • Forty percent of the patients at high risk for claustrophobia may also experience a claustrophobic event in an open MR scanner. • Self-hypnosis while listening to an audio in the waiting room before the examination may reduce claustrophobic events in over 50% of patients with high risk for claustrophobia. • Self-hypnosis may also reduce the need for sedation and other time-consuming non-sedation coping actions and is preferred by high-risk patients for future examinations.

The purpose of the study was to summarize data from foreign studies about the use of virtual reality (VR) technology in the treatment of patients with various mental disorders.Materialsandmethods:we selected and analyzed articles from MEDLINE / PubMed databases during the period from 2000 till 2020, as well as relevant references in the bibliography of the analyzed articles. 45 articles were included in further analysis from 575 English-language articles.Results:The use of VR technologies in the treatment of mental disorders appears to be one of the promising directions in psychiatry. The successfulness of these methods in patients with eating disorders, anxiety-phobic disorders, and obsessive-compulsive disorder is supported to be evidentiary information. There is evidence of the effectiveness of such methods in patients with schizophrenia, particularly, one of the most significant results is an increase in social functioning. The absence of side effects data makes it possible to consider t VR therapy as a safe method. It is needed to make further study the areas of application of VR therapy and conduct research to identify possible side effects of this method.Conclusion: The obtained results are important for drawing attention to the prospect of using VR technologies in Russian psychiatry and demonstrate the need for further study of this method.

Aims Medical procedures and hospitalizations can be experienced as traumatic and can lead to post-traumatic stress reactions. Eye movement desensitization and reprocessing (EMDR) shows promising results but very few long-term studies have been published. Therefore, our aim was to test the long-term (8 months post-treatment) effectiveness of EMDR in children and adolescents with medically related subthreshold post-traumatic stress disorder (PTSD). Methods and results Seventy-four children (including 39 with congenital or acquired heart disease) aged 4–15 (M = 9.6 years) with subthreshold PTSD after previous hospitalization were included into a parallel group randomized controlled trial. Participants were randomized to EMDR (n = 37) or care-as-usual (CAU) (n = 37; medical care only). The primary outcome was PTSD symptoms of the child. Secondary outcomes were symptoms of depression and blood–injection–injury (BII) phobia, sleep problems, and health-related quality of life (HrQoL) of the child. Assessments of all outcomes were planned at baseline and 8 weeks and 8 months after the start of EMDR/CAU. We hypothesized that the EMDR group would show significantly more improvements on all outcomes over time. Both groups showed improvements over time on child’s symptoms of PTSD (only parent report), depression, BII phobia, sleep problems, and most HrQoL subscales. GEE analyses showed no significant differences between the EMDR group (nT2 = 33, nT3 = 30) and the CAU group (nT2 = 35, nT3 = 32) on the primary outcome. One superior effect of EMDR over time was found for reducing parent-reported BII phobia of the child. Conclusion EMDR did not perform better than CAU in reducing subthreshold PTSD up to 8 months post-treatment in previously hospitalized children. Possible explanations and clinical implications are discussed.

Amaç: Araştırma, Sağlık Hizmetleri Meslek Yüksekokulu’nda eğitim gören öğrencilerin nomofobi ile kaygı düzeyleri arasındaki ilişkiyi incelemektir. Yöntem: Çalışma tanımlayıcı niteliktedir. Araştırma evrenini Sağlık Meslek Yüksekokulu’nda (SHMYO) eğitim gören öğrenciler oluşturmaktadır. Örneklem seçimine gidilmemiş olup, araştırmaya alınma kriterlerini taşıyan öğrenciler (n=1299) oluşturmaktadır. Bulgular: Akıllı telefon kullanımı ile ilgili sorulan sorulardan günde 5 saatten fazla telefonunu kullananların %45,3, gün içinde 40’tan fazla ekrana bakanların %32,2, sabah uyanır uyanmaz telefonunu kontrol edenlerin %54,3, yatmadan hemen önce bakanların ise %56,4 oranında olduğu saptanmıştır. Telefon kullanma nedeni olarak en fazla sosyal medya, en az ise alışveriş yapma tercih edilmiştir. Öğrencilerin %41,3’ü bağımlı olduğunu düşünürken, %63’ü telefonunu herhangi bir yerde unuttuğunu, %69,3’ü ise telefonu unuttuğunda kaygı yaşadığını belirtmiştir. Öğrencilerin Nomofobi Ölçeği toplam puan ortalaması 84,31±29,01, Durumluk Kaygı Ölçeği toplam puan ortalaması 44,22±11,37 ve Süreklilik Kaygı Ölçeği toplam puan ortalaması 46,39±9,58’dir. Nomofobinin kesme noktalarına göre değerlendirildiğinde Durumluk-Süreklilik Kaygı Ölçeği arasında anlamlı fark olduğu saptandı (p, Objective: The aim of the study was to investigate the relationship between nomophobia and the level of anxiety of undergraduate health sciences students.Method: Descriptive and correlational research design was used in the study. A Convenience sampling method was used for selection. Student volunteers (n = 1299) who met the study criteria were included in the study. Results: Of the students, 45.3% reported using smartphones for more than 5 hours a day. 32.2% reported checking their phones for more than 40 times a day. 54.3% indicated checking their phones first thing in the morning and 56.4% right before going to bed. The most common reason for using the phone was to access social media and the least common reason was shopping. 41.3% of the students thought that they had smartphone dependency. 63% of them said they have forgotten their phones somewhere at some point. 69.3% of the students reported feeling anxious due to forgetting their phones at some place. The mean score of the students for the Nomophobia Scale was 84.31±29.01, the mean score of the State Anxiety Scale was 44.22±11.37 and the mean score of the Trait Anxiety Scale was 46.39±9.58. The results of the study indicated that there was a significant relationship between nomophobia and anxiety (p

