Electroconvulsive therapy (ECT) is an efficacious treatment for many mental disorders, but is underutilized because of fears of adverse effects, including the risk of death.

To provide a full picture of the magnitude of ECT-related mortality worldwide.

We performed a systematic review and meta-analysis (PubMed and Embase) in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. Only publications reporting on a specific number of ECT treatments as well as specific number of ECT-related deaths were included in our analysis. The ECT-related mortality rate was calculated by dividing the total number of ECT-related deaths by the total number of ECT treatments. The 95% confidence interval (95% CI) of this estimate was calculated using Bernoullis principle of distribution.

Fourteen studies with data from 32 countries reporting on a total of 757,662 ECT treatments met the predefined inclusion criteria. Fifteen cases of ECT-related death were reported – yielding an ECT-related mortality rate of 2.0 per 100,000 treatments (95% CI: 1.0–3.0). In the eight studies published after 2001 (covering 406,229 treatments), no ECT-related deaths were reported.

The ECT-related mortality rate was estimated at 2 per 100,000 treatments. For comparison, a recent meta-analysis on the mortality of general anaesthesia in relation to surgical procedures reported a mortality rate of 3.4 per 100,000. Thus, our systematic review and meta-analysis documents that death caused by ECT is extremely rare. This information can be used to reassure patients in need of ECT.

The authors have not supplied their declaration of competing interest.

The purpose of this study was investigating the effectiveness of rTMS (repetitive transcranial of magnetic stimulation) on increase social performance in patients with recurrent major depression.

It was used a quasi-experimental, pretest–posttest design with control group, a sample consisting of 32 patients who had depression on the basis of DSM-IV diagnostic criteria, SCID and BDI-II scales and were randomly assigned to two groups.

The experimental group underwent 20 sessions of rTMS as the independent factor and both groups (control & experimental) had 12-session psychotherapy and drugs treatment. Upon the intervention, both groups were tested with two tests (BDI-II & SASS). To determine the effect of the independent factor on the dependent factor of rTMS.

Data were analyzed by t-test.

The comparison between pre- & posttest of all the tests showed the reduction of signs & symptoms of depression, (a = 0/05) (Beck scale P ≤ 0/001 & F = 30) and increase social performance in participants (P ≤ 0/001 & F = 83).

The rTMS is effect in the reduction of signs & symptoms of depression and increase social functioning in recurrent major depression.

The authors have not supplied their declaration of competing interest.

The research was conducted with Sprague-Dawley rats (n = 41, 2 month age). Experimental stages:

– control group (n = 10) compared to control + ECT group ([70 mA, 50 Hz, 500 μsec; 10 days] n = 10);

– control group (n = 9) compared to group with depressive-like disorder, formed by ultrasound ([20–45 kHz; 21days] US, n = 6) and group with depressive-like disorder received ECT (n = 6).

Memory was estimated in the “Object recognition” and “Morris water-maze” tests.

(1) ECT did not decrease cognitive function in the “Object recognition” test in normal rats (P = 0.1217). Also, it did not lead to cognitive impairments in the “Morris water-maze” test: time of platform searching did not differ significantly from the control group (P = 0.8573).

(2) ECT produced recovering effect on memory impairments of the US group in the “Object recognition” test (P = 0.0066). In the “Morris water-maze” ECT decreased time of platform searching by 7 times compared to the US group (P = 0.0025). That demonstrates the absence of ECT negative effect on rat's memory.

ECT does not produce negative effect on cognitive function in rats with depressive-like disorder and even recovers memory impairments.

The authors have not supplied their declaration of competing interest.

Urgency of psychophysiological examination of mitral valve prolapse (MVP) patients is suggested by a high incidence of anxiety disorders among these patients.

To study glucocorticoid function activity and emotional stress resistance in MVP patients with autonomic dysfunction (AD).

The trait anxiety level (TA) was assessed with the State-Trait Anxiety Inventory (Spielberger). Emotional stress resistance was undertaken with our modified version of Rosenzweig Picture-Frustration Test (Zinchenko, Pervichko). The cortisol level in blood plasma was measured by radioimmunoassay technique with radioimmune assay kit of cortisol in human blood plasma ‘KORT-3N’ (Belarus). There were 32 MVP patients (mean age was 28.5 ± 1.6 years) and 15 healthy people (mean age was 27.5 ± 1.3 years) who took part in the study.

