What do therapists do? The question seems obvious, yet systemic therapy has struggled to answer it with the philosophical rigor that both professional identity and ethical practice require. This paper proposes a reflexive scientific practice grounded in two theoretical traditions rarely brought into dialogue with systemic therapy: the pragmatist philosophy of C.S. Peirce and the reflexive sociology of Pierre Bourdieu. Drawing on Peirce, therapy is defined not as the treatment of dysfunction but as the professional resolution of doubt-the state arising when a client's habits of mind fail to navigate new social contexts. Drawing on Bourdieu, large-scale social forces are seen to produce the specific form of doubt Bourdieu calls hysteresis, and how unexamined therapeutic interventions risk enacting symbolic violence by imposing the therapist's habitus under the guise of clinical expertise. Together, Peirce and Bourdieu provide what systemic therapy has long needed: a framework that simultaneously grounds clinical authority in empirical, self-correcting practice and constrains that authority through systematic interrogation of the therapist's social position. Integrative Systemic Therapy (IST) is presented as the operationalization of this synthesis, demonstrating how its problem-centered, cost-effectiveness, and failure-driven guidelines function not merely as pragmatic efficiency measures but as ethical safeguards against symbolic violence. This framework responds to recent calls for theoretical rigor in systemic practice while addressing a dimension those calls do not fully reach: the risk that theoretical authority enacts iatrogenic harm when deployed without reflexive discipline.
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Type 2 diabetes accounts for over 90% of all diabetes cases and continues to rise globally, with projections reaching 853 million adults by 2050. Prediabetes, a key risk state, offers a critical window for prevention, as lifestyle changes can reduce progression to type 2 diabetes by nearly 50%. Despite clear guidelines emphasizing diet and physical activity, adherence remains challenging due to socioeconomic, cultural, and behavioral barriers. The aim of this study was to explore men's attitudes toward managing their diet and lifestyle after being diagnosed with prediabetes. A qualitative study used individual and group interviews with 21 Swedish men aged 60-72 with prediabetes, recruited from the Swedish CArdioPulmonary bioImage Study (SCAPIS) cohort via convenience sampling. Data collected from May to August 2025 through Microsoft Teams included open-ended questions. Interviews were audio-recorded and transcribed. Analysis followed Graneheim and Lundman's qualitative content analysis. The men recognized the importance of healthy habits but doubted they could maintain lasting change. This ambivalence was caused by personal limitations and a focus on short-term goals. Some men sought support from family or friends, moving from contemplation to preparation. Learning from successes and setbacks, they gained a more realistic view of their ability to change. The analysis identified one main theme, "Grasping the message about healthy habits but still doubting one's ability to change", and two additional themes, each with three subthemes. Men with prediabetes know how to eat healthy but struggle to turn knowledge into habits. Emotional distress, ambivalence, and triggers often undermine motivation. Short-term goals like weight loss dominate over long-term strategies. Yet, men seek social support and engaging activities, showing readiness for change. Interventions should target psychological barriers, use social networks, and offer practical strategies for lasting lifestyle changes.
Impostor phenomenon reflects persistent self-doubt and fear of failure despite success. This study examined the association of impostor phenomenon with self-compassion in 601 Czech university students (368 women; Mage = 23.46, SD = 3.05), using the Impostor-Profile 30 and Self-Compassion Scale. Employing correlation analysis, regression, and structural equation modelling, we investigated the relationships among the constructs and their dimensions. In the correlation analysis, competence doubt was moderately associated with isolation (r = .409) and overidentification (r = .427). The regression analysis indicated these subscales as being significantly associated with competence doubt (R² = .26, F(6, 594) = 35.18, p < .001). Structural equation modelling further supported the model with stronger links between negative self-compassion dimensions and impostor phenomenon compared with positive ones (e.g., self-kindness) (CFI = .99, TLI = .99, RMSEA = .031). These findings highlight the importance of considering feelings of isolation and overidentification when designing or interpreting self-compassion-focused approaches in the context of impostor phenomenon, particularly among university student populations vulnerable to stress and low self-efficacy.
