1/6/2018 Tank - Uncontrolled Glucose |AMPS 104, PMPS 599

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Vanessa and Tank

Vanessa and Tank

Member Since 2016
It has been a long time since I have been on this site. My cat's name is Tank. He is currently on Lantus. I had a good control on his glucose but now his numbers are all over the place. It seems like if his numbers are less than 150 and I give him 1 unit of insulin, it shoots his numbers up in the 500's. If his numbers are more than 180, the 1 unit seems to work ok. This morning his number was 104 and I gave him less that 1 unit and his numbers shot up to 599. Tank's numbers are usually between 150- 300. He is also a stage 2 CKD cat. He is taking Pet Wellbeing Kidney Gold Support, Phoshorus Binders, Probiotics and Cosequin. Has anyone had this happen to them before?? What am I doing wrong?? It is very frustrating.
 
Hello there!

It's really hard to say without seeing the data you are referring to (how long after the 104 was the 599)? If I had to take a completely blind guess, one possibility is he went a lot lower than 104 and then bounced to that higher number after several hours. That is pretty common. Have you looked in to setting up a spreadsheet to share your data? It's so much easier for people to help if they have something to look at. ;)
 
You are correct. When I first checked him at 7 this morning his number was in the 70's. So, I fed him and I waited until 8 and I rechecked him. Then his number was 104. So, instead of giving him 1 unit, I gave him less than 1 unit. What causes the numbers to jump so high like that??
 
Nessaone said:
You are correct. When I first checked him at 7 this morning his number was in the 70's. So, I fed him and I waited until 8 and I rechecked him. Then his number was 104. So, instead of giving him 1 unit, I gave him less than 1 unit. What causes the numbers to jump so high like that??
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If it is indeed what we refer to as a bounce, essentially what is happening is that he is not used to normal bg numbers, and it is his body responding to a perceived hypo number to protect itself (although the number doesn't have to be dangerously low, or even that low at all for that to happen, it just needs to be lower than what he is used to). Additionally, if the bg drops too rapidly, say from a 300 to 100 in an hour, this can also trigger a bounce. It is perfectly normal, and in fact, a good sign that he is responding to the insulin! With time in lower numbers, many cats will settle down with the bouncing.

As far as setting up the SS goes, the sticky up top "new, start here" has many links, including understanding our spreadsheets and how to set one up. If you need help setting up a SS, just give a shout, we have a couple people here who can help you set it up in no time. Once you have your sheet up, you can go through the history on your meter and fill in the blanks, it will really help people figure out what is going on with Tank and steer you how to get him feeling better.
 
The link to Tank's SS works just fine. Now to get him to stop bouncing! Read the sticky (informational post at the top of this forum) on the protocols, decide which one you want to follow (Tight Regulation or Start Low Go Slow) and follow the guidelines. It will take a while to get him to a dose that will work for him. Patience and deliberation are the keywords. The protocols are set up to be safe and effective, but you have to follow them. Don't skip around in dose!

Welcome back!
 
Nessaone said:
I have Tank's chart set up for this month. I am trying to figure out how to call the link Tank's SS. Thanks for your help. I really appreciate it.
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Awesome! The SS works, thanks for doing that.

I noticed you get preshot tests, which is great, they are so important as you know when it’s safe to shoot that way. Lantus, however, is dosed on how low the blood glucose goes in the cycle, which is ideally somewhere in the middle (+4 to +8ish), but could be anywhere between +1 and +12. If you could get a couple more tests in between shot times, that will help us get a better picture of what Tank is doing and how low his numbers are going. And if you move around the times you test, it will fill in even more blanks, so say one day you get a +2 and +8, the next day try to get some different hours, like +4, +10. If you can’t normally test in the middle of the days, many people will do a “curve” on the weekend and get tests every 2 hours for 12 hours, or every 3 hours for 18 hours and that can help quite a bit too by showing a good picture of what is happening in that cycle and how low he is going on that dose.

Given Tank’s history of DKA, it’s really important that you test for keytones. You can get ketostix at most pharmacies and dip them in urine to test for ketones. There are also glucose meters that double as keytone meters and use blood to test for keytones using special strips.