Objective: The Coronavirus Disease-2019 (COVID-19) has recently been identified as a pandemic by the World Health Organization. The outbreak of the disease has caused numerous individuals around the world to become extremely frightened and subsequently present the signs of phobia. Fear is the basic emotion of anxiety disorders and individuals cope with their emotions by different strategies. The present study aimed at developing and validating Emotion Regulation Strategies for Germophobia Questionnaire (ERS-GPQ). Methods: The study participants were 99 individuals (74 females) of the Iranian population with concerns about germs who were selected with the snowball sampling method. They completed the ERS-GPQ and GPQ in the Google Forms platform. Results: The present study results illustrated that the ERS-GPQ has acceptable internal consistency with Cronbach’s alpha coefficient (a=0.61), reliability coefficients with split-half (0.70), and one-week test-retest (0.92); the ERS-GPQ also presented a moderate positive correlation with the contamination obsessions checklist of GPQ (r=0.44) as the convergent coefficient. Besides, the confirmatory factor analysis indicated 2 factors of the ERS-GPQ. Finally, the ERS-GPQ has 2 components with good convergent and discriminate validities and composite reliability. Conclusion: Based on the current research findings, the ERS-GPQ has acceptable and good psychometric properties; researchers can use the ERS-GPQ as a reliable and valid instrument for assessing ER strategies concerning germophobia. Furthermore, it has some considerations for practitioners in epidemic and pandemic crises, like COVID-19.

Purpose Life satisfaction refers to a cognitive and global evaluation of the quality of one’s life as a whole. The arguably most often used measure of life satisfaction is the Satisfaction With Life Scale (SWLS). Persons with mental disorders generally report lower SWLS scores than healthy controls, yet there is a lack of studies that have compared different diagnostic groups, tested measurement invariance of the SWLS across these groups, and examined effects of treatment on life satisfaction. Methods Data of 9649 inpatients of seven diagnostic categories were analyzed: depressive episode, recurrent depressive disorder, phobic disorders, obsessive-compulsive disorder, trauma-related disorders, somatoform disorders, and eating disorders. Results The one-factor structure of the SWLS was replicated and full measurement invariance was demonstrated across groups. Patients with trauma-related disorders reported the lowest life satisfaction. Life satisfaction significantly increased during treatment across all groups and these changes were moderately related to changes in depressive symptoms. Conclusions Results support the excellent psychometric properties of the SWLS. They also demonstrate that although persons with mental disorder generally report lower life satisfaction than persons without mental disorders, life satisfaction also varies considerably between different diagnostic groups. Finally, results show that life satisfaction increases during inpatient treatment, although at discharge most patients have rarely reached levels of life satisfaction reported in non-clinical samples.