Gaslighting is a subtle and insidious form of psychological abuse in the workplace that operates through the distortion or denial of reality and the induction of cognitive doubt, ultimately undermining individuals' confidence in their perceptions and professional judgment. Although the concept has gained increasing attention in organizational and psychological literature, gaslighting remains theoretically underdeveloped and conceptually ambiguous within nursing practice. It is frequently conflated with related phenomena such as workplace bullying, psychological violence, or incivility, which limits accurate identification, measurement, and intervention. This study aimed to clarify the concept of gaslighting in nursing practice through a systematic concept analysis. This study employed Walker and Avant's eight-step concept analysis method. A comprehensive review of English- and Persian-language literature was conducted using databases including PubMed, Scopus, CINAHL, PsycINFO, Web of Science, SID, and IranDoc. All uses of the concept of gaslighting relevant to nursing and healthcare contexts were examined. Data were analyzed to identify defining attributes, antecedents, consequences, model cases, and empirical referents of gaslighting in nursing practice. The analysis revealed that gaslighting in nursing practice is a covert, processual, and power-based phenomenon. Its defining attributes include distortion or denial of reality, induction of cognitive doubt, persistent and patterned behavior, power imbalance, victim blaming, and a subtle, non-confrontational nature. Key antecedents were identified as hierarchical power structures, high workload and stressful clinical environments, and the absence of clear organizational policies and supportive reporting mechanisms. The consequences of gaslighting extend beyond individual psychological harm and include reduced professional self-confidence, burnout, organizational silence, decreased reporting of concerns, diminished quality of care, and potential threats to patient safety. Based on these findings, a conceptual model illustrating the relationships among antecedents, defining attributes, and consequences of gaslighting in nursing practice was developed. This concept analysis provides a clear and structured understanding of gaslighting in nursing practice and differentiates it from other forms of workplace mistreatment. The proposed conceptual framework offers a foundation for future empirical research, development of measurement instruments, and the design of educational and organizational interventions aimed at preventing and addressing gaslighting in nursing environments.
To summarize existing evidence of associations between religion and spirituality in relation to multiple dimensions of sleep health, illuminate strengths and limitations of the existing literature, and outline gaps that inform opportunities for future research. Positive dimensions of religion and spirituality, such as spiritual well-being, supportive coping, and community integration, were generally associated with better sleep outcomes across global populations. Adverse experiences, including doubt, conflict, and spiritual struggle, were often associated with poorer sleep. Among the 59 included studies, most were cross-sectional and relied on self-reported measures, used inconsistent conceptualizations of religion and spirituality, did not sufficiently assess potentially adverse religious or spiritual experiences, and were limited to certain geographic regions of the world (e.g., North America and Southwest Asia). Positive dimensions of religion and spirituality (e.g., meaning, coping) were generally associated with better sleep, while struggles and doubt were associated with poorer sleep. Future research that employs longitudinal and experimental designs, validated multidimensional measures, objective sleep assessments, and diverse populations is needed to clarify mechanisms and inform culturally responsive approaches to promoting sleep health. The online version contains supplementary material available at 10.1007/s40675-026-00374-y.
Orthoflaviviruses are etiological agents of neurological diseases in equines. Horses are susceptible to equine Tick-borne encephalitis virus (TBEV), Usutu virus (USUV), and West Nile virus (WNV), although mostly WNV has been associated with clinical disease. The aim of the present study was to estimate the prevalence of TBEV, USUV and WNV in 289 healthy horses from nine provinces of Algeria. This study was conducted between March 2021 and December 2023. Sera that tested positive, doubtful, or negative close to the doubtful threshold in the Orthoflavivirus-ELISA were further tested by the virus neutralization test (VNT), using TBEV, USUV, and WNV strains. The prevalence of Orthoflaviviruses antibodies by ELISA was 23.18% (67/289) compared with 16.95% (49/289) and 0.69% (2/289) detected by WNV and USUV VNT, respectively. TBEV antibodies were not detected in any samples. WNV seroprevalence varied with age, breed, climatic zones and altitude of the horses' locations. This is the first screening of horse sera for TBEV in Algeria. This study indicates that WNV and USUV have circulated/are circulating in the horse population in three Algerian climatic zones, unlike TBEV, which does not seem to be present.
