My cat gets worse symptoms - not due to hypoglycemia.

Discussion in 'Welcome to the Group - Post an Introduction Here' started by Sandrine, Feb 25, 2016.

  1. Sandrine

    Sandrine New Member

    Joined:
    Feb 25, 2016
    Hi all,
    I discovered that my cat, Mayumi, had diabetisis by noticing an increase of water consumption. The vet confirmed after several blood samples, even after changing her food intake to Hill's w/d prescription diet. So I read all forums about blood sample at home, glucose curve, hypoglycemia, etc. I was ready for what was to come... specially to overcome my personal fear to neeedles.

    Her levels are 420 and with the insulin dose she is taking, it goes down to 380... we are just starting so little by little we will increase dose, etc... till there all normal but...

    My concern is that my cat looks worse with insulin than without! She is normally wide awake, follows me around, waits for me at the door and now nothing! She is constantly sleepy and even wonky when walking.

    It is not hypoglycemia cos her levels are not even below 300. My vet says she is adapting and that she could be having difficulties with the insulin but doesn't want to change it cos he says it's the best he can find in the Spanish Market.

    I'm worried, I have a gut feeling that something is happening to her. She just simple doesn't move anymore and has sadness in her eyes... (let's not even talk about the looks she gives me due to needles and blood samples).

    Has anyone faced the same issue? Is it true that the first days of insulin intake she can be worse? No symptoms before. I was so worried that I insisted so much to my vet that he said to try and not inject insulin for the next 48hrs and she got better! but her blood levels spiked up to 480... so he said that his biggest concern is to reduce the glucose level and then work from there her symptoms...

    Thanks for the help.
    A worried mom
     
  2. Larry and Kitties

    Larry and Kitties Well-Known Member

    Joined:
    Dec 28, 2009
    Welcome.
    W/D is not a diabetic food. It is high in carbs, even the canned. The dry is very very high in carbs.
    What insulin are you using and what is the dose? Are you giving it about every 12 hours?
    When were the BGs measured with respect to giving the shot?
    Do you have an BG at shot time and periodically between shots?
    That is needed since dose is based on the lowest BG between shots.

    For detailed help please post in the Health forum
    http://www.felinediabetes.com/FDMB/forums/feline-health-the-main-forum.28/

    Make sure you providethe information I requested since that is needed
     
  3. Sandrine

    Sandrine New Member

    Joined:
    Feb 25, 2016
    Thansk for your interest Larry and Ups got the letter the wrong way around w/d...

    No idea what insulin... vet didn't tell... 0,75 every 12 hours.
    I didn't have the machine to measure the BG until today... vet said it wasn't a concern :(
    Measured at 8.10... 470
    Gave her shot given at 8.30
    10.30: 420
    12.30: 340
    14.30: 390

    So I was wondering why the hell does she look so crap and so tired while when she has no insulin she is wide awake.
    I did read something about the brain getting enough but not the rest of the body and that now cos it's started to regulate the symptons could appear.
     
  4. Larry and Kitties

    Larry and Kitties Well-Known Member

    Joined:
    Dec 28, 2009
    What is listed on the insulin vial/bottle?
    0.75 is a relatively small dose and yo are see a relatively good drop in BG after the shot.
    Based on posts here it seems that some cats just take a little time to feel better with the insulin.
    You can likely find a better (lower carb) commercial, cat food but I do not know what is available in Spain.
    It is very good that y are home testing.

    Most of us here record our reading and other info in a spreadsheet. See:http://www.felinediabetes.com/FDMB/...te-a-ss-and-link-it-in-your-signature.130337/
     
  5. Woodsywife

    Woodsywife Well-Known Member

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    Sep 6, 2015
    Isn't there a label on the bottle in insulin? Who is giving it?
     
  6. Sandrine

    Sandrine New Member

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    Feb 25, 2016
    The bottle is "vet made", I think they got some human insulin and dilute it.
    I'm the one who is doing the shots.

    Happy to know that the drop is good for the quantity I'm giving :)
    I guess we need some patience and wait a little. This is so new for both of us
     
  7. Larry and Kitties

    Larry and Kitties Well-Known Member

    Joined:
    Dec 28, 2009
    Can you post a photo of the bottle/vial?
    What kind of syringes are you using?
    where on the syringe is the "0,75 " mark?
    Is eh insulin clear or is it a suspension (milky while after mixing) where you have to mix/roll the bottle before drawing out the insulin?
     