Objective: An effort currently made to appraise the preliminary phytochemical, pharmacognostic criteria, antioxidant, GCMS and antihyperglycemic investigations of the Thunbergia coccinea leaves. Thunbergia coccinea (T. coccinea) is an ornamental plant considerably practiced by the tribes of forest areas of Assam (INDIA) as an analgesic, antipyretic, anti-inflammatory, antidote, hepatoprotective, antidiabetic and detoxificant substance. Methods: A comprehensive literature survey was conducted to recognize the ethnomedicinal value of T. coccinea, which is currently grown practically in all provinces. The physicochemical constants like moisture content, ash values especially total ash, insoluble acid ash, water-soluble ash and foreign organic matter were determined for the assessment of the drug. Pharmacognostic parameters like fluorescence examination and microscopic characters of the leaf were studied that would serve to verify for contamination. The extract secured by maceration was subjected to the phytochemical inquiry to determine the existence of substances and their antioxidant activity. The antihyperglycemic characteristic of alcoholic extract of the leaf was examined with the inhibition of α-amylase and α-glucosidase enzymes. Gas Chromatography-Mass Spectrometry (GCMS) studies of alcoholic extract of the plant leaf have undertaken to get an insight into the therapeutic properties of the molecules present based on online PASS prediction. Results: Various physicochemical, microscopic parameters studied gave a clear distinguishing and identifying features of T. coccinea leaf. Phytochemical screening gave an insight into the secondary metabolites existing in the plant leaf through picturizing its therapeutic properties against various ailments. Both extracts of T. coccinea leaf showed enhanced antioxidant activities. Nevertheless, the alcoholic leaf extract has shown significant antioxidant activity with an IC50 of 171.38±2.51 μg/ml and AQTC an IC50 value of 206.29±4.5 μg/ml respectively by DPPH method. Further, ACTC showed a better-reducing potential with an IC50 value of 105.74±0.61 μg/ml in comparison with AQTC IC50 value of 203.702±0.97 μg/ml by FRP method. The inhibition potentiality of α-amylase and α-glucosidase was found to be 71.66 % and 83.74 %, respectively at 500 µg/ml that rationally an adequate remedy in the treatment of type-2 diabetes. GCMS studies of the alcoholic extract unveiled the presence of different molecules like Glycerol, tris (trimethylsilyl) ether, 3,7,11,15-Tetramethyl-2-hexadecen-1-ol, Undecanoic acid, Ethyl ester, Phytol in comparison with NIST library, thereby giving its predicted therapeutic properties like sugar phosphatase inhibitor, antifungal, phobic disorders treatment, antiviral and so on. Conclusion: The selected plant had many proven therapeutic traits and, possibly, successively united on to the sort of potential therapeutic plants. Besides, isolation and discoveries will lead to the detection of certain novel compounds, which will be of potential medicinal value.

Obsessive-compulsive disorder (OCD) is a prevalent mental disorder characterized by intrusive thoughts (obsessions) and ensuing rituals (compulsions). Although OC patients exhibit various cognitive and behavioral problems, rigid and hypersensitive moral judgments are known to be one of the most striking problems in these patients. There is evidence indicating that OC patients often tend to make deontological judgments in moral dilemmas, significantly more than the healthy population. Therefore, numerous studies are dedicated to understanding the underlying cognitive processes responsible for such variation of moral judgments in OCD, which are reviewed and discussed in the current paper. First, it is previously discussed that abnormal moral judgments in OCD are due to executive dysfunctions. These dysfunctions include impaired cognitive control resulting in the domination of strong, uncontrolled emotional responses, impaired cognitive flexibility resulting in the inability to switch between aspects of a scenario, and decreased capacity and overload of working memory and its inability to resist the interfering information. The dual-process theory also emphasizes and acknowledges the role of executive functions in moral judgments. Second, it is thought that disobeying moral norms results in the abnormal feeling of deontological guilt in OC patients, to which these patients are highly sensitive. Feeling of guilt is also thought to be correlated with OCD symptomatology. The third impairment contributing to abnormal moral judgments in OCD is known to be the abnormal feeling of disgust for moral violations and immoral unwanted intrusive thoughts, which is regarded as one of the major causes of OCD symptoms. Finally, the abnormal fear of responsibility and being criticized due to not acting morally is regarded as one of the primary impairments contributing to the abnormal moral judgments in OCD. In conclusion, this review sheds light on the most striking cognitive and affective impairments contributing to abnormal moral judgments in OCD.

