First Ketone incident today....feeling overwhelmed. :(

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Haley&Diane

Haley&Diane

Member Since 2015
Well, Diane stopped eating again this past weekend. Friday morning she was eating fine, and ate her dinner too. I gave her Young Again zero carb dry for dinner for the first time to see if she liked it. Then, the next morning...NOTHING. She wouldn't eat any of her food that I gave her....but she'd eat pieces of turkey lunch meat and cooked chicken. She wanted food, just not HER food. She was acting normal/happy. She did have a few coughing incidents though.

I finally got a urine sample on Sunday (took forever to get!) and she had a "trace" of ketones it showed. Her glucose remained at 215-255 throughout the day. She ate some whiska's I gave her (which made her sugar go up but at least she ate!) and I took her to the vet Monday afternoon. The vet wasn't too concerned. She gave her an allergy med for the coughing and said her sense of smell may be slightly off. She wasn't very concerned about the ketones, but told me to come back in two days (today) to do a urine test and possibly Sub-Q fluids. She did lose a pound since her appt. 3 weeks ago. After the vet appointment, Diane got home and started eating a new food I got her (special kitty tuna) and she ate a good amount of it (1/4 can of a big/tall can). I've been giving her the allergy med and she hasn't had any coughing incidents since.

She still turns her nose up at most of her cat food, but last night she ate 1/4 of a chicken breast, some baby food, and some of her wet food. She also ate some of her wet food this morning (less than 1/4 can of friskies). She seems to lick her food more than actually eat it for some reason.

I took her back to the vet this morning for a re-check and she tested as +1 for ketones...they said it was just a trace. She also had some sugar in her urine. They gave her fluids to flush them out and an appetite stimulant. Thankfully the fluids were only about $20 and it wasn't too serious. The vet said it's probably time to start her on insulin, but we didn't do that today because I am moving tomorrow and she thinks it's better to get settled this next week before starting her on insulin. She also suggested glipizide as an alternative. She said levels under 300 are generally good and if it's under 250 on food alone, that's great. But because of the ketones she is slightly concerned it may not be low enough for Diane. She did say though that the ketones may have been there since 2 months ago when she was diagnosed (her levels were at 478 mg/dL at diagnosis). For some reason my old vet didn't think to check for Ketones when she was diagnosed, so I will never know how long she's had a trace of them in her urine. The vet also mentioned that her body may not be needing to take in as much food because she is becoming more regulated than she used to be.


I am planning on taking her to the vet next Saturday near where I will be moving to to get their opinions. Hopefully all goes well and I can get her started on insulin or something. My only concern is that I'm going to be staying with my parents for the next couple of months because my new house won't be ready to move in to until mid september. I worry about starting her on insulin because I will be about 40 minutes away at work throughout the week, and won't be able to closely monitor her. When I move into our new house, I will only be 4 minutes so thankfully I will be able to get home for lunch breaks and check on her halfway through the day...

I just realized how long this post is....sorry! D: It just feels good to let it out/rant about it a bit. I'm just feeling so overwhelmed right now. With moving tomorrow, starting a new job next week, and Diane not eating I am feeling so stressed! I just want her to start eating like normal again. She's acting fine...playing, jumping around, talking, chasing the dog, etc. And it's just odd because it's not that she won't eat at all...she just won't eat her cat food. She will eat lunch meat, baby food, chicken, etc....but not cat food. I'm REALLY hoping these fluids do the trick for now...
 
No real advice here, but I can tell you that whenever ANYTHING out of the ordinary is going on, Shiloh is a little off on her food. If we are planning a trip, for a couple of days before we leave, she is off. She just picks up on what is going on around her. I assume you are packing up, and there are boxes around, and things in different places.
 
I'd try to get her on insulin ASAP. The formation of ketones is because she's unable to utilize food as her energy source, so basically, without insulin, her body is starving itself. Add on the lack of appetite, and you have a dangerous situation setting up. I'm not trying to scare you, but DKA can be very dangerous and expensive to treat. You can reverse it now while it's early by adding insulin, but really you can't wait weeks or even a week.
 
Meya, can I give you a tip about the SS? I was doing what you are doing about copying the header row and inserting it every time it moved off the screen. If you highlight those top two rows, click view, freeze, and 2 rows, it will stay there on the screen as you scroll down.
 