  8. Woodsywife

    Woodsywife Well-Known Member

    Joined:
    Sep 6, 2015
    That does not sound right at all.

    Also sounds like the the vet is diluting the insulin to make it easier to give. It is wrong and can contaminate the insulin. It is not necessary at all.

    Are you in the U.S.? If the cat seems better without it, I would not give it. Find another vet if you can who knows more about insulin.

    I know cost is a concern as it is for most of us, but your paying money for medicine and it's making your cat sicker.
     
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  9. Larry and Kitties

    Larry and Kitties Well-Known Member

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    Dec 28, 2009
    No, the initial post included "My vet says she is adapting and that she could be having difficulties with the insulin but doesn't want to change it cos he says it's the best he can find in the Spanish Market.".
     
  10. Gill & George

    Gill & George Well-Known Member

    Joined:
    Oct 27, 2015
    Sandrine,
    Hello and Welcome, I am in Spain too, Granada, Andalucia.:)

    I am not sure why your vet is saying this?? There are various types of insulin are available here in the spanish market, Caninsulina is available and I have been using Lantus (insulina glargina)(I decided I wanted to use this after reading the studies as it is a long lasting insulin and gives good results) I get this from the pharmacy here in spain, it is a human insulin. My Vet here in Spain gave me a prescription and I got 5 pens for 70 euros, and I get the syringes from the pharmacy here as well (with the pen needles it is impossible to give small doses)
    As some of the others have said it is not advisable to have insulin diluted by the vet.

    I think the vet is not well informed, I am pretty certain that all the insulins available in US are available here. I am on Lantus easily bought at any pharmacy, I think the problem unfortunately is more with the veterinary profession here.

    Gill
     
  11. Sparkle

    Sparkle Member

    Joined:
    Jan 22, 2016
    OMG! This really sounds off. Is it possible to change vets? Please, please try to answer all of Larry's questions so someone can help out. You really do need to know what type of insulin you are giving, plus I have great concerns if this is something the vet is making. And I agree with Woodsywife, if Mayumi is feeling worse with the injections, it is probably wise to stop them.

    PLEASE keep us posted. There are many experienced people on this board from all over the world who can help.
     
  12. Sparkle

    Sparkle Member

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    Jan 22, 2016
    Good to see Gill chiming in! (waving to BFG)
     
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  13. Woodsywife

    Woodsywife Well-Known Member

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    Sep 6, 2015
    Gill, hope you can help here.
     
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  14. MrWorfMen's Mom

    MrWorfMen's Mom Well-Known Member

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    Feb 18, 2015
    I'd call the vet and see if it is Caninsulin (I presume that's the Caninsulina in Spain). I've seen other folks here report their cats feeling worse on it so if that's what you are using, you may be seeing the same phenomenon. In any event, you know your cat best so whatever the insulin is, if you really feel your cat is feeling worse with it than without it, I'd insist on a change.
     
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  15. Sandrine

    Sandrine New Member

    Joined:
    Feb 25, 2016
    Thank you all for your kindness.

    The vet is only diluting the insulin now as starters to see how it is working on Mayumi. The end result is to give pure insulin once we get dosage better.
    I'll ask him tomorrow the name of the insulin.
    Mayumi is doing much better, it seems it must have been an adapting period she needed to go through.

    I'll keep you posted with what happens next.
    I'd like to specially thank Gill for having speant the time talking to me in my mother language :) and for all the recomendations.
     
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  16. Gill & George

    Gill & George Well-Known Member

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    Oct 27, 2015
    We've been chatting mostly about food, dry versus wet, and the benefits of a LC diet in helping you attain regulation, and I have shared with Sandrine the wet foods that I have been buying from my online supplier, zooplus, turns out it is the same one she uses:)
    At the moment Mayumi is on Hills w/d. which as far as I can make out is 35% in the dry version and 26% in the wet.

    Glad you posted Sandrine,
    I am sure that the others were keen to know that all is well with Mayumi.

    un abrazo guapa:bighug::bighug::bighug:
     
  17. Larry and Kitties

    Larry and Kitties Well-Known Member

    Joined:
    Dec 28, 2009
    Waiting to hear what insulin is being diluted since some insulins like Lantus and Levemir can't be diluted and retain their effectiveness.
     