Among reactions to frustration revealed by MVP patients the following categories are dominating: extrapunitive (Е), ego-defensive (ED), and obstacle-dominance (OD). There was revealed a direct correlations: TA and Е (r = 0.49, Р < 0.001); TA and ED (r = 0.46, Р < 0.01); TA and indexes of AD (r = 0.43, Р < 0.01).

There was displayed a higher level of cortisol in MVP patients with severe grade of AD, against the level revealed by patients with average grade of AD (433.9 ± 78.0 mmol/L vs. 299.3 ± 42.9 mmol/L; Р < 0.05). Direct correlations were established between the cortisol level and the level of TA (r = 0.45; Р < 0.01); between the frequency of E-reactions in Modified Rosenzweig Test and cortisol level (r = 0.42; Р < 0.01).

Along with low stress resistance, registered AD and high level of TA, MVP patients reveal higher indexes of cortisol in blood plasma.

The authors have not supplied their declaration of competing interest.

Psychological distress is considered as a component of the cardiovascular risk. The present study aims to determine which psychophysiological, electrocardiographic and anthropometric factors are correlated with life events, depression and quality of life in healthy adults.

A total of 114 adults were examined using the Social Readjustment Rating Scale, the EuroQol Group 5-Dimension Self-Report Questionnaire, Beck Depression Inventory – Second Edition, Zung Self-Rating Depression Scale. Physiological measures included heart rate variability, skin conductance level and skin temperature. Anthropometric characteristics included weight, height, hip size, waistline, blood pressure, heart rate at rest and after mental activity, muscle mass, fat stock, percentage of the body fat, segmental distribution of muscle and fat mass, fat-free mass and the water content in the body. Finally, data from electrocardiographic examination included aortic pulse wave velocity, central aortic pressure and augmentation index.

Life events in last two years correlate with worse quality of life and a higher level of depression. Life events in last two years also correlate with the increase of the risk factors for cardiovascular problems in terms of several anthropometric and physiological measures. Finally, life events in last two years was also related with the overweight.

Results suggest some possible mechanisms by which stress may exert adverse effects on cardiovascular morbidity and mortality in healthy persons. Primary preventive strategies with the stress management training may prove beneficial.

The authors have not supplied their declaration of competing interest.

Evaluate the efficacy of art therapy during acute psychotic episodes.

Thirty-six inpatients with ICD-diagnoses of schizophrenia (F20.0–F20.9) age between 20–60 were randomised to either 12 twice-weekly sessions of psychodynamic group art therapy plus treatment as usual or to standard treatment alone. Art therapy was administered in 12 sessions of 90 minutes for 6 weeks. At 12 weeks, 55% of patients randomised to art therapy, and 66% of patients receiving treatment as usual were examined. Scales used: 17 – Item Hamilton Rating Scale for Depression (HRSD) for depression and Scale for the assessment of negative symptoms (SANS).

The approach was non-directive – patients could choose to create whatever they wanted and use any available material. Interventions by the art therapist aimed at supporting the art process and helping to understand the image. The last 30 minutes of a session were reserved for a shared viewing and reflecting on the images.

With post-treatment and follow-up scores of SANS and HRSD patients who had received AT had a significantly greater mean reduction of positive and negative and also depressive symptoms at 12-week follow-up than patients treated as usual. Social functioning was significantly higher in the AT group. There were no significant interactions between intervention group and gender.

Evidence on the efficacy and effectiveness of AT in patients with schizophrenia is far from being conclusive and benefits might be limited to a subgroup of patients. Results of this study suggest AT can be implemented in routine hospital settings for patients experiencing acute psychotic states.

The author has not supplied his/her declaration of competing interest.

Perseverative Negative Thinking (PNT) is a transdiagnostic cognitive process [1] characterized by repetitiveness, intrusiveness and difficulties to disengage (Ehring, 2011). The Perseverative Thinking Questionnaire (PTQ-15; [2]) is a self-reported instrument, developed to evaluate these characteristics. The Portuguese version assess two meaningful dimensions – Repetitive thoughts (RT); and Cognitive interference and unproductiveness (CIU) [3].

To confirm the bi-dimensional structure of the PTQ-15 using Confirmatory Factor Analysis, in two distinct samples.