The prevalence of contact allergy to linalool hydroperoxides (HPs) and limonene HPs is high and differs in different populations. Patch test techniques might affect the results. To report the prevalence of contact allergy when the HPs were tested in different test chambers. Consecutive adult dermatitis patients were patch tested during April 2023-July 2024 with linalool HPs and limonene HPs in Finn Chamber (FC), Finn Chamber AQUA (FCA) and IQ Ultra (IQ) chambers simultaneously. In total, 629 patients were tested. For linalool HPs, the highest prevalence was observed in FCA (7.0%), followed by IQ chambers (5.7%) and FC (5.1%) with a significant difference between FCA and FC (p-value = 0.036). Similarly, for the limonene HPs: FCA = 7.8%, IQ = 3.8% and FC = 3.0%, with significant differences between FCA and FC, and between FCA and IQ chambers (both p-values < 0.001). Up to 40% of the doubtful cases in one chamber could become positive when tested with another test chamber. For both HPs, using different patch test chambers can affect patch test results. A doubtful reaction in one chamber tested might be a weak allergic reaction when tested with other chambers. Contact allergy might be missed.
Imposter phenomenon is common in healthcare professionals and other high-achieving fields. It is exhibited as persistent self-doubt in one's abilities, fear of being labeled as a fraud despite evidence of achievements, and the belief that one's successes have been a result of luck rather than having been earned. Downstream effects of imposter phenomenon include impacts on mental health, job progression, and leadership potential. Some groups are disproportionately affected, including underrepresented minorities, women, and trainees/early career faculty. It affects all ages and career stages, yet often exists in a culture of silence. The authors designed a one-day, in-person symposium ("short course") in 2024 to address repeated self-descriptions of "imposter syndrome" in their colleagues. The purpose of the short course was to define imposter phenomenon, explore and identify contributing intrinsic and extrinsic factors, and provide tools for mitigating imposter phenomenon locally. There were 73 attendees who provided real-time aggregate, anonymized feedback. Eighty percent of respondents indicated they likely had imposter phenomenon or had moments of self-doubt. Themes on contributing factors included feeling different, lack of mentorship or social support, hierarchies and lack of leadership support, feeling actual or perceived pressure or going through a change, lack of confidence, taking on new tasks, and being an early career genetic counselor. Although not designed as a scientific study, our findings are the first reported from a cross section of genetic counselors, revealing similarities to those in other high-achieving healthcare professionals. We describe reported strategies and highlight the need for mitigation of feelings of imposter phenomenon on a personal and professional level. This is particularly relevant in light of advances in medical genetics, and genetic counselor leadership needed to incorporate these advances into broader areas of healthcare delivery.
Research indicates that perfectionism is on the rise among college students. This study updates and expands on this work in several ways. First, we investigate whether self-oriented and socially prescribed perfectionism continue to increase in tandem with personal standards, concerns about mistakes, and doubts about actions. Second, we examine generational differences in higher order dimensions of perfectionism (perfectionistic strivings and concerns). Third, we investigate whether changes in gross domestic product per capita and inequality account for temporal differences. Fourth, we test whether relationships between perfectionism and psychopathology are changing over time. Cross-temporal meta-analyses of 307 samples encompassing 82,939 American, Canadian, and British college students revealed that self-oriented perfectionism, concerns over mistakes, and doubts about actions increased linearly. Socially prescribed perfectionism followed a quadratic trajectory, with a notable acceleration starting in the early 2000s. At the higher order level, perfectionistic strivings increased linearly, whereas perfectionistic concerns followed a quadratic trajectory. Declining gross domestic product per capita was associated with higher perfectionistic strivings, while rising inequality was associated with steeper increases in perfectionistic concerns. Furthermore, correlations between perfectionism and psychopathology remained stable over time. Overall, results reveal that college students increasingly perceive others as excessively demanding while becoming more demanding of themselves, accompanied by growing indecisiveness, uncertainty, and sensitivity about making mistakes. (PsycInfo Database Record (c) 2026 APA, all rights reserved).
