? 3/9 Ducia +11 372, AMPS 405, 0.75U need help to monitor her jumpy BGs

[Tanya and Ducia]

Yesterday posts are here:

http://www.felinediabetes.com/FDMB/...2-3-306-5-96-6-65-6-5-75.174515/#post-1914598

Hello,
Ducia continues her 4th cycle on 0.75U dose.

Her overnight numbers were like this:

+2 BG 388, +3 BG 317, +6 BG 176, +9 BG 140, +11 BG 372.

No Yellows. Blue and Pink.

Earlier yesterday in the AM cycle we've seen some Greens, like BG 65 @+6 and after 1 Tbs LC BG 75 @6.5. It was close to the acceptable bottom. I am too inexperienced, only now beginning to understand and I panicked while monitoring her greens. Panicking makes me almost useless. I do my best to control it but it is difficult after the symptomatic hypo. That's why I ask that you please help me read her numbers thru the day and advise as to what to do. I am new to this.

She can go from Red to Green in 2 hours. She has shown big increases in 1 hour. I keep her SS updated.

This AMPS her BG was 405.

@AMPS she received Between 1/4 - 2/3 LC Friskie's Classic Pate, 19 ml water, Metranidazol 0.5 ml and Ringer's solution SQ 75 ml.

Thank you for being with us!

 

[Tanya and Ducia]

I inserted the wrong link earlier by mistake. It should OK now.

 

[tiffmaxee]

Looks like she bounced from the greens and now has to settle in to the lowered dose now that the depot has left. I'd get a +2.

 

[Bobbie And Bubba]

Good Morning Tanya , it looks like Ducia is bouncing this morning from yesterday's greens and they could have been a result of the 1 unit depot . I am glad you got a ketone test and it was just a trace . Are you still giving her sub- q fluids?

The trick is going to be to get enough insulin into safely because to the ketones. Let's see how this cycle goes today to decide what's next.

 

[Tanya and Ducia]

I will post +2 later

 

[Tanya and Ducia]

I'd get a +2.

I will

 

[Tanya and Ducia]

Are you still giving her sub- q fluids?

Yes, 0.75 ml SQ this AMPS. Vet said "daily". We are not sure for how long.

 

[Bobbie And Bubba]

Yes, 0.75 ml SQ this AMPS. Vet said "daily". We are not sure for how long.

That is good because the fluids help to flush ketones.

 

[Tanya and Ducia]

looks like Ducia is bouncing this morning from yesterday's greens and they could have been a result of the 1 unit depot

What if to assume that on 02/28, the hypo day, she was accidetally OD with 10U. If so what with that depot?

 

[Tanya and Ducia]

We give SQF and do ketone test daily

 

[Nan & Amber (GA)]

What if to assume that on 02/28, the hypo day, she was accidetally OD with 10U. If so what with that depot?

That's an interesting question. That's a pretty big dose, but if that happened I would think the depot would still only take a few days to drain. I don't think there'd be any lingering effects now, other than the lingering effects of the hypo itself which might cause some increased sensitivity to insulin.

It is pretty tough to sort out all the different and overlapping forces (the depot, bounces) affecting BGs in a new diabetic under the best circumstances. You're doing a fantastic job collecting data to help with that task!

 

[Tanya and Ducia]

It is tough to read her.
+2 BG 437 is just in.
That's how it was yesterday AM cycle.
At this +2 time what does 1U do? Has start working already or not?
Is it her 1/4 - 2/3 Friskie 9% carbs AMPS meal interferes?

 

[Tanya and Ducia]

if that happened I would think the depot would still only take a few days to drain.

In addition to that possible OD, we also meddled mindlessly by switching doses and by skipping dose

 

[Tanya and Ducia]

Ducia's +2 is 437

 

[Wendy&Neko]

Any depot from 10 units would be long gone, and you are starting to lose any 1 unit depot. The higher depot can influence 4-6 cycles. You should be starting to get a good picture of what the .75 unit dose can do.

She seems to start doing a big drop around +3. I might give an+2 or +2.5 snack of her regular low carb to see if you can slow the drop. Big drops can also cause bounces.