A sample composed of 256 students (Mean age = 20.58 ± 1.870; 78.1% girls) and a sample composed of 480 adults from the community (parents of the students; mean age = 50.84 ± 5.310; 53.1% women) filled the PTQ-15. We used software AMOS.

The second-order model of PTQ-15 with two dimensions presented good fit, in both students (CMIN = 2.449; RMSEA = 0.075; CFI = 0.958, TLI = 0.949, PGFI = 0.776; P < 0.001) and their parents (CMIN = 3.46; RMSEA = 0.072, CFI = 0.955, TLI = 0.942, PGFI = 0.632; P < 0.001). Internal consistency of the total scale, measured though Cronbach's alpha was α = 0.95/0.94; both factors presented good/excellent reliability: repetitive thoughts (a = 0.93/0.92); cognitive interference and unproductiveness (a = 0.88/0.92).

Taken together, both CFAs provided additional evidence that PTQ-15 is an adequate measure for perseverative thinking.

The authors have not supplied their declaration of competing interest.

The medical model assumes the professional psychotherapeutic assistance at all stages of the rehabilitation process and pharmacological treatment of comorbid mental disorders.

Evaluation of the efficacy of the medical model rehabilitation based on the clinical, psychological, and social characteristics of patients at the all stages of the treatment.

Eighty-five drug-addicted patients with psychiatric comorbidity. The inclusion criteria were: age above 18 years, withdrawal status. The patients were examined four times:

– 1 – during the first weeks of treatment;

– 2 – after 45 days;

– 3 – after 6 months;

– 4 – after 12 months.

The primary evaluation the highest scores noted in the sections: “family and social connections”, “health status”, “psychiatric status” and “legal aspects” received lower scores. In the second measurement, the results established a significant improvement on the scale of “health status”, “mental status”, “alcohol”, “drug use” compared with original values. Early retired patients the most high-end performance observed on the scale of “drug alcohol using”, “job/livelihood”, “health status”, “legal aspects”, the “psychiatric status”, “family and social connections” recorded lower scores. Indicators on the scale of “drug use”, “alcohol” in this group of patients was significantly higher than patients who remain on treatment, which may indicate a possible updating of the attraction to the drugs. The third measurement showed a significant improvement ASI according to the all scales as compared to the previous ones. In the course of the rehabilitation process revealed positive changes in clinical, psychological and social characteristics of patients.

The author has not supplied his/her declaration of competing interest.

Predictive biomarkers are tools that identify a subpopulation of patients who are most likely to respond to a given therapy. In order to identify them a strict methodology is necessary (RCT's studies). In consideration of its cost in economic and medical terms, predictive biomarkers would be useful to distinguish clozapine-resistant patients before its administration.

The evidence concerning genetic biomarkers was reviewed with the aim of assessing whether there is enough evidence to claim for predictive biomarkers useful in practice. Secondary aims were the assessment of the evidence concerning genetic prognostic biomarkers and predictors of side effects in clozapine-treated schizophrenic patients.

One hundred and twenty-eight studies, searched on the Pubmed database or referenced in other studies, were included in this review. Sixty-five papers were related to clozapine efficacy and explored 167 genetic variants.

Fifty-four variants were supported as prognostic biomarkers, three were successfully replicated: rs6280, rs6314 and rs4680; 49 papers were related to clozapine weight gain and explored 216 different genetic variants. Forty-five of which were positively related to weight gain during clozapine treatment. Among these 45 variants, only two, Rs3813929 and Rs779039, were successfully replicated.

Fourteen studies explored 111 genetic variants potentially correlated to Clozapine-induced agranulocytosis. Thirty-four variants were found to be associated with agranulocytosis. Five variants had positive results, successfully replicated. In particular, HLA B38.

To date there is no evidence to support a modification of clinical practice towards predictive medicine. The research could ideally progress with RCTs involving the prognostic factors found in association studies.

The authors have not supplied their declaration of competing interest.

The core workplace for a surgeon is the operating theatre. Secondary duties may include visits to small health centers for outpatient examinations and visitor work to psychiatric hospitals.

The objective of our study is to highlight the mistakes of management that lead to half-empty provincial health centers and psychiatric hospitals.

Presentation of the 2-year-experience of a surgeon visitor in provincial health centers and in a large psychiatric hospital in Greece.