Purpose of review To present evidence of a functional interrelation between the vestibular and the anxiety systems based on a complex reciprocally organized network. The review focuses on the differential effects of various vestibular disorders, on psychiatric comorbidity, and on anxiety related to vertigo. Recent findings Episodic vertigo syndromes such as vestibular migraine, vestibular paroxysmia, and Meniere's disease are associated with a significant increase of psychiatric comorbidity, in particular anxiety/phobic disorders and depression. Chronic unilateral and bilateral vestibulopathy (BVP) do not exhibit a higher than normal psychiatric comorbidity. Anxiety related to the vertigo symptoms is also increased in episodic structural vestibular disorders but not in patients with chronic unilateral or bilateral loss of vestibular function. The lack of vertigo-related anxiety in BVP is a novel finding. Several studies have revealed special features related to anxiety in patients suffering from BVP: despite objectively impaired postural balance with frequent falls, they usually do not complain about fear of falling; they do not report an increased susceptibility to fear of heights; they do not have an increased psychiatric comorbidity; and they do not report increased anxiety related to the perceived vertigo. Subtle or moderate vestibular stimulation (by galvanic currents or use of a swing) may have beneficial effects on stress or mood state in healthy adults, and promote sleep in humans and rodents. The intimate structural and functional linkage of the vestibular and anxiety systems includes numerous nuclei, provincial and connector hubs, the thalamocortical network, and the cerebellum with many neural transmitter systems. Summary The different involvement of emotional processes and anxiety - to the extent of 'excess anxiety' or 'less anxiety' - in structural vestibular disorders may be due to the specific dysfunction and whether the system activity is excited or diminished. Both psychiatric comorbidity and vertigo-related anxiety are maximal with excitation and minimal with loss of peripheral vestibular function.

Extinction learning is assumed to represent a core mechanism underlying exposure therapy. Empirical evaluations of this assumption, however, are largely lacking. The current study investigated whether neural activations and self-report outcomes during extinction learning and extinction recall could specifically predict exposure therapy response in specific phobia. In this double-blind randomized controlled trial, individuals with spider phobia (N = 45; female/male = 41/4) were on group basis randomly allocated to exposure therapy (n = 25; female/male = 24/1) or progressive muscle relaxation (PMR; n = 20; female/male = 17/3). Intervention effects were measured with the Fears of Spiders questionnaire. Participants also underwent a three-day fear conditioning, extinction learning, and extinction recall paradigm during functional magnetic resonance imaging at baseline. Extinction outcomes were self-reported fear and threat expectancy, and neural responses during conditioned stimulus processing and during extinction-related prediction errors (US omissions) in regions of interest (ventromedial prefrontal cortex (vmPFC) and nucleus accumbens). Results showed that exposure therapy resulted in stronger symptom reductions than PMR (Cohen's d = 0.90). Exposure therapy response was specifically predicted by prediction-error related vmPFC activation during early extinction. There were also indications vmPFC activations during conditioned safety stimulus processing at early extinction predicted therapy outcome. Neural activations during extinction recall and self-report data did however not predict therapy outcome. These findings indicate that exposure therapy may rely on neural extinction learning processes. Prediction errors are thought to drive the extinction learning process, and prediction error-related vmPFC activation specifically predicted therapy outcome. The extent to which vmPFC processes safety signals may additionally be predictive of exposure therapy response, but the specificity is less clear.

Objective Cannabidiol (CBD) has a proposed novel role in the management of anxiety owing to its actions on the endocannabinoid system. The purpose of this systematic review was to evaluate the current evidence on the safety and efficacy of CBD in anxiety and anxiety-related disorders. Data sources A literature search was conducted on PubMed, Google Scholar, and International Pharmaceutical Abstracts from database inception through June 2019. A bibliographic search of relevant articles was also conducted. Study selection Articles published from case reports, case series, or randomized controlled trials on human subjects were included in the review if they examined the safety and efficacy of CBD therapy in anxiety and anxiety-related disorders. Data extraction Two reviewers independently extracted the following data from the articles: year of publication; study design; patient characteristics (sex; type of anxiety disorder; use of concomitant anxiolytic therapy); dosing strategy and route of CBD administration; and safety and efficacy outcomes. Results Eight articles were included in the review: 6 small, randomized controlled trials; 1 case series; and 1 case report. These studies examined the role of CBD in the anxiety response of healthy volunteers; in generalized anxiety disorder; in social anxiety disorder; and in the anxiety component of posttraumatic stress syndrome. No articles that evaluated CBD in panic disorder, specific phobia, separation anxiety, and obsessive-compulsive disorder were identified. In the studies, CBD was administered orally as a capsule or as a sublingual spray and as either monotherapy or adjunctive therapy. Doses varied widely, with studies employing fixed CBD doses ranging from 6 mg to 400 mg per dose. Various anxiety assessment scales were used in the studies to assess efficacy, with CBD demonstrating improved clinical outcomes among the instruments. In general, CBD was well-tolerated and associated with minimal adverse effects, with the most commonly noted adverse effects being fatigue and sedation. Conclusion CBD has a promising role as alternative therapy in the management of anxiety disorders. However, more studies with standardized approaches to dosing and clinical outcome measurements are needed to determine the appropriate dosing strategy for CBD and its place in therapy.