Agreed. Insulin asap.

We have not seen any success here with Glipizide.. Thw thinking is that it taxes the pancreas; it doesn't allow it to rest and recover like insulin does.

Can we help you brainstorm some ways to make this process more doable? Maybe plan to keep her away from the move, taking her over when it is all done. We accomplished this by emptying one room and leaving the cat in there with food, water and a blanket that smelled like us. We also tried a trick I read somewhere about putting vaseline on their paws. They walk on the carpets and get the smell of the old house. Then they transfer that to the new one.

Can you arrange to be home the first day of insulin or to start on the weekend. Once you have a few shots and blood glucose levels, you may feel better about leaving her.
 
Unfortunately I am re-locating 3.5 hours away from where I am now. I'm sure the stress of the packing isn't helping her. Thankfully though, when she and I go this weekend it will just be us, her stuff, and my clothes. I'll just be living with my parents for a while until we can do the big move (mid-september) when our house is ready. I just need to go now to start my new job next week and didn't want to leave her with my boyfriend who is staying at our current apartment with our other animals until September. He doesn't know much about diabetic cats.

So, does glipizide not lower the glucose levels? All of the vets I've talked to where I'm at now (and where I will be moving to) said they've had some success with it and would prefer to do insulin as a worst case scenario. They say with her levels being at about 225 off of insulin, their concern is the insulin dropping her too low since her numbers are already fairly good for a diabetic.

I contacted my vet and am trying to see if she will write me a prescription for that or insulin to see if I can get her started this weekend...I'm just waiting to hear back. I used to work at a vet's office and have given insulin injections/monitored diabetics before, so I will at least know what to keep an eye out for this weekend. My only concern with starting insulin specifically this weekend is the cost. How much does it typically cost? I wanted to order from Canada but that would take weeks so I know if I go the route of insulin I will have to just get it from a local pharmacy.

Also, is she considered DKA if she just had a trace of ketones? Wouldn't the fluids have flushed them out? I'm just wondering about that. I'm also wondering if she's had them this entire time and she didn't go downhill quickly after diagnosis if so. She is still acting normal, thankfully.
 
Luna's been at a moderate-small amount of ketones for awhile, no symptoms though.. working hard to get her insulin to a level where the ketones get taken care of. Last check was 16.8mg/dL which is well above trace :(
 
Haley&Diane said:
Unfortunately I am re-locating 3.5 hours away from where I am now. I'm sure the stress of the packing isn't helping her. Thankfully though, when she and I go this weekend it will just be us, her stuff, and my clothes. I'll just be living with my parents for a while until we can do the big move (mid-september) when our house is ready. I just need to go now to start my new job next week and didn't want to leave her with my boyfriend who is staying at our current apartment with our other animals until September. He doesn't know much about diabetic cats.

So, does glipizide not lower the glucose levels? All of the vets I've talked to where I'm at now (and where I will be moving to) said they've had some success with it and would prefer to do insulin as a worst case scenario. They say with her levels being at about 225 off of insulin, their concern is the insulin dropping her too low since her numbers are already fairly good for a diabetic.

I contacted my vet and am trying to see if she will write me a prescription for that or insulin to see if I can get her started this weekend...I'm just waiting to hear back. I used to work at a vet's office and have given insulin injections/monitored diabetics before, so I will at least know what to keep an eye out for this weekend. My only concern with starting insulin specifically this weekend is the cost. How much does it typically cost? I wanted to order from Canada but that would take weeks so I know if I go the route of insulin I will have to just get it from a local pharmacy.

Also, is she considered DKA if she just had a trace of ketones? Wouldn't the fluids have flushed them out? I'm just wondering about that. I'm also wondering if she's had them this entire time and she didn't go downhill quickly after diagnosis if so. She is still acting normal, thankfully.
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Having ketones does not mean DKA, as it is more of a precursor to DKA. DKA is a state that can happen if ketones remain unchecked or the levels get too high. I've also heard some cats are more prone/resilient to it than others. I think my Luna is very resilient to it because she is at small/moderate levels (above trace) and has 0 symptoms.

From what I understand ketones develop when there is not enough insulin in the body to properly metabolize calories from food? Insulin I believe is the 'treatment' for non-DKA episode level's of ketones. I'm sure someone could word that better then me.