  18. Woodsywife

    Woodsywife Well-Known Member

    Joined:
    Sep 6, 2015
    I'm confused on the insulin. Wouldn't a diluted dose (ex: 2u) be weaker than a full strength dose of 2u ? When the "vet" decides he has the dosage better and not dilute it anymore wouldn't the full strength be to much?
     
  19. Larry and Kitties

    Larry and Kitties Well-Known Member

    Joined:
    Dec 28, 2009
    The does of insulin is not dependent upon the dilution/concentration. If a an insulin is diluted 1:1, then it would take twice the volume of the diluted insulin to be the same dose and the undiluted insulin. Insulin is dosed in terms of units, not volume.
    Almost all human insulins like lantus and Levemir are U100 concentration, that means 100 units of insulin per ml. However, the manufacturer's of Lantus has recently released a U300 Lantus insulin called Toujeo that is only available in a pen. Testing of U100 lantus and U300 Lantus (Toujeo) showed that
    • U300 is based on the glargine molecule but requires a smaller volume of SQ injection and U300 demonstrates a flatter and longer PK/PD profile than that of insulin glargine.
    http://www.diabetesincontrol.com/insulin-glargine-u300-versus-lantus/

    Thus the concentration fo the insulin can effect how one respons to the insulin even if the same does (units is given)

    Most animal insulins like ProZinc are U40 (40 units per ml)
     
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  20. Elizabeth and Bertie

    Elizabeth and Bertie Well-Known Member

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    Sep 6, 2010
    Gosh. That is interesting. Thanks, Larry.
    .
     
  21. Gill & George

    Gill & George Well-Known Member

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    Oct 27, 2015
    Perhaps the concern is measuring out small doses? My vet wasn't aware of the needles with the half unit markings which allow us to measure the small doses. The BD u100 syringes with half unit markings are readily available here in Spain, but not common my very helpful local pharmacist helped me track them down.:)
     
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  22. Sandrine

    Sandrine New Member

    Joined:
    Feb 25, 2016
    I've got the farmacy BD U-100 with 0.5ml capacity so syringes is not an issue. I still don't know the insulin cos when I went for more it wasn't my vet and they were pretty busy. I'll send them an e-mail maybe that way they respond.
    Yes, the dilution is 1:1 and it's done so that the dose is "softer" on the cat giving it time to adapt. It's going ok, with diluted insulin 1.5 starts at 500 and then in 4 hours goes down to 280... issue is that it keeps going up again. In 2-3 days I'll increase the dose but vet wants to wait a little just in case - doesn't want to be to drastic.
     
  23. Gill & George

    Gill & George Well-Known Member

    Joined:
    Oct 27, 2015
    Hi Sandrine,
    The Syringes that I use are 0,3ml capacity, they have the grading scale in half units
    [​IMG]




    from what you are saying I think it's the ones below that you are using 0,5ml capacity these come with gradings just in 1unit, much harder to measure 0.25 units on these.

    [​IMG]


    Good idea about emailing your vet, I think there is some concern about the insulin being diluted, as @Larry and Kitties said above.
    For example Lantus which is widely used for treating FD is not supposed to be diluted, some insulins can some can't the worry is that we have seen here on the board vets diluting lantus, not saying this is what your vet is doing but it would not be the first time, correct me if I am wrong Larry, I just have a vague recollection of reading that somewhere.
    I only have experience with Lantus.
    The other concern with diluting is that if it is not done in a completely sterile environment then there is an increased risk of causing infection.

    Its good that you can see her numbers coming down.
    Do you want to put your numbers on the Spreadsheet that we all use, it will be easier for people to look at the numbers and offer suggestions/advice here is the link
    http://www.felinediabetes.com/FDMB/threads/fdmb-spreadsheet-instructions.130337/

    Sandrine, I also meant to aske, what glucometer are you using? How much are you paying for the strips? Would be interested to know as locally they are very expensive so I have been ordering them from the UK.

    Hope you hear from the vet soon.

    Un abrazo:bighug::bighug::bighug:
     
  24. Sandrine

    Sandrine New Member

    Joined:
    Feb 25, 2016
    I'll have a look at those syringes online. And I'll give it a go to the spreadsheet.