Even with the technical-scientific advance in Dentistry, it is still seen as a profession that causes anxiety in children and adults. Therefore, in addition to the technical knowledge, the dental surgeon must have different strategies in the management and conduct of this situation once anxiety if aggravated can become pathological and interfere in the patient's oral health and his or her quality of life. Thus, the present study was conducted in order to realize the main aspects of dental anxiety, aiming to improve patient-dentist relationship, avoiding the onset of phobic disorders. This is an integrative review of the literature, using the Lilacs and SciELO databases with the descriptors anxiety, phobia and dentist verified individually and later they were crossed with AND operator with search period from 2000 to 2019, articles in Portuguese and in fulltext. The exclusion criteria were: thesis, books, final paper and dissertations. 20 articles were identified which showed that anxiety directly interferes with the effectiveness of treatment in different age groups. Priority should be given to communication between the dental surgeon and his or her patient, to recognize possible causes of discomfort. In addition, it is necessary to carry out more studies because there are differences in the literature concerning the interference of social and economic factors and schooling levels in the anxiety development. Keywords: Anxiety. Dentist. Phobia. ResumoMesmo com o avanço técnico-científico na Odontologia, esta ainda é vista como uma profissão que provoca ansiedade em crianças e adultos. Dessa forma, além do conhecimento técnico, o cirurgião-dentista deve possuir estratégias diferenciadas no manejo e na conduta perante esta situação, uma vez que, se agravada, a ansiedade pode torna-se patológica e interferir na saúde bucal do paciente, afetando diretamente sua qualidade de vida. Assim, o presente estudo foi conduzido com intuito de perceber os principais aspectos da ansiedade odontológica, visando aperfeiçoar as relações paciente-dentista, evitando o desencadeamento de transtornos fóbicos. Trata-se de uma revisão integrativa da literatura, utilizando as bases de dados Lilacs e Scielo com os descritores: medo, fobia e dentista, verificados individualamente e posteriormente feito cruzamenento com AND, com período de busca de 2000 a 2019, artigos em portugues e na íntegra. Os critérios de exclusão foram: teses, livros, trabalhos de conclusão de cursos e dissertações. Foram identificados 20 artigos que evidenciaram que a ansiedade interfere diretamente na efetividade do tratamento em diferentes faixas etárias, devendo-se priorizar a comunicação entre o cirurgião-dentista e seu paciente, para reconhecer possíveis causas de desconforto. Porém, é necessário realizar mais estudos devido as divergências na literatura referente a interferência de fatores sociais, econômicos e níveis de escolaridade, no desenvolvimento da ansiedade. Palavras-chave: Ansiedade. Dentista. Fobia.

About 1–2% of people of European origin have red hair. Especially female redheads are known to suffer higher pain sensitivity and higher incidence of some disorders, including skin cancer, Parkinson’s disease and endometriosis. Recently, an explorative study performed on 7,000 subjects showed that both male and female redheads score worse on many health-related variables and express a higher incidence of cancer. Here, we ran the preregistered study on a population of 4,117 subjects who took part in an anonymous electronic survey. We confirmed that the intensity of hair redness negatively correlated with physical health, mental health, fecundity and sexual desire, and positively with the number of kinds of drugs prescribed by a doctor currently taken, and with reported symptoms of impaired mental health. It also positively correlated with certain neuropsychiatric disorders, most strongly with learning disabilities disorder and phobic disorder in men and general anxiety disorder in women. However, most of these associations disappeared when the darkness of skin was included in the models, suggesting that skin fairness, not hair redness, is responsible for the associations. We discussed two possible explanations for the observed pattern, the first based on vitamin D deficiency due to the avoidance of sunbathing by subjects with sensitive skin, including some redheads, and second based on folic acid depletion in fair skinned subjects, again including some (a different subpopulation of) redheads. It must be emphasized, however, that both of these explanations are only hypothetical as no data on the concentration of vitamin D or folic acid are available for our subjects. Our results, as well as the conclusions of current reviews, suggest that the new empirical studies on the concentration of vitamin D and folic acids in relation to skin and hair pigmentation are urgently needed.