 

[Nan & Amber (GA)]

In addition to that possible OD, we also meddled mindlessly by switching doses and by skipping dose

Well, that does add a little more complexity to the interpretation of the patterns because of the changing depot, but you can still see some major features like how she tends to bounce (some cats can bounce for up to three days, but Ducia seems to have much shorter ones!). And of course, the depot is now stabilizing, no matter what came before.

Lantus is usually thought to "onset" around +3, but it is possible to start seeing some effects earlier. The 437 isn't all that different from the pre-shot 405 so she's holding pretty steady so far, but I'd agree with Wendy that given Ducia's patterns of big early drops, it'd be good to try to anticipate and slow down any dive she has planned for today.

 

[Tanya and Ducia]

I might give an+2 or +2.5 snack of her regular low carb to see if you can slow the drop.

I have 1 Tbs Friskie 11% ready.
Is it "snack" size?
I will offer it at +2.5.

Or, I can give *5 Tbs.
Which one is better?

 

[Tanya and Ducia]

Any depot from 10 units would be long gone, and you are starting to lose any 1 unit depot. The higher depot can influence 4-6 cycles. You should be starting to get a good picture of what the .75 unit dose can do.

She seems to start doing a big drop around +3. I might give an+2 or +2.5 snack of her regular low carb to see if you can slow the drop. Big drops can also cause bounces.

Her big drops worry me a lot. How to flatten it, how to make it smoother?

 

[Nan & Amber (GA)]

Her big drops worry me a lot. How to flatten it, how to make it smoother?

That's exactly what we're trying to do with the snacks now, even before she's started going down. Hopefully, by the time the insulin starts to work to bring her down, the effect of the food will already be in place to act in the other direction, smoothing things out.

 

[Tanya and Ducia]

Any depot from 10 units would be long gone, and you are starting to lose any 1 unit depot. The higher depot can influence 4-6 cycles. You should be starting to get a good picture of what the .75 unit dose can do.

She seems to start doing a big drop around +3. I might give an+2 or +2.5 snack of her regular low carb to see if you can slow the drop. Big drops can also cause bounces.

Is 1 Tbs a snack size?

 

[Wendy&Neko]

I would just give a tablespoon. Keep track of how much you feed. I used the Remarks section on the SS To record the amounts and it allows you to easily see the results. Based on that, then next time do more or less. I would do something under 10% to start. Trying to see what works requires experimenting, as each cat is different in how carb sensitive they are.

 

[Tanya and Ducia]

Thank you Wendy.She had a few bites out of 11% but switched to 9% right away. She eats. I am going to the SS Remarks section

 

[Wendy&Neko]

I don't know if you have seen the post called Where Can I Find, but it's a good one to bookmark. In it is a post called Feeding the Curve, Tashie, that may help you understand how to slow down those fast drops.

 

[Tanya and Ducia]

I don't know if you have seen the post called Where Can I Find, but it's a good one to bookmark. In it is a post called Feeding the Curve, Tashie, that may help you understand how to slow down those fast drops.

I don't see this particular post at the moment but will check it right away. Thank you!

 

[Jill & Alex (GA)]

@Kris & Teasel @Nan & Amber @Bobbie And Bubba

@Tricia Cinco(GA) & Harvey @Wendy&Neko @tiffmaxee

@PumpkinsMom @rhiannon and shadow (GA) @Chris & China

For Ducia's sake, I can no longer bite my tongue. I'm jumping in on this thread with thoughts for consideration...

The basic recipe for developing DKA = an insufficient supply of insulin + inappetance + infection OR other systemic stresses.

Contrary to the apparent prevailing concept, ketones are not about the numbers. When dealing with ketones at home, we're dealing with an "exception"... not the norm. Throw the "usual" out the window!

To rid kitty of ketones it's not necessary to drop kitty into normal numbers. In fact, it can not only be dangerous, but taking this route can often make it harder on the caregiver because kitty has to be watched closely, 24/7, for fear of kitty bottoming out.

In fairness to all, sometimes getting some insulin, food, and fluids (oral + sub-q) into the cat is all it takes to get rid of ketones, BUT it's not happening here. Ducia continues to throw trace ketones. When kitty is throwing ketones we worry about DKA. In Ducia's case, she just came off of DKA, continues to throw ketones... and yet her dose has been reduced.

The fact that Ducia continues to throw ketones tells us she's not receiving enough insulin. I can already hear the objections! How can we possibly increase the dose, let alone hold it, when she's dropping so low? That takes us right back to ketones not being about the numbers.