Ask all the questions you need to, read as much as you can and hopefully Tank will be feeling a lot better soon. :bighug:
 
This morning Tank's preshot reading was extremely low. (28) So, I fed him and waited an hour. I checked him again and his numbers was 127. I waited another hour and his numbers shot up to 242. I gave him 1 unit. I went to church and checked him when I got back. That puts him in the +5 time frame from the time his insulin was administered which was 9:30 am and his reading is now 303. Technically his times are 7 am and 7 pm. However, if his reading is to low, I wait. Should I have tried to administer him some insulin at the 127 reading??
 
I’m just going to bump this for you and see if you get some responses from people with DKA experience to chime in.
 
Thanks for setting up the ss.

As tank has had DKA in the past and as his numbers appear a bit high it would be wise to check for ketones.

How is tank?
Apart from high BG is he acting behaving normally?
Does he appear off in any way?
Is he eating well?

As to the numbers it is really hard to say what is going on with the data you have on the ss at the moment.

He may be staying high or he may be dropping fast and low and bouncing up by next PS.

Are you able to grab any midcycle tests?
Lantus dosing is based on how low a dose is taking your cat, at the moment we have no idea what that is.

That 104 yesterday may well have been his BG on the way up from visiting lower greens, and that along with the BCS, could have resulted in the 599 at pmps.....or....... 104 might have been the low. We just don't know. If it was the former, you'd want to reduce, if the latter you'd maintain the dose. Can you see the dilema?? Without a little more data it's impossible to give you good advice.

I would suggest you try and fill in the blanks.

Do you think you could
1) always grab a before bed test in the pm cycle
2) grab at least at some point in the am cycle? +4 or +5 would be great, but if that's not feasible anytime between +1 and +11 would be better than nothing.
3) if work/life commitments limits your ability to get midcycle tests, do you think you could run a curve?

If you can do the above we will be able to help you more effectively.
 
Tank is still eating well. He loves to eat. He is still playing with the other cats. I have a total of 3 cats. I will try to obtain some data. I had to order some more strips. If a cat is bouncing, do you still give them insulin or do you wait the 3 days and start over??
 
Vanessa and Tank said:
Tank is still eating well. He loves to eat. He is still playing with the other cats. I have a total of 3 cats. I will try to obtain some data. I had to order some more strips. If a cat is bouncing, do you still give them insulin or do you wait the 3 days and start over??
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You absolutely still give insulin during a bounce, and especially with DKA history, you really wouldn’t want to skip shots if you can at all help it. We typically ignore the bounces as far as doing decisions go, they happen, they pass, but it’s not the data you base your dosing off of.
 
Can a cat have a sliding scale?? So, the dose is dependent upon the glucose reading or do you always have use the same dosing no matter what the reading is??
 
Vanessa and Tank said:
Tank is still eating well. He loves to eat. He is still playing with the other cats. I have a total of 3 cats.
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So all the p's in place then?

Vanessa and Tank said:
If a cat is bouncing, do you still give them insulin or do you wait the 3 days and start over??
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You would, usually not stop insulin just because they are bouncing. (I am not sure I understand your question), and with a history of DKA stopping or reducing the dose dramatically is not advisable, especially if kitty is off his food, stressed, has an infection or is in anyway off. Not enough calories, not enough insulin and infection is a recepie for a repeat of a dka episode.

On TR you would re assess the dose every 6 cycles.

Bouncing is when the go high after
1) dropping fast
2) dropping lower than they are used to
3) or both

This results in liver 'panicking' and dumping glucose into the system resulting in high BG. The BG can stay high for upto 6 cycles.

When it comes to dosing we are not really interested in the high numbers, we largely ignore those, we must look at the lows it is those that govern what you do with the dose.

So we would not increase the dose just because we are seeing high numbers from a bounce. We need to know what caused that bounce, Was it a drop into blue? A drop of 200pts in one hour from 400 to 200? Or did kitty actually drop below 50??

On the ss you have just input data from january, did you run any curves get any midcycle data in dec 2017? It may be helpful to see what you had in December along with what insulin you gave.
 
Vanessa and Tank said:
Can a cat have a sliding scale?? So, the dose is dependent upon the glucose reading or do you always have use the same dosing no matter what the reading is??
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We use the TR protocol and SLGS method on this board, neither use a sliding scale dose, I think that may work well with other forms of insulin, but in general, not with Lantus. It works best on very consistent doses at 12 hours apart.