The taxonomic status of Pseudoheterolebes cotylophorus (Ozaki 1935) Yamaguti 1959 (Opecoelidae: subfamily Opistholebetinae) has been a subject of taxonomic confusion since its initial description by Ozaki in 1935 as Opistholebes cotylophorus Ozaki 1935 from diodontid fish in Japan. The species' current recognised classification dates back to Yamaguti's reclassification of O. cotylophorus as Pseudoheterolebes cotylophorus; however, doubts persist regarding this classification and the validity of this species. The species was reported by Bray in 1986 from off the coast of South Africa, based on a single specimen infecting the evileye blaasop, Amblyrhynchote honckenii (Bloch) (Tetraodontidae). However, recently, this report from the South African coastline was considered doubtful. Parasitological assessments of South African marine fishes provided the opportunity to recollect this taxon from the same host species reported by Bray, allowing a reassessment of its taxonomic status. Morphological and molecular phylogenetic analyses, incorporating ITS2 and 28S rDNA, as well as cox1 and nad1 mtDNA sequence data, support the identification of the South African material as Opistholebes cf. amplicoelus; demonstrating both the value of molecular approaches in the identification and classification of marine parasites and the need for additional life-cycle data to fully resolve species boundaries.
Diagnostic errors significantly impact patient outcomes and are often linked to dysfunctional team dynamics. Gaslighting, characterized by patterned distortion and doubt induction, is increasingly recognized among health care professionals and may compromise diagnostic safety. Traditionally examined in provider-patient relationships, gaslighting within teams remains underexplored. This concept analysis examines gaslighting within health care teams in the context of diagnostic safety, identifying its defining attributes, antecedents, consequences, and implications. The Walker and Avant method was used to guide this concept analysis. A systematic literature search was conducted across PubMed, CINAHL Plus with Full Text, Medline, PsycINFO, and Embase, yielding 12 articles meeting inclusion criteria. Extracted data were analyzed to identify common themes, focusing on gaslighting's characteristics, triggers, and outcomes within interprofessional teams. Gaslighting in health care teams is characterized by dismissiveness, undermining behavior, and induced doubt in colleagues' clinical judgments. Antecedents include hierarchical power structures, workplace stress, and poor communication. Consequences involve emotional distress, loss of trust, and increased risk of diagnostic error. Tools like the Gaslighting at Work Questionnaire may assist in assessment. Recognizing and addressing gaslighting is critical to improving diagnostic safety. Organizational strategies must support psychological safety, open dialogue, and professional respect.
This project explored COVID-19 workplace hazards and factors influencing the implementation of risk mitigation approaches among small businesses in a high-risk community. Using a novel framework, data were collected from 90 workplaces through site visits and consultations with at least one owner, manager or supervisor ("employer") and at least one non-managerial staff member ("employee"). A risk assessment and mitigation plan were prepared based on site-specific hazards; later, a follow-up visit assessed whether recommendations had been implemented and factors influencing these decisions. A total of 84 businesses (93.3%) implemented at least one recommendation, citing ease and staff and/or customer preferences as motivating factors; businesses that did not implement controls doubted their effectiveness and/or reported lack of feasibility. Although employers and employees generally agreed on job-related exposures, discrepancies existed that may have underestimated employees' time at risk. Importantly, this project provides evidence that small business owners are receptive to - and, often, eager for - targeted occupational health and safety information and support. To our knowledge, this is the first effort to provide small businesses with worksite-specific respiratory disease risk assessments and tailored remediation plans as well as the first to assess their willingness to implement such recommendations.
Hybridization can be widespread among closely related plant species, and the resulting intermediate traits may complicate species delimitation and identification. Such taxonomic uncertainty can lead to misinformed conservation actions or poor resource management. Aquilegia incurvata is a Chinese endemic species restricted to the Qinba Mountains. Despite numerous field surveys in its reported distribution area, over a five-year period, no specimens fitting its description in "Flora Tsinlingensis" have been found, casting doubts on the validity of this species. To determine whether A. incurvata truly exists, we examined the type specimens of A. incurvata (including holotype and paratypes), as well as fresh material from four populations of Aquilegia occurring at the type locality. We also conducted morphological and genetic analyses to explore species boundaries between A. incurvata and four closely related species (A. ecalcarata, A. kansuensis, A. yabeana and A. yangii). Additionally, we integrated morphological and genetic data from 12 previously reported populations of these four closely related species. We performed morphological clustering via principal component analysis (PCA), as well as phylogenetic and population genetic analyses. Eleven floral traits from six type specimens and four populations were quantified for interspecific differentiation. Strict filtering of whole-genome resequencing data yielded 9,073 high-quality SNPs and 20 cpDNA loci from A. incurvata's type specimens and its closely related species. Our study revealed two key findings: (1) The type specimens of A. incurvata are hybrids between A. kansuensis, A. yangii and A. ecalcarata, with genetic components of all three species and floral morphology intermediate between A. kansuensis and A. yangii; (2) Samples from the locus classicus and the provenances of the paratype specimens of A. incurvata cluster into two groups-One corresponds to A. yabeana and the other one to A. kansuensis. Our study confirms A. incurvata is not an independent species but a local hybrid.