Objective Iatrophobia – fear of doctors, medical care, or the medical care system – is common among patients and can negatively impact their health-seeking behaviors and relationships with health care professionals. Despite this, academic literature on iatrophobia often fails to explore its nuanced causes. Methods We establish a conceptual framework of iatrophobia, categorizing sources of fear that may create barriers to accessing medical care, and recommend a research agenda to address this phenomenon and understand its role in medical care. Results The framework includes three categories of determinants of iatrophobia: patient fear of illness and the medical exam, patient fear of physician reaction, and patient fear related to barriers to care. These categories represent influences from individual to more system-related factors associated with the physician-patient relationship. Research examining iatrophobia should focus on understanding its prevalence, how patients cope with their fear, discussing iatrophobia in the physician-patient encounter, the sociopolitical contribution to iatrophobia, and how iatrophobia can be reduced. Conclusions Iatrophobia can be categorized into three primary domains, but it remains poorly understood. Practice Implications A more thorough understanding of iatrophobia will help to contextualize its role amid other barriers to care and patient health outcomes.

Importance: Virtual reality in head-mounted displays (HMD-VR) may be a valuable tool in occupational therapy to address anxiety. Findings from the virtual reality exposure therapy (VRET) literature may facilitate translation of HMD-VR to occupational therapy psychosocial practice. Objective: To explore how HMD-VR has been used to treat anxiety through VRET and could be translated to occupational therapy. Data Sources: We searched seven electronic databases for articles published between 2000 and 2020: CINAHL, Cochrane Library, Embase, ERIC, Ovid MEDLINE, PsycINFO, and Web of Science. Search terms included HMD-VR constructs, products, and therapy concepts. Study Selection and Data Collection: We used Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to report studies implementing VRET to treat anxiety. At least two reviewers assessed each citation, and a third resolved disagreements. Articles were included if they were in English, reported experimental data, and used HMD-VR. Letters, commentaries, book chapters, technical descriptions, theoretical papers, conference proceedings (≤4 pages), and reviews were excluded. Findings: Twenty-eight studies used HMD-VR to treat posttraumatic stress disorder (n = 3), specific phobias (n = 19), and performance-based social anxiety (n = 6); protocols and levels of evidence varied (randomized controlled trials, n = 11; controlled trials without randomization, n = 6; case–control or cohort studies, n = 11). Qualitative examination indicates HMD-VR is an effective treatment tool. Conclusions and Relevance: HMD-VR can be a valuable tool for occupational therapy to simulate environments where clients with anxiety disorders participate. Eliciting presence through multisensory features and body representation may enhance outcomes. What This Article Adds: Drawing from the VRET literature, this scoping review suggests that HMD-VR can be used by occupational therapy practitioners to simulate ecologically valid environments, evaluate client responses to fearful stimuli, and remediate anxiety though immersion in virtual tasks when participation in natural contexts is unfeasible. Having ecologically valid environments is particularly important for people with anxiety disorders because they need support to cope when they encounter triggers in everyday life environments.