When kitty is hospitalized for ketones and/or DKA they put kitty on a glucose drip. Why? Because they want to get as much insulin into the cat as they can without kitty dropping too low... going into hypoglycemia. Initially, they're not concerned with pulling down BG numbers into double digits (that comes later, after kitty is no longer throwing ketones). They're more likely to look for nadirs in the 100 - 200 mg/dL range. This provides a buffer of sorts.

When treating kitty at home for ketones/DKA, we don't have the luxury of putting kitty on a glucose drip. So what are our options? What can we do? We can continue as y'all have been and hope for the best OR we can feed kitty foods with a higher percentage of carbs in them... HC or MC or food mixed with karo, depending on the cat. Doing so will help kitty from bottoming out while allowing an increased dose or holding a dose (similar to the work of a glucose drip). Increasing the dose and/or holding a dose is what is needed when a cat continues to throw ketones.

Because Ducia likes to take those early dives, she may need HC to start the cycle and possibly MC continued for several hours. Forget the LC for now. It might take a little experimenting to figure out what works best for her.

With all due respect, please think about what I'm saying. It makes sense. Get rid of the ketones by providing a sufficient supply of insulin... then worry about pulling numbers down.


FWIW, just my thoughts.
And on that note, I have to finish packing for vacation.

@Meya14

 

[Tanya and Ducia]

I am just so confused about it all.


It's +4 time, I'll be back

 

[Phoebes (GA)]

@Kris & Teasel @Nan & Amber @Bobbie And Bubba

@Tricia Cinco(GA) & Harvey @Wendy&Neko @tiffmaxee

@PumpkinsMom @rhiannon and shadow (GA) @Chris & China

For Ducia's sake, I can no longer bite my tongue. I'm jumping in on this thread with thoughts for consideration...

The basic recipe for developing DKA = an insufficient supply of insulin + inappetance + infection OR other systemic stresses.

Contrary to the apparent prevailing concept, ketones are not about the numbers. When dealing with ketones at home, we're dealing with an "exception"... not the norm. Throw the "usual" out the window!

To rid kitty of ketones it's not necessary to drop kitty into normal numbers. In fact, it can not only be dangerous, but taking this route can often make it harder on the caregiver because kitty has to be watched closely, 24/7, for fear of kitty bottoming out.

In fairness to all, sometimes getting some insulin, food, and fluids (oral + sub-q) into the cat is all it takes to get rid of ketones, BUT it's not happening here. Ducia continues to throw trace ketones. When kitty is throwing ketones we worry about DKA. In Ducia's case, she just came off of DKA, continues to throw ketones... and yet her dose has been reduced.

The fact that Ducia continues to throw ketones tells us she's not receiving enough insulin. I can already hear the objections! How can we possibly increase the dose, let alone hold it, when she's dropping so low? That takes us right back to ketones not being about the numbers.

When kitty is hospitalized for ketones and/or DKA they put kitty on a glucose drip. Why? Because they want to get as much insulin into the cat as they can without kitty dropping too low... going into hypoglycemia. Initially, they're not concerned with pulling down BG numbers into double digits (that comes later, after kitty is no longer throwing ketones). They're more likely to look for nadirs in the 100 - 200 mg/dL range. This provides a buffer of sorts.

When treating kitty at home for ketones/DKA, we don't have the luxury of putting kitty on a glucose drip. So what are our options? What can we do? We can continue as y'all have been and hope for the best OR we can feed kitty foods with a higher percentage of carbs in them... HC or MC or food mixed with karo, depending on the cat. Doing so will help kitty from bottoming out while allowing an increased dose or holding a dose (similar to the work of a glucose drip). Increasing the dose and/or holding a dose is what is needed when a cat continues to throw ketones.

Because Ducia likes to take those early dives, she may need HC to start the cycle and possibly MC continued for several hours. Forget the LC for now. It might take a little experimenting to figure out what works best for her.

With all due respect, please think about what I'm saying. It makes sense. Get rid of the ketones by providing a sufficient supply of insulin... then worry about pulling numbers down.


FWIW, just my thoughts.
And on that note, I have to finish packing for vacation.

@Meya14

Very interesting take.

 

[Tanya and Ducia]

+4 BG 313. Not dropped goes slowly. I will retest @+5

 

[Tanya and Ducia]

Very interesting take.