    I'm using the Accu-Chek Aviva Glucometer -I bought them online in Framaline.
    The Starter Kit cost €28 and the strips were €48.94 for 50x2 (apparently in offer)
     
  25. Gill & George

    Gill & George Well-Known Member

    Joined:
    Oct 27, 2015
    That's not bad for here, I bought 50 for that price.
    But I have been getting mine from this uk supplier, http://homehealth-uk.com/all-products/codefree-blood-glucose-monitoring-system-mmoll-or-mgdl/
    takes about a week to get the order, you would need a new meter, but it's worth it:
    meter 16 euro
    250 strips 58 euros (that includes the delivery charge)

    I use that and then I also have a freestyle lite which I can get strips from in case of emergency from my local pharmacy, but at nearly 50euros for 50strips its too expensive for all the testing I do. I keep it as a back up meter in case my usual one stops working.

    The syringes I get from the pharmacy in town 10 for 3,50 euro.

    Just in case you find it helpful
     
  26. Sandrine

    Sandrine New Member

    Joined:
    Feb 25, 2016
    Thanks Gill - it's worth the investment once I've used up my strips.
    BTW:- Caninsulin would be the insulin that we are using.
     
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  27. Gill & George

    Gill & George Well-Known Member

    Joined:
    Oct 27, 2015
    Sandrine I am not sure if Caninsulin should be diluted, the paragraph in purple is taken from the manufacturers website FAQ (preguntas frequentes) it explains why, Also the syringes you need to use with the caninsulin(if you were using it as the manufacturer intended) are U40 not the U100
    The Spanish website won't let me see the FAQs.:rolleyes: only vet's can access it.

    I think that this should be a discussion for the Feline main health(assuming that you are interested to have one), that way you will get people that are familiar with using this insulin giving you the best advice possible, I will help you with any translation you are having difficulty with.:)

    The little bit I have read on the manufactures site suggests that diluting it affect the way the insulin behaves, so doing what your vet is suggesting, diluting till you figure it out and then giving the accurate dose does not make sense.
    It may be why you are seeing the number go all over the place.

    Sandrine if you would be so kind could you post a new thread on the main forum it has more traffic than the welcome to the group forum. When you make your new post link this one to the thread by
    going to this link and creating new thread
    http://www.felinediabetes.com/FDMB/forums/feline-health-the-main-forum.28/

    • copying the url on the tool bar
    • clicking on the link icon above
    • pasting the URL in the box that appears
    • and then clicking insert


    http://www.caninsulin.com/faq-answers-p.asp

    What type of insulin is Caninsulin?


    Caninsulin is an intermediate-acting, lente insulin containing 40 IU per mL of highly purified porcine insulin. As a lente insulin, Caninsulin is an aqueous suspension containing approximately 30% amorphous and 70% crystalline zinc crystals in a neutral buffer of pH 7.35.



    How long can the Caninsulin vial be kept after opening?

    Before use, Caninsulin should be stored in a refrigerator and not frozen. It is usually advised that any pharmaceutical product should be disposed of around 1 month after opening. The Caninsulin label stated that the product should be used for 21 days, 28 days or 42 days after first opening, depending on the country. This is based on studies that were carried out looked at Caninsulin use for up to 42 days after first use. Many of the authorities that regulate medicines do not allow product labels that permit the use of sterile products for more than 28 days after first opening.



    Can Caninsulin be pre-loaded into syringes?

    Caninsulin can be preloaded into syringes for clients. However, this will be off label (extra label) use since it is outside the primary packaging (a glass vial or a cartridge for use in a tailor-made U40 insulin pen). In addition, it may be difficult to re-suspend small volumes of insulin in a syringe.



    What should Caninsulin look like?

    Caninsulin is a mixture of two different types of insulin. Normally, after gentle mixing (invert (upend) several times) the vial or cartridge, Caninsulin will appear uniformly milky and should not have any agglomerates (clumps or flakes) in it. Do not use the product if you see agglomerates in the vial or cartridge after you have re-suspended the product.

    A small white ring of sediment may be seen in the neck of some vials of Caninsulin. The ring of sediment forms when the product has not been kept stored continuously in an upright position. A small ring of dried out insulin does not affect the quality of the product. Prior to first use, Caninsulin vials and cartridges should be stored refrigerated and in an upright position.

    Always check on the appearance of the Caninsulin before using it!