It is a depot insulin, which means it creates a storage tank in a sense and you fill up that tank over time. When you move the dose around, the tank never knows when it is full and you will not see what the dose is doing either, because it hasn’t had a chance to stabilize and work. I hope that makes sense.
 
Welcome back!

When you first were here, did you decide on a dosing method you wanted to follow? There is the Tight Regulation Protocol or Start Low Go Slow.There are sticky notes at the top of the bard which describe each approach.

One of the basic "rules" of Lantus is that it likes consistency. Obviously, if you get a pre-shot test in the 20s, it's not safe to shoot. Depending on what you fed Tank -- and with numbers in the 20s, I would have been shoveling high carb (HC) into my cat and re-testing every 15 min, you want to see the effects of HC leveling off so you know that it's safe to shoot. In other words, the numbers aren't dropping low again and instead, they are steady or rising without the influence of food. Hopefully, this morning was an exception. So, setting an exception aside, when a kitty bounces, the numbers are high so it's fine to shoot. The bounce is initiated due to numbers dropping low, dropping fast, or dropping into a range the kitty isn't used to spending time in. (Does that answer your question regarding a bounce?) With Tank dropping so low today, you need to reduce the dose. I'm just not sure what your dose is. Let me explain.

Lantus is a depot-type of insulin. What that means is that you base your dose on the nadir -- how low that dose of insulin brings your cat's numbers. You do not adjust the dose based on the pre-shot number. (The latter approach is only used with short acting insulin and Lantus is a long-acting insulin.) You test at pre-shot time to insure it's safe to shoot but the change in dose is based on the nadir (lowest point in the cycle). This also means that it's important to get spot checks. If you only test at pre-shot times, you have no idea how low the dose is taking Tank. I suspect that you're not getting the results you want because your basing your dosing on the pre-shot numbers and this isn't the strategy that is effective for a depot-type of insulin. Every time you adjust a dose, it has an effect on the depot. Thus, you need to hold a dose for at least 3 days in order for the depot to adjust to a change in dose. If you make rapid changes in the dose, it generally results in wonky numbers.

I also suspect that some of those very high numbers are due to numbers having dropped into low ranges earlier in the cycle. Those numbers in the 500s are likely bounces.

Are you around to be able to get any spot checks during the day and/or evening cycles?

 
Vanessa and Tank said:
Can a cat have a sliding scale?? So, the dose is dependent upon the glucose reading or do you always have use the same dosing no matter what the reading is??
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We don't use sliding scales with Lantus on this forum.
With Lantus being a depot insulin, we try to use that to kitties advantage, by dosing consistently. Flip flopping with the dose, makes it difficult to judge how well a dose is doing for a cat. So the protocols/dosing methods we follow allow enough time for the depot to settle before we make an increase, if you don't wait you won't necessarily be seeing the full effect of the dose, and run a risk of missing a good dose.

Sliding scales are more commonly used with the more old fashioned in/out insulins.
 
Venessa --

I didn't see that 28 or 127 on Tank's spreadsheet. Did you not know how to enter the information? If not, you could put it in the AMPS column and write in +12 = 28 and keep adding in the cell the information regarding any subsequent tests until you get to the number where you shoot. If you look at Gabby's SS, there are a number of instances where I had to stack numbers in a cell. The other thing is that you need to manually color code the cell.

Right now, we would have no idea that Tank's numbers dropped so low and there's a good chance that a month from now, you may not remember!
 
This is really great feedback. Thanks everyone for responding as I am very concerned about Tank's glucose levels. I will try to fill in the blanks and be consistent with his dosing. I am at work during the day so I am going to try to get some readings during this coming weekend. I may see if my husband can get some readings since he is home during the day. I am not sure if Tank will let him do it by himself. I will go slow and keep him at 1 unit and see what happens.
 
Sienne and Gabby (GA) said:
Venessa --

I didn't see that 28 or 127 on Tank's spreadsheet. Did you not know how to enter the information? If not, you could put it in the AMPS column and write in +12 = 28 and keep adding in the cell the information regarding any subsequent tests until you get to the number where you shoot. If you look at Gabby's SS, there are a number of instances where I had to stack numbers in a cell. The other thing is that you need to manually color code the cell.

Right now, we would have no idea that Tank's numbers dropped so low and there's a good chance that a month from now, you may not remember!
Click to expand...