In what way?

 

[Phoebes (GA)]

In what way?

Whenkitty is hospitalized for ketones and/or DKA they put kitty on a glucose drip. Why? Because they want to get as much insulin into the cat as they can without kitty dropping too low... going into hypoglycemia. Initially, they're not concerned with pulling down BG numbers into double digits (that comes later, after kitty is no longer throwing ketones). They're more likely to look for nadirs in the 100 - 200 mg/dL range. This provides a buffer of sorts.

When treating kitty at home for ketones/DKA, we don't have the luxury of putting kitty on a glucose drip. So what are our options? What can we do? We can continue as y'all have been and hope for the best OR we can feed kitty foods with a higher percentage of carbs in them... HC or MC or food mixed with karo, depending on the cat. Doing so will help kitty from bottoming out while allowing an increased dose or holding a dose (similar to the work of a glucose drip). Increasing the dose and/or holding a dose is what is needed when a cat continues to throw ketones.
It kinda makes sense. Why wouldn't we treat with more insulin and steer with higher carbs. I wondered about this a few times.

 

[Nan & Amber (GA)]

+4 BG 313. Not dropped goes slowly. I will retest @+5

Sounds like a plan!

Hopefully the extra snacks is helping to slow her down-- she's dropping, but not as fast as previous days.

 

[Tanya and Ducia]

Whenkitty is hospitalized for ketones and/or DKA they put kitty on a glucose drip. Why? Because they want to get as much insulin into the cat as they can without kitty dropping too low... going into hypoglycemia. Initially, they're not concerned with pulling down BG numbers into double digits (that comes later, after kitty is no longer throwing ketones). They're more likely to look for nadirs in the 100 - 200 mg/dL range. This provides a buffer of sorts.

When treating kitty at home for ketones/DKA, we don't have the luxury of putting kitty on a glucose drip. So what are our options? What can we do? We can continue as y'all have been and hope for the best OR we can feed kitty foods with a higher percentage of carbs in them... HC or MC or food mixed with karo, depending on the cat. Doing so will help kitty from bottoming out while allowing an increased dose or holding a dose (similar to the work of a glucose drip). Increasing the dose and/or holding a dose is what is needed when a cat continues to throw ketones.
It kinda makes sense. Why wouldn't we treat with more insulin and steer with higher carbs. I wondered about this a few times.

The steering which I started to learn/understand this morning is too risky because
1. My inexperience
2. In case of emergency I have no car and no one to drive us to ER until late afternoon
3. I cannot afford it. Card maxed out. Cash very limited.
4. Yesterday AM during drop my hands were shacking, it was difficult to take tests. I cannot help the hands yet.
5. During recent hypo I was so shocked that I could barely understand the help I was getting from the Board. English is not my language.

 

[Tricia Cinco(GA) & Harvey]

@Kris & Teasel @Nan & Amber @Bobbie And Bubba

@Tricia Cinco(GA) & Harvey @Wendy&Neko @tiffmaxee

@PumpkinsMom @rhiannon and shadow (GA) @Chris & China

For Ducia's sake, I can no longer bite my tongue. I'm jumping in on this thread with thoughts for consideration...

The basic recipe for developing DKA = an insufficient supply of insulin + inappetance + infection OR other systemic stresses.

Contrary to the apparent prevailing concept, ketones are not about the numbers. When dealing with ketones at home, we're dealing with an "exception"... not the norm. Throw the "usual" out the window!

To rid kitty of ketones it's not necessary to drop kitty into normal numbers. In fact, it can not only be dangerous, but taking this route can often make it harder on the caregiver because kitty has to be watched closely, 24/7, for fear of kitty bottoming out.

In fairness to all, sometimes getting some insulin, food, and fluids (oral + sub-q) into the cat is all it takes to get rid of ketones, BUT it's not happening here. Ducia continues to throw trace ketones. When kitty is throwing ketones we worry about DKA. In Ducia's case, she just came off of DKA, continues to throw ketones... and yet her dose has been reduced.

The fact that Ducia continues to throw ketones tells us she's not receiving enough insulin. I can already hear the objections! How can we possibly increase the dose, let alone hold it, when she's dropping so low? That takes us right back to ketones not being about the numbers.