    Can Caninsulin be diluted?

    Caninsulin is a mixture of amorphous (soluble) insulin and crystalline insulin. The crystalline part is relatively insoluble which is why the insulin activity lasts more than a few hours. Caninsulin has a balance between the amorphous and crystalline parts. If Caninsulin is diluted, this may result in an
    alteration of the characteristics of the product (pharmacokinetics and Pharmacodynamics) in the animal. In addition, the stability of the new suspension is unknown. Dilution of Caninsulin would constitute off label (extra label) use.

    @Larry and Kitties Do you know of folk diluting it and is it recommendable? Out of my depth here, thanking you in advance.

     
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  28. Maggies Mom Debby

    Maggies Mom Debby Well-Known Member

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    Dec 28, 2009
    Could your vet be diluting the U-40 insulin so it's U-100 and can be used with the U-100 syringes without using a conversion chart?
     
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  29. Larry and Kitties

    Larry and Kitties Well-Known Member

    Joined:
    Dec 28, 2009
    No, U40 insulin is diluted compared to U100.
    U40 mean 40 units per ml
    U100 mean 100 units per ml
    One could, with right diluent if one exists, dilute a U100 insulin to U40.

    Caninsulin (Vetsulin USA) is provided by the manufacturer as a U40 strength.

    Y can use U100 syringes for a U40 insuln for fine dosing. If y draw up a U40 insln in a U100 syrine to the 2 1/2 unit mark that is one unit of U40 insulin.
     
  30. Maggies Mom Debby

    Maggies Mom Debby Well-Known Member

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    Dec 28, 2009
    Ooops! My arithmetic was, as ever, messed up. Sorry!!
     
  31. Critter Mom

    Critter Mom Well-Known Member

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    Jun 16, 2014
    Hi Sandrine,

    Not every insulin agrees with every cat. The Caninsulin may be disagreeing with Mayumi. It absolutely hammered my Saoirse's system when she was being treated with it. Her day would go like this:

    Before Caninsulin injection:
    - OK in herself - alert and mood OK - but she tried very hard to hide from me after her meal because she knew her injection was coming.

    Next 60-90 minutes:
    - OK for a while but then mood deteriorated and she started getting quite lethargic.

    +1.5 - +10.5 hours after injection:
    - lethargic, miserable, no energy or engagement. Spent the whole time hiding behind sofa or behind floor-length curtain. Only emerged to eat then retreated back to hiding place.

    +10.5 - +12 hours after injection:
    - Saoirse came out from her hiding place, depression lifted, more alert, more herself.

    It was like having two different cats. Indeed things were so bad that if Caninsulin had been the only treatment option available to Saoirse I would not have been able to carry on treating her. Feeling lousy for 21 hours out of every 24 would mean she had no true quality of life.

    There is good news! Because I kept records of Saoirse's very poor clinical signs on Caninsulin our vet was able to prescribe Lantus insulin for her. The difference in Saoirse between when she was receiving Caninsulin to when she was switched to Lantus (insulin glargine) was like night and day: the improvement was pretty much immediate! Saoirse would get a little sleepy for an hour or so after each Lantus injection but after her nap she was a much happier cat on this insulin - good mood, alert, engaged, sociable. I got my girl back - and she went on to achieve remission for over a year. :)

    I've just shared our experience with you to reassure you that your instincts about how Mayumi is reacting to Caninsulin are very much worth paying attention to. I would definitely recommend you discuss the effect Caninsulin is having on Mayumi's clinical signs with your vet and ask to explore other insulin options. If your current vet won't do that, are there other vets in your area that might have a more progressive, partnership-style approach to helping you get the best treatment for Mayumi?

    By the way, in the UK EU law states that Caninsulin must be the first insulin prescribed for newly diagnosed feline diabetics. You have to be able to prove that Caninsulin isn't working for your cat before the vet can legally prescribe a different insulin under the drug cascade rules. I don't know whether the prescribing rules are the same in Spain as in the UK. If they are the same then any evidence you can gather about Mayumi's reaction to Caninsulin will be invaluable in helping your vet to build a case for prescribing a different insulin. I see that other members have given you a link to the instructions for setting up a spreadsheet for tracking Mayumi's blood glucose test results. If you also keep a journal of her clinical signs every day in the 'Remarks' column your notes will quickly build to form an evidence base for you to present to your vet.