Medical education's pursuit of excellence often inadvertently fosters a "hidden curriculum" of perfectionism and shame. This culture can transform adaptive striving into maladaptive perfectionism, where a fear of failure leads learners to view mistakes not as growth opportunities but as evidence of moral failings and personal inadequacy. When errors inevitably occur, the potential result is shame or an identity-focused belief that "I am bad." The resulting isolation and self-doubt potentially can lead to imposter syndrome, burnout, and depression. This paper explores the critical role of shame-informed mentorship, an approach that recognizes how shame influences learner behavior and development. By responding with intentional strategies that preserve dignity, mentors can mitigate shame's potential impact and transform it into a catalyst for professional growth. We argue that by helping learners distinguish between corrosive shame ("I am the problem") and productive guilt ("I did something wrong"), mentors can facilitate behavioral change without damaging the learner's core identity. The paper offers practical, evidence-based strategies organized into three themes: Recognition-identifying "shame primers" such as perfectionistic histories and "shame triggers" like public questioning; Navigation-using validation, self-compassion, and the practice of "failing forward" to process active shame events; Cultivation-building long-term resilience through intellectual humility and the normalization of shared narratives. Collectively, these strategies provide a framework for intentionally building psychological safety and normalizing mistakes. By equipping mentors with tools to recognize and respond to shame, and by creating a culture that prioritizes formative feedback and a growth mindset, mentors can help transform shame from a destructive force into a catalyst for professional identity development and sustainable practice.
Artificial intelligence (AI) is increasingly applied in medicine, including clinical decision-making. AI-based decision support systems (DSS) can enhance early risk detection and treatment optimization. However, the perspectives of patients and their support persons on AI-assisted DSS in clinical care, particularly regarding shared decision-making (SDM), remain underexplored. This study investigates the expectations, informational needs, and perceptions of patients who underwent kidney transplantation and their support persons regarding AI-assisted DSS and its influence on SDM in posttransplant care. In a longitudinal qualitative study, 36 semistructured interviews were conducted with patients who underwent kidney transplantation and their support persons at a German kidney transplant center. Participants were asked about their views on AI's role in follow-up care, its impact on communication, trust, and decision-making, as well as their informational needs regarding AI-assisted DSS. Interviews were transcribed, pseudonymized, and analyzed using framework analysis. Participants recognized AI's potential to support clinicians by identifying risks of transplant loss, rejection, and infection, and by providing data-driven treatment recommendations. However, they emphasized that final decisions should remain with physicians. A majority of participants (n=28, 78%) expressed concern that AI might depersonalize care and diminish physician-patient communication due to a lack of "human touch." Participants demonstrated limited understanding of AI-based DSS functionality and highlighted the need for simple, accessible educational materials (eg, leaflets) explaining AI operations. While most doubted AI could replicate human empathy, some acknowledged that AI might be perceived as more attentive than time-pressured physicians, offering consistent monitoring and support. Participants consistently stressed that AI should augment, not replace, clinical decision-making. Patients who underwent kidney transplantation and support persons endorse the integration of AI in follow-up care when it enhances clinical decision-making without supplanting the physician's role. Acceptance and trust depend on transparency, accountability, and preserving the "human touch" in care. The development of educational tools to communicate AI functions and limitations is crucial to empower patients and support persons in SDM processes and to ensure AI complements, rather than undermines, patient-centered care.