Are you home-testing for ketones? I personally use a blood monitor to test for ketones, works great. There is also urine strips. Both are much cheaper then going to the vet each time.

Also according to your spreadsheet I think you could definitely use some insulin. ~250-300 is still very high, and with proper monitoring I think insulin would really help. Realistically you want to see numbers in the 50-150 range which is below the rental threshold of 220 I believe. What the vet said about those numbers being 'good' is kind of wonky to me as those number's need to coem down.
 
Ketones will continue to develop as long as her metabolism is burning her fat for fuel. It's somewhat independent of the blood sugars. Ketones don't always mean DKA, however, they increase the likelihood of dehydration which can put a cat into DKA very quickly. Often the first sign that ketones are progressing to DKA is lack of appetite and nausea. Decreased calories further the issue. It's a very vicious cycle.

Insulin is more effective in producing remissions than oral antidiabetics in cats. It's also easier to titrate the dose in my opinion which makes it safer. Glipizide can cause hypoglycemia as well, so either way you do have to monitor for this. Glipizide vs insulin doesn't really reduce the incidence of hypoglycemia events.

I buy my insulin from the vet. Levemir and lantus have 300 unit pens that are around $100 a piece. They usually come in boxes of a few pens, but some pharmacies might split a box and sell you a single pen. The vials are about $300 and really are way more insulin then most people can use quickly enough. Walmart and target both have cheap meters/strips for testing. Syringes can range anywhere from $10-$40 a box depending on what you like.
 
pevsfreedom said:
Having ketones does not mean DKA, as it is more of a precursor to DKA. DKA is a state that can happen if ketones remain unchecked or the levels get too high. I've also heard some cats are more prone/resilient to it than others. I think my Luna is very resilient to it because she is at small/moderate levels (above trace) and has 0 symptoms.

From what I understand ketones develop when there is not enough insulin in the body to properly metabolize calories from food? Insulin I believe is the 'treatment' for non-DKA episode level's of ketones. I'm sure someone could word that better then me.

Are you home-testing for ketones? I personally use a blood monitor to test for ketones, works great. There is also urine strips. Both are much cheaper then going to the vet each time.

Also according to your spreadsheet I think you could definitely use some insulin. ~250-300 is still very high, and with proper monitoring I think insulin would really help. Realistically you want to see numbers in the 50-150 range which is below the rental threshold of 220 I believe.
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Aw, i hope your Luna gets better! I'm glad she isn't showing symptoms though. that's always good!

I started home testing this past week for ketones. It showed up as a trace in her urine. I will keep testing her urine, but may look into a blood monitor to test for it too. If only they made glucometers that tested the blood sugar and the ketone levels!
 
Meya14 said:
Ketones will continue to develop as long as her metabolism is burning her fat for fuel. It's somewhat independent of the blood sugars. Ketones don't always mean DKA, however, they increase the likelihood of dehydration which can put a cat into DKA very quickly. Often the first sign that ketones are progressing to DKA is lack of appetite and nausea. Decreased calories further the issue. It's a very vicious cycle.

Insulin is more effective in producing remissions than oral antidiabetics in cats. It's also easier to titrate the dose in my opinion which makes it safer. Glipizide can cause hypoglycemia as well, so either way you do have to monitor for this. Glipizide vs insulin doesn't really reduce the incidence of hypoglycemia events.

I buy my insulin from the vet. Levemir and lantus have 300 unit pens that are around $100 a piece. They usually come in boxes of a few pens, but some pharmacies might split a box and sell you a single pen. The vials are about $300 and really are way more insulin then most people can use quickly enough. Walmart and target both have cheap meters/strips for testing. Syringes can range anywhere from $10-$40 a box depending on what you like.
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To properly use a 1000 mL 'vial' of lantus would require 5.5 units/day of Lantus in 6 months if I remember right, which is about a long as you want to store lantus once opened and in the fridge. So basically if you're not giving 5.5 units/day it's not worth it. I also use the 300mL pens which run about $75 at VetRXDirect.com
 
Haley&Diane said:
Aw, i hope your Luna gets better! I'm glad she isn't showing symptoms though. that's always good!

I started home testing this past week for ketones. It showed up as a trace in her urine. I will keep testing her urine, but may look into a blood monitor to test for it too. If only they made glucometers that tested the blood sugar and the ketone levels!
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Haley&Diane said:
Aw, i hope your Luna gets better! I'm glad she isn't showing symptoms though. that's always good!