The provincial health center of Lagada needs at least 4 surgeons to serve; too many patients to be examined or/and operated in 2–3 hours only. Subsequently problems arise, as simultaneously in the emergencies department a surgical eye for an abdominal pain or a bad looking leg is needed every 15 minutes. The health center of Koufalia needs 3 hours of driving per day for 3–8 surgical patients only. The psychiatric hospital offered work for 3 surgeons 5 days a week for a long period of time. During 2012–2014, only one surgeon visited the hospital once a week. The work needed to be done may kill the surgeon or force him to receive antidepressants in order to keep his functions alive.

Not a hint of scientific motivation for two years is a strong reason for a surgeon to avoid the duty to provincial health centers and psychiatric hospitals which is obligatory according to our national health system Laws until two years are completed for newly appointed surgeons. Managers might encourage surgeons if some balancing convenience was offered.

The authors have not supplied their declaration of competing interest.

The authors have not supplied their declaration of competing interest.

Individual placement and support (IPS) is an evidence-based intervention where IPS consultants support people with severe mental illness in achieving competitive employment. IPS is a recovery-oriented intervention, but vast evidence regarding its ability to influence recovery-oriented outcomes challenges this position.

To investigate how an IPS-intervention influences the personal recovery process in people with severe mental illness.

A qualitative phenomenological study including interview of 12 participants in an IPS-intervention. Analysis was made using a four-step phenomenological analysis method.

IPS contributed to personal recovery in a number of ways: The IPS consultants’ ability to create an equal, acknowledging and safe relationship where participants’ needs were taking into consideration in the search and support for job or education was found valuable. In combination with employment, the role of the IPS consultant contributed to normalization and stabilisation of participants’ daily lives, changed their behaviours and beliefs about maintaining new achievements, personal goals and dreams.

Individual placement and support provides opportunities to gain personal goals and contributes to stabilisation and normalization of participants’ daily lives. This study supports the notion that the individual placement and support positively influences personal recovery in people with severe mental illness.

The authors have not supplied their declaration of competing interest.

Mental health issues and illnesses are associated with poor self-care and unhealthy lifestyles that contribute to morbidity, mortality and overall decrease in quality of life when compared to the general population. Healthy lifestyle promotion is infrequently considered a priority in mental healthcare services, especially in acute psychiatric inpatient units.

To present a healthy lifestyles promotion programme implemented in an acute psychiatric inpatient unit.

To reflect on how to design an adequate programme for patients with complex needs.

In a general psychiatric inpatient unit, a team of two psychologists and one psychiatrist, ventured to introduce weekly activities that included drawing, colouring, painting, crafts and games, that provided a context for patients and the team to sit down together or to gradually “drift” together and make possible conversations focusing on tobacco smoking, caffeine consumption, weight control, physical activity and health promoting activities.

Instead of individual or group psychoeducation talk interventions, play and art strategies, in closer proximity with the patients, made it far easier to engage difficult patients and made psychoeducation possible and fun.

Patients with severe mental illness are frequently reluctant to engage in activities targeting healthy lifestyles, especially in acute psychiatric inpatient units, when insight and motivation for change may be low due to illness and consequences of illness. Play and art therapy interventions led by a team of mental healthcare professionals who participate directly with the patients, may be an innovative, more effective and enjoyable strategy.

The authors have not supplied their declaration of competing interest.

Population attributable fraction (PAF) represents the proportion of treatment failure, which could be avoided, if the individuals at high risk were similar to the individuals at low risk. The PAF, however, has not been available for repeated measures designs.

A relatively prevalent and strong risk factor for many adulthood disorders, such as depression and anxiety, are adversities and traumas experienced in childhood. Little is, however, known of their implications for common treatments such as psychotherapy.

To develop PAF for repeated measures, and to provide a useful tool in various research fields to provide decision-makers results, which are easier to interpret.

This study will examine the relative importance of different childhood traumas as predictors of psychotherapy outcome in a patient population with depressive and anxiety disorders.

PAF was calculated using generalized linear mixed models and Bayesian predictive distributions.

The data is based on 326 outpatients, randomized in one long-term and two short-term psychotherapies by the Helsinki Psychotherapy Study. Patients were assessed up to 10 times during a 5-year follow-up. A combination of psychiatric symptoms measured, is used as the outcome measure.