I am still learning how to post his numbers. I did not know how to document the numbers when you wait for them to go up and then give the insulin. I think I got it now. I normally document that information in the note section.
 
Vanessa and Tank said:
I may see if my husband can get some readings since he is home during the day.
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If you can enlist his help that would be great.

When George stayed at the petsitter, she would wear leather gardening gloves to get the BG tests. George never put up a fight with me, but he gave her a hard time the first few times she tried to get a test, and after he drew blood she resorted to the gauntlets :eek:
 
I have one more question. How long do you use your vial for. What I have noticed is that it starts to lose it's potency after so many months.
 
I agree, let the DH test training begin! ;)

Here’s a screen shot of how I recorded some delayed shots for Asia, like Sienne said, you’ll have to manually color any cell that isn’t a whole number by itself, but it’s important to record the delays in the cells.

601A2C30-A7B8-41B3-AEBB-CB681975178B.png
 
Vanessa and Tank said:
I have one more question. How long do you use your vial for. What I have noticed is that it starts to lose it's potency after so many months.
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Are you keeping it refrigerated? It should last a decent amount of time (many months), but if you notice a drop in potency, I would go for a new one. You can also get the pens and use them just like a vial, they have less insulin so you use them up quicker and they stay fresh.
 
Yes, I keep his insulin in the fridge. His vet recommended that I get a new vial every 4 months. Does that sound reasonable??
 
I always used pens. With the pens or cartridges, you can pretty much use them to the last drop since they contain less insulin than a vial although I've used a pen for almost 3 mos. There are people here who have used a vial to the last drop, as well. The manufacturer says to discard after a month. No one here does that. Frankly, if at the 4 month mark, Tank's numbers look good and you still have more insulin than you want to throw away, I'd say keep using it.

If you want more feedback about using a vial, put something in your subject line and people will stop by and provide their input.
 
Awesome on adding the stalling numbers today to your SS, can you add the one from yesterday AMPS as well? Didn’t you get a lower number than the 104 initially? I know it seems like being picky, but all that info really does help paint a picture of what’s going on. ;)
 
I have updated all of Tank's numbers. I added his December number's out there as well. His numbers for 01/06 was lower than 70. I must have gone the wrong way on the monitor but I have corrected it on his spreadsheet. I am sorry that I do not have any spot check numbers but I will get on that as well. Thanks everyone for your help. It is greatly appreciated. Hopefully, you guys educating me will help Tank get to where he needs to be!!
 
That 28 and 39 the past couple of mornings are very low numbers on an AT meter and could be very dangerous and life threatening. When you see numbers that low, you always want to feed and retest and make sure they come up higher than 68. How was Tank acting in those numbers? Usually those numbers mean too much insulin. @Sienne and Gabby (GA) @Gill & George

If I had to guess (again, a pretty blind guess) he is going quite low overnight and bouncing in the day (going into higher numbers as a reaction). Any way you could get a +2 after his evening shot and maybe set your alarm and get something in the pm cycle anywhere from a +4 to +9 to get an idea of where he is going low? We need to stop him from going that low as soon as possible.
 
Stacy asked for other experienced eyes in case Sienne and Gill don’t see the tags.

First, please avoid increasing the dose based on the PS.

Lantus is a depot insulin meaning one shot builds upon the previous. It is not an in and out insulin like the shorter acting insulin. While there are some forums that shoot sliding scales with Lantus, we don’t do it in this forum as we’ve found the cats generally do better when the dose is consistent.

Do you have any data from the last two weeks in December? Do you check his urine ketones every single day?

We don’t normally do rebound checks (lower the dose to see if the cat is overdosed) as that can put them at too high of a BG. However, he is clearly overdosed....we just don’t know by how much because of the frequent changes in dose. If you have any data from the last two weeks in December, it would be really helpful in us determining a good dose for him.

I’m rather leaning toward a recommendation to shoot 0.5u, keep a really close eye on his ketones, and get as many BG tests as you possibly can but I’d like to see any other recent data you have. If we do suggest you reduce and you decide to do so, if he doesn’t have a green BG once he clears the bounce, we can get his dose back up quickly, if need be.

We do have to be cautious about taking his dose down too much due to the DKA history but if you check the ketones and let us know if you even see trace and if he eats, drinks, and isn’t lethargic, then he’s ok. If he starts to go off his food, acts lethargic, doesn’t want to drink, or shows even trace ketones, we need to know right away.