I started home testing this past week for ketones. It showed up as a trace in her urine. I will keep testing her urine, but may look into a blood monitor to test for it too. If only they made glucometers that tested the blood sugar and the ketone levels!
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They do. The Precision Xtra monitor tests both, though the blood sugar strips are overpriced. I use that monitor for ketones (buy the strips on eBay) and a bayer contour next for blood sugar, so I use 2 monitor's but it's very cheap.

And thanks I hope I can get her down too. I only started home testing 2 weeks ago and am barely getting her under 300. She has a vicious appetite (she always has, I think her old home never fed her or something) so those ketones (should) be held at bay until her insulin gets to the proper level.
 
Thanks everyone! I did a urine test just now and her levels have gone from "trace" on Monday and this morning....to MODERATE.

Do ketones go up due to stress? I guess I was expecting the fluids to have made them go away, but I def. wasn't expecting to see moderate. The vet just called me and told me that she's not concerned about the ketones because they are likely up due to stress, but that she suggests I get Diane to a new vet in the area to start her on insulin Saturday if I'm concerned. She told me I could probably wait until next weekend, but to get her in if it eases my mind. So...looks like I'll be calling clinics tomorrow! Hopefully I will find a good one and get her started on insulin Saturday and Sunday! I'm nervous since I won't be able to monitor her at home next week while I'm at work though :(
 
With increasing ketones, you do need to stop this progression - she's burning her body's fat instead of the food she's eating. Her body needs the insulin to use the food properly. DKA (diabetic ketoacidosis) - right now she's 'ketonic' headed toward acidic as she burns more fat. Fluids will HELP flush ketones there right now but more are replacing those flushed faster than you can keep up with them. Please DO get her somewhere to start her on insulin ASAP to stop this, even waiting until this weekend may be stretching it now. It's a lot easier to stop it right now than trying to bring her out of DKA. Please also check for an infection of some kind.

HUGS from someone that's lived thru that ketonic stage!
 
Unfortunately, i don't have much of a choice today. My vet wouldn't write me the prescription because she said it'd be more dangerous to start giving her insulin today/tomorrow before I have a vet lined up where I'm moving to. I called and made an appt. where I'm moving tomorrow at a vet office that got okay reviews.

The only problem is that it is $69 a visit! ($29 for the first visit). I can't afford $69 a visit just to see the vet in the future. I'd like to take her to a vet I can keep her with in the future...rather than go to this vet for the prescription and then never go back and switch to another vet.

She isn't acting like she is ketonic. I just wonder why the vet says it's nothing to worry about yet. She said if the ketones are there monday, then i need to worry. But she says stress causes them to go up. I'm just a basket case tonight. i don't want to go to an emergency clinic because I really couldn't afford $100 just to see a vet (or whatever the prices are)
 
Stress does not cause ketones to go up. Ketones are caused by either lack of food (starvation) or lack of insulin necessary to process the food. If $69 is too expensive now, please consider that DKA can happen very quickly (in a matter of a day sometimes), and the cost for treating DKA can be upwards of $1000. It might be worth seeing another vet or a mobile vet to see if you can get a prescription.

Moderate ketones increased from trace is concerning and needs to be addressed today. If you do get the script, there will be people here to answer questions until you can get yourself to the new vet.

Heres some more info: http://www.felinediabetes.com/FDMB/...oacidosis-dka-and-blood-ketone-meters.135952/
 
It's 7:00 pm where I'm at now. I don't know any vet that is open right now. And i dont know a vet that will give me a prescription right now. My vet wont. I'm going to call a vet where I'm moving tomorrow and see f they can squeeze me in. Hopefully I can get there by lunch time. I'm fine with spending the money if I really need to.

Would emergency clinics write prescriptions if I went to one?
 
To be honest the vet you're seeing now sounds kind of shady. I would try and call around any 24 hour vets and bring in your diagnosis perhaps of diabetes and see if they can just approve an Rx for insulin. Tomorrow I would demand a prescription from your current vet. Tell her you did your homework and your cat NEEDS insulin.

Yes, emergency clinics should give you a prescription if you can show you have a diagnosis, but you'll probably get charged a consult fee or whatever, just see if you can explain the situation to one and maybe they'll let you off easy with an Rx.
 