Case report - Introduction Behçet’s disease (BD) is a systemic inflammatory, variable-vessel vasculitis manifesting most commonly with recurrent oral or genital ulcers and uveitis. The heterogeneous presentation may also include skin, joint, gastrointestinal and central nervous system involvement. There is a geographical prevalence in countries along the “Old Silk Road” and a strong association with HLA-B51 antigen. Paediatric-onset BD commonly has an incomplete clinical picture thereby causing a diagnostic challenge. We present the case of a 10-year-old boy of Lithuanian origin whose history, imaging and results led to a rapid diagnosis which is unusual in the paediatric population. Case report - Case description The patient presented with a 1-month history of abdominal pain, distension and a cough that did not respond to oral antibiotics or inhalers from his GP. His mother recalled swollen proximal interphalangeal joints on both hands, a rash and red eyes approximately 4 days earlier which had now resolved. She also reported mouth ulcers occurring at least once a month from a young age and cold sores without any genital or anal ulcers. He also had a history of reactive arthritis at the age of 3 with bilateral knee swelling and anaemia. He was afebrile, tachycardic with respiratory distress and an oxygen requirement to maintain saturations over 94%. Chest X-ray showed large bilateral pleural effusions and cardiomegaly. Echocardiography confirmed a large pericardial effusion with signs suggestive of tamponade physiology. After admission to PICU he was intubated and sedated to facilitate pericardial and pleural drain insertion. Post-procedure he was haemodynamically stable. Empirical antibiotic therapy was commenced with IV ceftriaxone. Investigations showed a CRP 58mg/L, ESR 37mm/hr, LDH 325U/L, Haemoglobin 98g/L, platelets 223x109 and a blood film showed non-specific changes. All microbiology samples were negative including T spot, mantoux and broncho-alveolar lavage. Serology included negative Anti-Nuclear Antibody, Extractable Nuclear Antigen, double stranded-DNA, and Rheumatoid Factor with normal complements, immunoglobulins and serum amyloid. HLA B51 was reported as positive. Faecal calprotectin was high at 539µg/g Antiphospholipid antibody screen was positive (anticardiolipin antibody 68U/mL, Beta2-glycoprotein 111U/mL). CT demonstrated multiple pulmonary emboli (PE), splenomegaly and moderate volume ascites. Ophthalmology assessment was unremarkable and biopsies taken during oesophago-gastro-duedenoscopy and colonoscopy were normal. He was diagnosed with BD and secondary antiphospholipid syndrome (APS) based on a combination of clinical, radiological and blood markers. Treatment included colchicine as monotherapy, diuretics to manage effusions and dalteparin for the PEs. Case report - Discussion The Consensus Classification of Paediatric Behçet’s Disease (2015) requires 3 out of 6 of the following features to diagnose BD; recurrent oral ulcers, genital ulcers, skin involvement, ocular inflammation, neurological signs and vascular abnormalities. Our patient would score 3 out of 6, thereby meeting criteria for diagnosis. The extensive vascular findings on CT are in keeping with variable vessel vasculitis. Antiphospholipid antibodies including Anticardiolipin (aCL) antibeta- 2 glycoprotein I (B2-GP1) and Lupus anticoagulant (LA) are observed in autoimmune diseases including BD, with around 2% of secondary APS cases on the Ped-APS registry being associated with BD. The frequency of vascular involvement is reported to be 5—20% in paediatric series with deep vein thrombosis (DVT) and superficial vein thrombosis (SVT) being most common. The combination of antibodies and levels are important in assessing risk of thrombosis. There is no difference in the acute treatment of thrombosis attributable to APS as compared to other causes. Current guidelines following thrombosis with persistently positive antiphospholipid antibodies is for long-term coagulation. Children are most commonly transitioned from low molecular weight heparin to warfarin for long-term anticoagulation with a target INR of 2-3 following the first thrombotic event. Direct oral anticoagulants (DOACs) are not currently recommended pending further evidence. Recent studies include an RCT in adults with APS which was halted early due to excessive arterial thrombotic events in the rivaroxaban arm and in another study, rivaroxaban didn’t reach the non-inferiority threshold. However, recent EULAR recommendations regarding APS treatment in adults concluded that DOACs may be considered in certain settings. Colchicine was chosen as initial therapy based on presentation with history of mucocutaneous involvement and arthritis. Despite widespread inflammation there were no ocular or neurological findings suggesting the need for anti-TNF-a as first line therapy. Case report - Key learning points Paediatric BD is still a poorly understood condition and presents diagnostic challenges. This case highlighted the importance of a thorough history including a full systemic enquiry, without which the diagnosis would have been more difficult. Once the effusions were drained and the patient was started on colchicine, his follow up echocardiograms returned to normal and he has only reported one much smaller mouth ulcer in the last 4 months. Uveitis screening has continued without any clinical concerns. At this stage there is no clinical need to progress to second-line treatment. The patient developed significant needle phobia during his intensive care admission, so DOAC therapy was considered for long-term anticoagulation for the APS, given the lack of need for INR monitoring. However, it was decided to continue on warfarin due to the aforementioned international paediatric guidance.

Background Coronavirus currently cause a lot of pressure on the health system. Accordingly, many changes occurred in the way of providing health care, including pregnancy and childbirth care. To our knowledge, no studies on experiences of maternity care Providers during the COVID-19 Pandemic have been published in Iran. We aimed to discover their experiences on pregnancy and childbirth care during the current COVID-19 pandemic. Methods This study was a qualitative research performed with a descriptive phenomenological approach. The used sampling method was purposive sampling by taking the maximum variation possible into account, which continued until data saturation. Accordingly, in-depth and semi-structured interviews were conducted by including 12 participants, as 4 gynecologists, 6 midwives working in the hospitals and private offices, and 2 midwives working in the health centers. Data were analyzed using Colaizzi’s seven stage method with MAXQDA10 software. Results Data analysis led to the extraction of 3 themes, 9 categories, and 25 subcategories. The themes were as follows: “Fear of Disease”, “Burnout”, and “Lessons Learned from the COVID-19 Pandemic”, respectively. Conclusions Maternal health care providers experience emotional and psychological stress and work challenges during the current COVID-19 pandemic. Therefore, comprehensive support should be provided for the protection of their physical and mental health statuses. By working as a team, utilizing the capacity of telemedicine to care and follow up mothers, and providing maternity care at home, some emerged challenges to maternal care services can be overcome.