As @Stacy & Asia said, a 28 and 39 is dangerously low on a human meter and even more so on an AT. We need to sort this out so that doesn’t happen again. Are you up for it?:)
 
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Marje and Gracie said:
Stacy asked for other experienced eyes in case Sienne and Gill don’t see the tags.

First, please avoid increasing the dose based on the PS.

Lantus is a depot insulin meaning one shot builds upping the previous. It is not an in and out insulin like the shorter acting insulin. While there are some forums that shoot sliding scales with Lantus, we don’t do it in this forum as we’ve found the cat’s generally do better when the dose is consistent.

Do you have any data from the last two weeks in December? Do you check his urine ketones every single day?

We don’t normally do rebound checks (lower the dose to see if the cat is overdosed) as that can put them at too high of a BG. However, he is clearly overdosed....we just don’t know by how much because of the frequent changes in dose. If you have any data from the last two weeks in December, it would be really helpful in us determining a good dose for him.

I’m rather leaning toward a recommendation to shoot 0.5u, keep a really close eye on his ketones, and get as many BG tests as you possibly can but I’d like to see any other recent data you have. If we do suggest you reduce and you decide to do so, if he doesn’t have a green BG once he clears the bounce, we can get his dose back up quickly, if need be.

We do have to be cautious about taking his dose down too much due to the DKA history but if you check the ketones and let us know if you even see trace and if he eats, drinks, and isn’t lethargic, then he’s ok. If he starts to go off his food, acts lethargic, doesn’t want to drink, or shows even trace ketones, we need to know right away.

As @Stacy & Asia said, a 28 and 39 is dangerously low on a human meter and even more so on an AT. We need to sort this out so that doesn’t happen again. Are you up for it?:)
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I included Tank's December numbers in my signature. Just click on his spreadsheet and there is a tab there for December. I am up for what is going to help my baby. Please send all advice my way.
 
I'm in complete agreement with Marje. Seeing Tank's numbers from the last 2 mornings, he really, really needs to be on a smaller dose. I think 0.5u should be OK. Are you able to get tests in addition to the pre-shot tests. I'm very concerned that Tank's numbers are dropping considerably during the PM cycle. Several of us are rather worried that Tank's numbers are courting disaster.

If you are following Tight Regulation, doses are reduced when numbers drop below 50. If you are following SLGS, the reduction point is 90. Numbers considerably below 40 put Tank at considerable risk for symptomatic hypoglycemia.

If your vet indicated that getting pre-shot tests is sufficient, your vet isn't up to speed with using Lantus -- you need to be able to identify when Lantus onset and nadir occur so you know your kitty is safe. Gabby could start the day with numbers in the 400s, drop to 40 and then bounce back to 400s. If I didn't catch that drop into the 40s, I would have been increasing her dose rather than decreasing based on what the numbers indicated. Please go back and look over what I mentioned in one of my earlier posts today. Marje has reiterated several of the important aspects of using Lantus.

How can we help?
 
Sienne and Gabby (GA) said:
I'm in complete agreement with Marje. Seeing Tank's numbers from the last 2 mornings, he really, really needs to be on a smaller dose. I think 0.5u should be OK. Are you able to get tests in addition to the pre-shot tests. I'm very concerned that Tank's numbers are dropping considerably during the PM cycle. Several of us are rather worried that Tank's numbers are courting disaster.

If you are following Tight Regulation, doses are reduced when numbers drop below 50. If you are following SLGS, the reduction point is 90. Numbers considerably below 40 put Tank at considerable risk for symptomatic hypoglycemia.

If your vet indicated that getting pre-shot tests is sufficient, your vet isn't up to speed with using Lantus -- you need to be able to identify when Lantus onset and nadir occur so you know your kitty is safe. Gabby could start the day with numbers in the 400s, drop to 40 and then bounce back to 400s. If I didn't catch that drop into the 40s, I would have been increasing her dose rather than decreasing based on what the numbers indicated. Please go back and look over what I mentioned in one of my earlier posts today. Marje has reiterated several of the important aspects of using Lantus.

How can we help?
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I am going to attempt the SLGS regulation. I was dosing Tank based on his preshot and now I know not to do that and to give him his 1 unit consistently. I would like to start there and see how it goes. Thanks so much for your help. I am so excited about all the responses I got for him today.
 