The other alternative is if you know of any human diabetics on lantus or levemir who have a vial that is getting close to past the 28 days these people keep them. Lots of people don't finish they whole vial before they get the refill. You may be able to snag a vial from someone you know until you can find a vet who will give you a script. But you still need to touch base with a vet pretty soon even if you do get the insulin.
 
So....I talked to my sister who is a veterinarian. Unfortunately, she said it's illegal for her to write a prescription unless she's seen Diane in an official office visit so she said she doubts other vets would be able to. But she told me that she thinks it'd be fine to just wake up early tomorrow, drive 3.5 hours for our move, and immediately go to the vet in my hometown that my parents still use. I'm just going to leave at about 6 am, call the vet when they open at 7:30 and tell them I'm on my way.

I know the vets there so I'm hoping they will be easy to work with. I'll just tell them I want a prescription that day, and I'm not going to wait on it. Then my plan is to pick up some Lantus tomorrow after the vet and get her started on it tomorrow. She's acting fine so I'm not going to take her to the emergency clinic tonight....plus they told me on the phone that they can't even guarantee they'd write me a prescription for her tonight.

I like my current vet because she is so nice and is great with cats, but this worries me. If I can get her started tomorrow then I can monitor her the entire weekend to get her regulated so that I will be okay with leaving her for work next week.

I will keep everyone posted!! Thank you all so much!!
 
Oh she thought it was ridiculous that the vet wouldn't just write the prescription today. She said she gets the holding off on insulin since Diane's numbers haven't been too terrible, but that she probably would've had her on insulin sooner. She just couldn't believe the vet would say that I should probably start diane on insulin and then tell me to wait till the weekend or next weekend to go find a vet to work with where I am moving. She told me ketones aren't anything to take lightly.
 
Sadly, no. She will still be about 2-2.5 hours away. If she were closer I would just go to her tomorrow! Would've been so much easier. lol.
 
That sounds like a good plan, and probably the earliest you would be able to get everything going. Hopefully everything goes smoothly with the new vet. Having a vet in the family is probably pretty nice, even if it is just to bounce ideas off of. It's probably not great timing with moving and job changes and all that, but is there really any good timing for illnesses/diabetes? Good luck!
 
It is good to have a vet in the family in these situations for sure! The only bad part is that we have disagreements on foods for diabetics and other things though. :) She only recommends DM, of course.

You're right there is definitely never a good timing for stuff like this....hopefully she will start feeling better though after I get her situated tomorrow...then it will all be worth it!

Thanks again!
 
In some states, you can get Humulin or Novolin NPH from a pharmacist without an Rx; I can in Ohio. While it is not an optimal insulin long-term, it can help if you very cautiously start giving some (like 0.5 units). Your aim is not to drop the glucose to normal right away. @Meya14 will tell you to feed, and test diligently as needed and bring down the ketones gradually. Going too fast can cause other problems. And you absolutely must keep your cat hydrated.
 
MY OPINION ONLY - with moderate ketones already present, a faster acting insulin than Lantus is needed right now. Yes Lantus is wonderful for cats but it takes at least 3 days and possibly 4 to begin providing enough insulin to affect the ketonic state. 'Humulin N' or 'Novolin N' (just different mfg'rs) or ProZinc (available from vet) would be better to start with then begin Lantus when ketones are gone.

@BJM @Meya14 @Jill & Alex (GA) - additional opinions on this?
 
NPH can be obtained over the counter in some, if not most, states in the US. But, it is harsh and ketones are present, so starting with a low dose (0.5) and monitoring like a hawk is needed. Giving insulin starts changing the potassium levels and other electrolytes, so it must be done carefully, and is better done at the vet when DKA is a possibility.
 
I agree, the shorter acting insulins are sometimes faster at getting rid of the ketones, but they will also have a faster reduction in the potassium which is dangerous. Also, the potential for hypoglycemia is higher for the shorter acting insulins such as NPH or regular, so unless someone has experience or is able to watch like a hawk, I think these are best left to inpatient care where a dextrose drip can be initiated as needed. Prozinc might be a good compromise, however, the benefit of starting on lantus or levemir is that when the ketones are gone, these basal insulins are much better for preventing further DKA as they provide a constant insulin supply. Prozinc can leave cats for a couple hours a day without insulin.
 