Case report - Introduction Needle phobia is a common issue amongst children, particularly with long-term illnesses requiring repeated interventions. Psychological interventions such as coping strategies and distraction techniques can be effective in many of these children, but is not universally successful. Recent research has reportedthat the use of virtual reality (VR) headsets as a distraction technique can be effective at alleviating both pain and fear in children receiving intravenous (IV) injections, cannulation and venepuncture. Although use of VR distraction is becoming more widespread in some disciplines (such as paediatric oncology/A&E), it is yet to be widely adopted in paediatric rheumatology. Case report - Case description We report the case of a 9-year-old boy (ME) who in early 2019 developed psoriatic juvenile idiopathic arthritis (JIA) and an associated severe, widespread plaque psoriasis causing him substantial discomfort and distress. He has been treated with subcutaneous adalimumab biosimilar 40 mg fortnightly and oral methotrexate 20 mg weekly, alongside Keppra 1000 mg twice daily for epilepsy. Although he is just tolerating the subcutaneous adalimumab, he is requiring intermittent steroid joint injections under general anaesthetic for recurrent flares of his polyarticular arthritis and regular monitoring phlebotomy. He has been developing progressive needle phobia over the past 8 months, with superimposed anxiety about general anaesthetics with particular fear of the anaesthetic provoking an epileptic seizure. Despite psychological intervention to teach coping strategies and standard play therapy distraction techniques, both phlebotomy and cannulation for general anaesthetics have become more distressing and challenging for him. During two recent day case admissions for joint injections, despite premedication with sedatives, distraction techniques and psychology interventions, he became so distressed that attempts to anaesthetise him had to be abandoned. This has resulted in prolonged periods of continuing joint inflammation and pain. Discussion with local paediatric oncology colleagues resulted in a suggestion of using recently acquired VR headsets as an effective distraction technique. He has had a previous positive experience of using VR headsets in a play environment. He is receiving VR training intervention from the oncology team and is now fully engaged with the idea of using VR to distract him from negatively focussing on his next planned general anaesthetic intervention. Case report - Discussion Unmanaged needle-related procedural pain in children is associated with increasing pain and stress in subsequent procedures and fear/avoidance of medical care which can affect compliance in chronic disease management. The psychological distress for children with needle phobia can add to existing psychological impact from JIA and increase family stress of caring for an ill child. The cost of poor management of needle-phobic children can be considerable, with cancelled or increased time for procedural interventions and restricted therapeutic interventions. Needle phobias in childhood may persist into adulthood. Employing distraction techniques when children undergo medical procedures can help them reduce anxiety. VR is a method of captivating an individual’s interest in a virtual environment and can help divert attention from potentially distressing situations in the real world. Recent studies have reported VR as an effective distraction technique in children. Chan (2019) reports that VR significantly decreased the pain and post procedural anxiety experienced by children aged 4—11 years old during venepuncture/IV cannulation compared to controls. The majority of children in the VR group expressed interest in utilising VR again in the future, to improve their experience of IV injections. Chen (2020) subsequently reported a randomised controlled trial which significantly reduced pain and fear experienced from IV injections by the children in the VR group. There are cost implications to both buying VR headsets/software and training play specialists/specialist nurses to use the equipment effectively. Furthermore, the acceptability of using VR with regards to the child’s age, engagement with age-appropriate software packages and whether a passive VR or a more interactive ‘gaming’ experience is preferred should be considered. The use of VR is not a panacea, but is potentially effective as an additional new tool in clinicians’ efforts to reduce the impact of needle phobia. Case report - Key learning points Addressing needle phobia in children can require novel strategies. VR has shown success as a distraction technique to alleviate pain and fear in children undergoing needle related procedures. The implementation of VR in paediatric rheumatology has cost and staff training implications. The use of age-appropriate software and an individual child’s preference for passive/active interaction with VR should be considered.