Vanessa -- please give serious consideration to dropping the dose to 0.5u. It looks like the 1.0u was dropping Tank to the 20s and 30s. It is so much safer to have his numbers running a little higher than to risk a hypoglycemic response. I'll be nervous if you shoot 1.0u.

And please, please, please get some spot checks. If we can help you puzzle through testing and your schedule, we're happy to help. Just like you, we want take to be well regulated and safe.

 
Sienne and Gabby (GA) said:
Vanessa -- please give serious consideration to dropping the dose to 0.5u. It looks like the 1.0u was dropping Tank to the 20s and 30s. It is so much safer to have his numbers running a little higher than to risk a hypoglycemic response. I'll be nervous if you shoot 1.0u.

And please, please, please get some spot checks. If we can help you puzzle through testing and your schedule, we're happy to help. Just like you, we want take to be well regulated and safe.
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I have a question. When you wait for example 2 hours before you give your cat a shot (AMPS) and then still give them their PMPS at their normal time, does that also cause their numbers to bounce or become extremely low the following day??
 
Vanessa and Tank said:
I have a question. When you wait for example 2 hours before you give your cat a shot (AMPS) and then still give them their PMPS at their normal time, does that also cause their numbers to bounce or become extremely low the following day??
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Yes, shooting closer than 12 hours apart can also cause lower numbers, it’s not recommended.

Stalling can act like a decrease, and shooting early like an increase, but when you stall, you would shoot the PMPS dose 12 hours after the stall and then work your way back 15-30 minutes a day to your original shot time. So say you shoot 8:00 and 20:00, but you stall the am shot by an hour and shoot at 9:00 instead, you would then shoot the pm dose at 21:00 and the shots following you would inch back in 15 minute increments: 8:45/20:30/8:15/20:00 to get you back slowly, over time, as 12 hours apart is the way to go.
 
I didn’t look at those Dec numbers because it states “Dec 2016” and I was looking for Dec 2017. Could you please fix that?

I’ll look at his numbers now.
 
That Dec, 2017 SS is very enlightening. Thank you for adding those number, and thanks for correcting the date, and I’m sorry I didn’t click on the tab earlier.

After looking at those numbers, I see numerous times that he earned reductions regardless of which method you use. In fact, if you had given all the reductions for a long-term diabetic, and he held every reduction, he would likely be on a minuscule dose if not off the insulin.

I urge you to drop the dose back to 0.5u and be consistent with it unless he drops below 68 again. N that event, I’d drop the dose to 0.25u. Let’s see how he does.

It’s always easier to take a dose back up than to end up at the ER with a cat in the midst of a symptomatic Hypo.
 
Thank for adding all that extra information.

I also agree with marje and sienne regarding the dose.
If he were my cat I would be taking the dose back t 0.5u, monitoring for ketones, and getting some midcycle data in.

Getting DH testing, even if it is just once a day while you are out of work will really help you help Tank.

Stay safe Tank.
 
I saw that you got a couple overnight tests, that is awesome. How is Tank doing this morning? I checked your SS but it's not updated yet.
 
Vanessa and Tank said:
I am going to attempt the SLGS regulation. I was dosing Tank based on his preshot and now I know not to do that and to give him his 1 unit consistently. I would like to start there and see how it goes. Thanks so much for your help. I am so excited about all the responses I got for him today.
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Hi, two of our most experienced members have strongly recommended adjusting Tank's dose downward to 0.5u. They sound very concerned about Tank "tanking". If I were you, I would not shoot 1u. I would take their recommendations and shoot 0.5U
 
I posted Tank's results for today. They were actually not bad with the 1 unit. I learned a lot from you all in such a short time. I was doing many wrong things with Tank in regards to his administration of insulin. I was adjusting his dose based upon his preshot. If I stalled his insulin, I would not adjust the evening time. Tank's body did not know how to handle all of these changes of going back and forth. Also, we tried .5 with him before and it did not work. The vet recommended the 1 unit so, I am going to start with the 1 and keep it consistent and see what happens. We also tried 2 units at one point and that was to much insulin for him and it seems like the 1.5 is to much as well. I will keep you all posted. Thanks for the help. I have to start low and go slow but most of all have patience.
 
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