It's been such a long day already! Got up at 6, drove to where I will be living temporarily for the next 2 months, and thankfully my parents' vet that they've used for the past 10 + years had an opening. I've taken my dog to this vet in the past too...she's great!

They did a glucose check and urinalysis on Diane. Her glucose was 223 mg/dL and they think it was that at a stressed level...so they suspect her normal glucose to be about 200 or lower (my glucometer at home always read +20 of what the vets' reads so she was 250 when I tested before the vet).

The vet spent about 30 minutes looking over her records, asking questions, looking at Diane, etc. She wasn't concerned that Diane has lost 4 lbs since diagnosis because she said Diane really needs to lose a few more anyway (she suggest 9-10 lbs.). She suspected Diane may have a UTI and once she checked the urinalysis, it was confirmed she does have a UTI. She also has a reading of 2+ ketones with some sugar in the urine. The vet said her kidneys are being slightly stressed.

But, she said there's a good chance the UTI is the main issue here. She did also say that ketones can increase due to stress due to increased blood levels. She gave her a strong antibiotic shot and gave me antibiotics to start her on tomorrow. She also wanted me to try giving her Hills M/D due to the high fiber and protein content. She wasn't happy with Diane's protein levels. She also had protein, red/white blood cells, and bacteria in her urine. She was okay with the FF feeding, but she really wanted me to try the M/D because it will help her lose weight and get her protein back. She also gave Diane more fluids today just to help her to feel better.

The vet said next week at this time if there are still ketones we will likely just hospitalize her for one or two days. But she says the ketones should be gone completely by next Friday with this treatment. In regards to food, she said if Diane eats even just a few bites at breakfast/dinner then that's good enough for now. Once the UTI goes away, she will likely get an appetite back.

In regards to insulin, she says Diane's levels aren't very high at all and she wouldn't recommend insulin. She said we can get rid of the ketones by clearing up the UTI, giving fluids, and getting her to eat full meals again once she feels better. Since she suspects Diane's levels are at 200 and maybe even less than that when she isn't stressed, she doesn't want to put her on insulin.

So...Diane is now resting in the bedroom and watching the birds outside. She seems to be feeling better...still won't touch her food but I didn't expect her to only 2 hours after we get out of the vet's office. She's adjusting perfectly to our new temporary home (thankfully!).
 
I've heard Hills is one of the worst things you can give a diabetic cat, and oddly the most pushed food by vets. Everything else sounds good though. From what I understand infections (UTI) can absolutely stress BG level's and promote ketones if I'm not mistaken, maybe that's the only problem here! Would be great.
 
Yeah, that's what I read about the Hills too. That's why when the vet tried sending me home with a case, I told her I only wanted 2 cans. I figured I'd try it to get her to eat something, but I doubt I will switch over to it completely. I'm really hoping the UTI is the issue here. *fingers crossed*
 
I wouldn't give her the Hills at all personally.

Per the cat food chart:
Veterinarian-Prescribed Hill's m/d 46 41 14

that's 46% protein, 41% fat, 14% carbs.
8% is the 'max' people recommend for diabetic cats in regards to carbs.

Compare that to fancy feast which you said you're giving (check the FLAVORS on the chart to see if they're as good as the chicken/tuna #'s):
Fancy Feast Flaked Chicken & Tuna Feast 57 35 8

that's more protein then the hills (and your vet wants a high protein diet) and less carbs.

I'd stick with the fancy feast completely.
 
It's possible that fixing the infection will improve the blood sugars as well as decrease and get rid of ketones. It's also possible that it doesn't too without insulin, so keep a very close eye on her. If she isn't eating for more than a day or two, it can be very damaging to the liver, and the ketones can increase. Keep testing for ketones at least daily, and make sure they are going down. If they go up, you really need to have her on insulin.

Also, even for diabetes where the blood sugars aren't that high, there is value in starting insulin. Cats who are started on insulin and get the blood sugar under control pretty quickly have an increased chance at remission of the diabetes.

If you are testing at home, there's really no good reason not to start. Vets are taught management of diabetes where most people don't home test. In order to keep the cats in these situations safe, they run them a little higher, in the low 200s. This is not ideal, though, just safe if no glucose checks are being done. Normal blood sugars are always ideal, and can prevent complications.
 
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