Qiancao is a common medicinal herb worldwide, which roots and rhizomes exhibit properties of cooling blood, arresting bleeding, activating meridians, and promoting blood circulation, colloquially known as "Bloodstanch" (Xue Jian Chou). Since its 1963 edition, the Pharmacopoeia of the People's Republic of China has stipulated Rubia cordifolia L. as the sole botanical origin for the medicinal herb Qiancao. However, the morphological similarities among various medicinal Rubia species pose a significant challenge for accurate identification, commonly resulting in their substitution or adulteration, some of which are documented in local standards. This review systematically summarizes the traditional use, morphological characteristics, phytochemical composition, pharmacological effects and toxicology of Rubia cordifolia L. and two widely studied medicinal Rubia species (Rubia yunnanensis Diels and Rubia tinctorum L.), providing insights into the feasibility of these common alternatives. A total of 166, 130, and 143 compounds have been isolated from them, respectively. Extensive studies have demonstrated that extracts and isolated compounds from Rubia plants exhibit diverse pharmacological activities, including anti-inflammatory, anti-tumor, antioxidant, antibacterial, anti-platelet aggregation, and neuroprotective effects. However, chronic use of Rubia tinctorum induces hepatorenal tumors in mice, with identified carcinogens including lucidin, rubiadin, and alizarin. Currently, the phytochemical profiles of these three herbs have been extensively studied, which reveals that they possess only a limited set of common constituents, casting doubt on their clinical interchangeability. Future research should compare the levels of common compounds and the distinct profiles of components with marked bioactivity among these three herbs to further substantiate their potential substitutability.
Increasingly in psychiatric and psychotherapeutic training, simulated patients (SPs) participate in the teaching and evaluation of clinical skills and knowledge. Despite their widespread involvement, doubt remains as to whether a genuine therapeutic alliance can be established with SPs. Further, little is known about the SP's perspective on alliance formation which is an important gap given the correlation between patient perception of alliance and therapeutic success. We interviewed three simulated patients about their perception of the bond formed during role plays of standard full-length psychiatric diagnostic assessments. Each SP played their role multiple times yielding sixteen unique interactions and therefore sixteen interviews. SPs watched a complete video recording of each of their role plays. After watching each role play, they rated their interaction with the psychiatrists using the bond subscale of the Working Alliance Inventory (WAI). Following the ratings, each SP was interviewed about the bond formation in each interaction. Despite the simulation, SPs were able to form bonds with psychiatrists across full-length diagnostic assessments. Feeling respected by the psychiatrist, both in the psychiatrist's attempt to understand the problem and in their approaches to finding solutions facilitated bond formation. However, SPs had different preferences as to how respect should be conveyed. When it went well and when it went wrong, bond formation was affected by the same factors in the simulations as is the case in real practice. Our results suggest that from the point of view of SPs, a therapeutic alliance as reflected by bond formation can be established between psychiatrists and SPs in the context of full-length diagnostic assessments. These findings would be strengthened through replication involving comparison of both the SP and the psychiatrist perspectives.
In the randomized controlled trials (RCTs) of the non-vitamin K dependent oral anticoagulants (NOACs) that led to their approval, the vitamin K antagonist (VKA) warfarin was used as a comparator drug. The efficacy and safety of NOACs compared to phenprocoumon, the VKA predominantly used in Germany, are unknown, as it has not been studied in RCTs. For this systematic review and meta-analysis (registration: CRD42024619047), we systematically searched 3 databases for studies based on routine data that yielded matched or adjusted results for overall mortality, thromboembolism, and major hemorrhage in anticoagulant-naïve patients who were treated with either phenprocoumon or a NOAC. Seven studies based on German routine data were identified, covering a total of 1 842 015 anticoagulant-naïve patients. In a pooled analysis of all NOACs (apixaban, dabigatran, edoxaban, and rivaroxaban), these were associated with a notably higher risk of mortality (hazard ratio [HR] 1.14, 95% confidence interval [1.00; 1.30]), a higher risk of thromboembolic events (HR 1.08, [1.01; 1.15]), and a lower risk of major hemorrhages (HR 0.80, [0.72; 0.90]) than phenprocoumon. Among individual NOACs, rivaroxaban was associated with a notably higher risk of mortality than phenprocoumon; the other NOACs also displayed a higher risk of mortality than phenprocoumon, but the differences were not statistically significant. In this meta-analysis of NOACs versus phenprocoumon, the former were found in a pooled analysis to be associated with a higher overall risk of mortality and a higher risk of thromboembolic events on the one hand, but a lower risk of major hemorrhages on the other hand. Warfarin was the comparator drug in all of the clinical trials that led to the approval of NOAC. The findings of this meta-analysis cast doubt on the benefit of the preferential use of NOACs in countries where phenprocoumon is the standard VKA.