When kitty is hospitalized for ketones and/or DKA they put kitty on a glucose drip. Why? Because they want to get as much insulin into the cat as they can without kitty dropping too low... going into hypoglycemia. Initially, they're not concerned with pulling down BG numbers into double digits (that comes later, after kitty is no longer throwing ketones). They're more likely to look for nadirs in the 100 - 200 mg/dL range. This provides a buffer of sorts.

When treating kitty at home for ketones/DKA, we don't have the luxury of putting kitty on a glucose drip. So what are our options? What can we do? We can continue as y'all have been and hope for the best OR we can feed kitty foods with a higher percentage of carbs in them... HC or MC or food mixed with karo, depending on the cat. Doing so will help kitty from bottoming out while allowing an increased dose or holding a dose (similar to the work of a glucose drip). Increasing the dose and/or holding a dose is what is needed when a cat continues to throw ketones.

Because Ducia likes to take those early dives, she may need HC to start the cycle and possibly MC continued for several hours. Forget the LC for now. It might take a little experimenting to figure out what works best for her.

With all due respect, please think about what I'm saying. It makes sense. Get rid of the ketones by providing a sufficient supply of insulin... then worry about pulling numbers down.


FWIW, just my thoughts.
And on that note, I have to finish packing for vacation.

@Meya14

Jill, I appreciate your chiming in at this point. I agree with everything you say. Just for the record, some of us have tried to encourage Tanya to hold the dose and feed higher carbs, but because of the very scary hypo event Ducia had recently, Tanya has been very reluctant to follow those suggestions. She has been more concerned about another hypo than a DKA.

 

[Tanya and Ducia]

she's dropping, but not as fast as previous days.

Can you please check us out @+5?
She was lowering at around +5 for 4 am cycles.

 

[PumpkinsMom]

Jill, I was wondering what vet treats this way? I have paid the bills for dozens of cats in DKA and have treatment plans and invoices for each and no vets do simultaneous glucose and insulin. Simultaneous glucose and insulin hasn't been used, to the best of my knowledge, in at least 8 years. It's only currently used to treat severe hyperkalemia.

 

[Tricia Cinco(GA) & Harvey]

She was lowering at around +5 for 4 am cycles.

That is because she is at or nearing her nadir. This is what is supposed to happen. She's safe, Tanya.

 

[Tanya and Ducia]

Jill, I appreciate your chiming in at this point. I agree with everything you say. Just for the record, some of us have tried to encourage Tanya to hold the dose and feed higher carbs, but because of the very scary hypo event Ducia had recently, Tanya has been very reluctant to follow those suggestions. She has been more concerned about another hypo than a DKA.

Not exactly so.
Her habitual drops may mean that her body tells me the dose of 1 is too much.
Hypo is important factor to consider not solely because of my fears but also because during the day I have no car and no ,oney to go to ER.
Keeping Ducia on honey with shaky hands resulted her going in to convulsions very fast. The BG readings were inaccurate because honey was everywhere.
I do worry about DKA.
I think and hope that stabilizing her within blue yellow BG range, urine test, SQf administering will help with ketones.

 

[Nan & Amber (GA)]

Can you please check us out @+5?
She was lowering at around +5 for 4 am cycles.

This is true, she definitely has a pattern of dropping very quickly around this time-- as Tricia says, that's the typical action of the Lantus (although Ducia's drops have been more dramatic than many cats).

Looks like the last snack she got was at +2.5-- is that true? Let's see what she is at +5 today-- if she's dropped a lot, then (first) I think we want to give her some food to try to slow her down today, but then going forward we can do more snacks in the mid-morning to try to smooth out her patterns more.

 

[Tanya and Ducia]

Sounds like a plan!

Hopefully the extra snacks is helping to slow her down-- she's dropping, but not as fast as previous days.

 

[Tanya and Ducia]

This is true, she definitely has a pattern of dropping very quickly around this time-- as Tricia says, that's the typical action of the Lantus (although Ducia's drops have been more dramatic than many cats).

Looks like the last snack she got was at +2.5-- is that true? Let's see what she is at +5 today-- if she's dropped a lot, then (first) I think we want to give her some food to try to slow her down today, but then going forward we can do more snacks in the mid-morning to try to smooth out her patterns more.