The repeated measures PAF will provide a useful aggregate measure over the follow-up time and over the patient population.

The repeated measures PAF will provide insight on the relative importance of the different domains of childhood traumas on therapy outcome. Associations of individual-level risk factors do not provide guidelines for policy decisions, which should acknowledge also prevalences of the risk factors in the patient population.

The authors have not supplied their declaration of competing interest.

The available literature suggests that treatments and health services for psychosis are considered to be poorly organized and highly variable. Little is known, however, about how inpatient care is provided to individuals experiencing early psychosis. To facilitate quality improvement activities, we characterized the care this patient group receives in an inner city hospital.

We performed chart reviews of individuals admitted to psychiatric inpatient units at St. Paul's Hospital, Vancouver, British Columbia between 01/04/2014 and 31/03/2016. Those who were 17–25 years of age and hospitalized for psychotic symptoms at the time of admission were included. Demographic and health service use were summarized using descriptive characteristics.

We identified 73 inpatients (mean age = 22; males = 78%; Caucasian = 41%) that met study inclusion criteria, having a combined total of 102 care episodes and an average length of stay of 30.7 days (median = 18; min = 3; max = 268). Half of the care episodes were repeat admissions, with up to 30% of the patients readmitted within 28 days of discharge. Physical and mental status examinations (MSE) were performed in virtually all care episodes, although frequency is low (31.4% had daily physical examinations and 18.6% had MSE every nursing shift). In 49% and 50% of care episodes, patients were given oral antipsychotics and discharged on depot medications. Even when indicated, not all care episodes had follow-up appointments (60%) or referrals to income assistance (35%), community mental health teams (61%), and housing support (38%).

Specific programs are needed to address current gaps in inpatient care for patients with early psychosis.

The authors have not supplied their declaration of competing interest.

Mental health conditions (MHC) have been associated with restrictions in daily life participation and functioning affecting health and well-being. Substantial numbers of people with MHC experience hospitalizations, however, there is limited evidence supporting functional interventions in the in-patient setting to promote recovery. The OC is an intervention implemented during sub-acute hospitalization, which attempts to promote activity and participation of people with MHC, both during the in-patient stay and upon return to the community, with a view to enabling recovery. To facilitate its implementation, we investigate the OC effectiveness.

Investigate the OC contribution to cognition, symptoms and functional capacity among inpatients with schizophrenia.

This is a quasi-experimental, prospective, pre/post-designed study with convenience sampling. Inpatients with schizophrenia were enrolled into the study group participating in the OC intervention (n = 16); or the control group participating in hospital treatment as usual (n = 17). The study participants completed evaluations at baseline and at discharge or after 10 weeks with: Neurocognitive State Examination, Trail Making Test, Ray Complex Figure, and Category Fluency Test for aspects of cognition; Positive and Negative Syndrome Scale for symptoms severity, and Observed Tasks of Daily Living-Revised for functional capacity.

Statistically significant improvement in cognitive functioning, symptoms severity and functional capacity was found in the study group after the intervention. These changes were not observed in the control group.

The results support the OC effectiveness for cognitive and functional capacity improvement and symptomology relief. The findings advance the body of evidence for functional interventions in hospital settings.

The authors have not supplied their declaration of competing interest.

The participation of informal caregivers in the café of patients with psychotic symptoms in coordination with self-help groups have been found to reduce the expressed emotion in combination with psychoeducations interventions help create a supportive environment.

This study investigates the differences in the family atmosphere of informal caregivers of patients with psychotic symptoms.

To compare whether or not the participation of informal caregivers of patients with psychotic symptoms in self-organized associations helps to foster a supportive family environment, hence reducing the risk of relapse.

Snowballing sampling consisting of 510 informal caregivers of patients with psychotic symptoms was used in the current study. The Family Environment Scale of Moos and Moos and socio-demographic questions were implemented to collect the data. Control Cronbach's Alpha reliability of scale gave value a = 0.795.

The comparison showed that informal caregivers of patients with psychotic symptoms irrespective of their participation or not in self-help associations do not show significant differences in Family Environment Scale. Significant statistical difference between the two groups (P < 0.05) only occurred in the subcategory “organization”, as the first group (m = 4.68, df = ± 2.233) were found to have lower values compared to the other group (m = 5.21, df = ± 2.233).