    I hope that Mayumi starts feeling better very soon. I'm glad you found FDMB. :bighug:


    Mogs
    .
     
    Last edited: Mar 8, 2016
  32. Gill & George

    Gill & George Well-Known Member

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    Oct 27, 2015
    being in the eu you would think wouldn't you???
    Not sure what the 'rule' is but we started on lantus, though our vet recommended canninsulin she gave me the RX for lantus when I said I would rather try that as my first option instead.
     
  33. Sandrine

    Sandrine New Member

    Joined:
    Feb 25, 2016
    On Thursday I'll talk to my vet - Thanks Mogs, what you describe is basically what is happening to Mayumi.
    She now simple sleeps all day and night in the bathroom.
    I'm going to try and convince my vet to change but will probably have to wait until next month - I'm going on holidays and cannot start making changes while I'm not here to see the reactions.
     
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  34. Critter Mom

    Critter Mom Well-Known Member

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    Jun 16, 2014
    I'm glad you've got a vet with such a progressive approach, Gill. It took me nearly 3 months to get Saoirse onto Lantus. It would have been my first choice, too.

    Hope that you and George are keeping well. Thank you again for helping Saoirse and me. :bighug:


    Mogs
    .
     
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  35. Critter Mom

    Critter Mom Well-Known Member

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    Jun 16, 2014
    I really am sorry that the Caninsulin seems to be making Mayumi feel so lousy. :( Be sure to keep us posted with how you both are getting on and shout if there's anything we can do to help you both.


    Mogs
    .
     
  36. Dawn and Peek-a-Boo (GA)

    Dawn and Peek-a-Boo (GA) Member

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    Dec 27, 2015
    Same experience here.
     
  37. Critter Mom

    Critter Mom Well-Known Member

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    Jun 16, 2014
    @Dawn and Peek-a-Boo -

    I'm sorry to hear that, Dawn. :( How is your darling boy doing? I hope his little mouth is better now. :bighug:


    Mogs
    .
     
  38. Dawn and Peek-a-Boo (GA)

    Dawn and Peek-a-Boo (GA) Member

    Joined:
    Dec 27, 2015
    Hi Mogs,

    Peeks is doing good, his mouth is back to normal so I'm very thankful that he won't have to be put on a second antibiotic.

    :bighug::bighug:
     
  39. Critter Mom

    Critter Mom Well-Known Member

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    Jun 16, 2014
    Wonderful news, Dawn! :bighug: Please give Peek-a-Boo some scritches for me. :)


    Mogs
    .
     
  40. Dawn and Peek-a-Boo (GA)

    Dawn and Peek-a-Boo (GA) Member

    Joined:
    Dec 27, 2015
    You got it Mogs...he's eating so I gave him some back scritches :cat::bighug:. How's your girl's eye doing?

    Dawn
     
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  41. Critter Mom

    Critter Mom Well-Known Member

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    Jun 16, 2014
    It's healing and the fur is growing back.

    (Apologies for the slight frankenthread, Sandrine. :oops:)


    Mogs
    .
     
  42. Critter Mom

    Critter Mom Well-Known Member

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    Jun 16, 2014
    It would be great to hear how you got on today, Sandrine. Was the vet helpful?


    Mogs
    .
     
  43. Sandrine

    Sandrine New Member

    Joined:
    Feb 25, 2016
    Hi Mogs,

    Sorry I was away for the weekend. Things are actually going better.

    I've started with pure insulin and inject 0.75ml, she went directly from 480 to 200 - so that's really nice.
    Now I've got to try and find hte right amount to keep her levels in line cos I've a feeling if I inject 0.75ml at night when she has 200 and not 480 she might crash.
    I guess I'll give it a go with 0.5ml and see what happens :)

    Also, Mayumi has started to be a cat again... I see her move around and she is not so drousy.
    Cross fingers that things keep going this well.

    Love,
    Sandrine
     
  44. Critter Mom

    Critter Mom Well-Known Member

    Joined:
    Jun 16, 2014
    Hi Sandrine,

    Thank you for sending us an update. I am so glad to hear that Mayumi is starting to feel better. That's what all of this is about. :) I'm sure seeing Mayumi improving must be making you feel a bit better, too.

    Sending fusses for Mayumi and :bighug:s for you.


    Mogs
    .
     

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