Her reg feeding time is between +4 and +5. No show of appetite so far.
Last snack at +2.5

 

[Nan & Amber (GA)]

OK, let's see where she is at the +5 then. She may not be hungry because of the +2.5 snack. That may have been enough to slow her down today, or else we may have to experiment with the timing and carb content of the snack. I agree with Jill that more AM carbs may be a good strategy for keeping Ducia safe from both hypo and DKA (because it will allow you to keep giving enough insulin without fear of hypo).

 

[Tanya and Ducia]

OK, let's see where she is at the +5 then. She may not be hungry because of the +2.5 snack. That may have been enough to slow her down today, or else we may have to experiment with the timing and carb content of the snack. I agree with Jill that more AM carbs may be a good strategy for keeping Ducia safe from both hypo and DKA (because it will allow you to keep giving enough insulin without fear of hypo).

+5 BG 257 12 min after 1 teaspoon snack and 2.2 hours sinse +2.5 larger snack.
She wasn't hungry around her reg feeding time.
I am going to offer it now.
Is that right what I am doing?
This AMPS she got larger portion of about 2/3 8%.

 

[Jill & Alex (GA)]

@PumpkinsMom

Jill, I was wondering what vet treats this way? I have paid the bills for dozens of cats in DKA and have treatment plans and invoices for each and no vets do simultaneous glucose and insulin. Simultaneous glucose and insulin hasn't been used, to the best of my knowledge, in at least 8 years. It's only currently used to treat severe hyperkalemia.

I'm sorry, I don't have a whole lot of time to look for multiple sources at the moment. I now realize I should have worded my post better. I probably should have used the word "dextrose" instead of "glucose". Dextrose is commonly added to fluids to avoid hypos.

Dextrose: the dextrorotatory form of glucose (and the predominant naturally occurring form).

Here's one source I found quite easily from NAVC - AAHA VetFolio:

Understanding and Treating Diabetic Ketoacidosis
Scroll down to "Insulin Therapy" --- "Insulin therapy should be administered in such a way as to lower the blood glucose gradually (50 mg/dl/hr) to 200 to 250 mg/dl over 6 to 10 hours.2 This slow, steady decrease prevents the osmolarity from changing too rapidly.2 Once the blood glucose level has reached 200 to 250 mg/dl, 2.5% to 5% dextrose should be supplemented in the fluids to avoid hypoglycemia while the ketosis resolves.2,5"


Have to get back to work, but will check back later in case there are more questions...

 

[Shelly & Jersey (GA)]

I vaguely remember conversations (quite a while back) about sub-q fluids causing the insulin to "kick in faster"???? I apologize - I don't remember all of the details, and I don't know if it's even relevant in this case. I'm just thinking about those fast drops and wondered if the timing of the fluids is somehow playing a role. Hoping someone with experience can chime in.

 

[Tanya and Ducia]

I'm just thinking about those fast drops and wondered if the timing of the fluids is somehow playing a role. Hoping someone with experience can chime in.

Please do, or we will have to keep giving it every AM.
There is no one to give SQF during the day Pacific time 7am to 6pm.

 

[Tanya and Ducia]

I vaguely remember conversations (quite a while back) about sub-q fluids causing the insulin to "kick in faster"???? I apologize - I don't remember all of the details, and I don't know if it's even relevant in this case. I'm just thinking about those fast drops and wondered if the timing of the fluids is somehow playing a role. Hoping someone with experience can chime in.

Thank you for bringing my attention to it.
So far we give it in the time convenient for us but can move to another time, late PM or night.

 

[Shelly & Jersey (GA)]

I hope you didn't misunderstand. I'm not saying not to give SQ fluids. I just vaguely remember some tip or trick about giving fluids and insulin together.

 

[Tanya and Ducia]

Shelly & Jersey,
I got it. We will keep giving 75 ml SQf @AMPS every 24 hours.

 

[Tanya and Ducia]

I hope you didn't misunderstand. I'm not saying not to give SQ fluids. I just vaguely remember some tip or trick about giving fluids and insulin together.

Sorry, posted the reply in the wrong place again. Here it is:
I got it. We will keep giving 75 ml SQf @AMPS every 24 hours.

 

[Nan & Amber (GA)]

I'm also curious about this, it would be good to know if there was evidence for that kind of interaction between sub-Q and insulin. The only thing I've been told is that they should be separated by at least 45mins-1hr.