The study demonstrated that informal caregivers of patients with psychotic symptoms involved in self-help groups do not show to have a particular difference in the family atmosphere than families who do not participate in self-help associations.

The authors have not supplied their declaration of competing interest.

Self-referral to inpatient treatment (SRIT) has recently been implemented in Norway in several community mental health centers (CMHC) in an effort to increase activation and to improve access to mental health services and timely treatment.

To examine the effect of having a contract for self-referral to inpatient treatment (SRIT) in patients with severe mental disorders. This intervention was based on personalized care planning, legislation regarding patients’ rights and is intended to enhance user participation.

To assess the 12-month effect on patient activation measure-13 (PAM-13).

A randomized controlled trial with 53 adult patients; 26 participants got a SRIT contract which they could use to refer themselves into a CMHC up to five days for each referral without contacting a doctor in advance. Preliminary results on the primary outcome after 12 months with the self-report questionnaires Patient Activation Measure (PAM-13), will be analyzed using linear mixed and regression models.

The preliminary results showed no significant effect on PAM-13 (estimated mean difference [emd] −0.41, 95% CI [CI]: −7.49 to 6.67). A post hoc analysis found an effect of SRIT on PAM-13 in those with baseline PAM-13 scores below ≤ 47.

There were no group differences.

Clinicaltrials.gov NCT01133587.

The authors have not supplied their declaration of competing interest.

Despite concerns about rising treatment of psychiatric patients with psychotropic medications and declining treatment with psychotherapy, actual treatment profiles of psychiatric patients is largely unknown.

To describe patterns in the treatment of patients in a large psychiatric university hospital department.

A descriptive mapping of treatment of in- and outpatients in a psychiatric department at Aarhus University Hospital Risskov, Denmark. Information was collected by health care staff using a 25-item survey form. The P-value was calculated with a Chi2 test and P < 0.05 was considered significant. The study was preceded by a pilot study on 41 patients.

Over a 1 month period we assessed a total of 343 consecutive patients and hereof included 200 in the age range 18–90 years (mean 53.76); 86 men and 114 women. One hundred and eighty-eight patients (94%) used psychotropic medication, 37 (19%) as monotherapy and 148 (74%) in combination with non-pharmacological therapy. Ninety-seven (49%) had psychotherapy and 104 (52%) social support. Among inpatients, 21 (64%) had physical therapy, and 10 (30%) electroconvulsive therapy. In total, 163 (82%) had non-pharmacological therapy. Fifty-two (26%) patients had monotherapy and 148 (74%) polytherapy. Mean number of treatment modalities used pr. patient was 2.07 for all patients and 3.23 for inpatients.

In our department, polytherapy including non-pharmacological modalities is applied widely across all settings and patient categories. However, psychotropic medication clearly dominates as the most frequently applied treatment.

The authors have not supplied their declaration of competing interest.

The scientific community assumes that rigorous methodology research is more likely to be published in high impact psychiatry journals (HIJ). We aimed to test which methodological variables could predict publication in HIJ.

We conducted a systematic review of the MEDLINE and EMBASE databases from 2013, January 1st to 2015, June 15th. Inclusion criteria were studies that were RCTs whose at least one arm of the study should be fluoxetine regarding adult patients (> 18 years old) with MDD. We performed logistic regression regarding the number of participants, intention-to-treat analysis, blinding, multicenter study, sample losses, positive result, sponsorship of pharmacy's industry, and h-index of the last author. A HIJ was considered if journal impact factor was above the median or 3rd quartile of our sample.

Forty-two studies were considered for the final analysis. The results of the univariate logistic regression found no differences between HIJ and low impact psychiatry journals for all methodological variables, except the h-index of the last author. By considering HIJ when impact factor was above the mean, h-index had an odds ratio = 1.09 (1.01–1.17), P = 0.02; considering HIJ when impact factor was above the 3rd quartile, h-index had an odds ratio = 1.07 (1.01–1.14), P = 0.02.

Our results indicate that the author productivity may be a relevant predictor for publication in a HIJ in the psychiatry/psychology field. Our study proposes that journals focus on identifying what are the relevant criteria for publication approval in the peer-review process.

The authors have not supplied their declaration of competing interest.