Trash the Vitamins - Convince Your Patients

This is an attitude prevalent among many members of the medical community. They have a complete dislike for supplements and some are very vocal about it. This study gives them one more reason to vocalize their feelings. While the American Heart Association is the only medical group advising against supplements, they proclaim that with all the groups against it that older patients should not be using supplements.

Now I will agree that some vitamins and minerals, plus some herbal supplements are more than a passing concern. Some deadly hazards exist if taken with some prescriptions. So how do we warn patients, certainly not by taking them away from patients and advocating against them. Talk with the patient and explain to them the actual hazards for the particular supplements that generate the problems with the prescription medications.

According to the study, there is some evidence that some supplements in general are raising the mortality rate, but this has been concluded without some factors being confirmed. This being an observational study leaves open the possibility of confounding by indication. Specifically, there is the possibility that women with higher risks for mortality or who developed serious chronic illnesses, as they grew older had a wider use of supplements.

Physicians are offered several lessons. They should ask what nonprescription therapies are used by the patient and make sure their records reflect these therapies. The study does say that physicians make such errors as the peril of their patient. Physicians should be a trusted resource for patients, but many physicians refuse to recognize dietary supplements and ignore their existence rather than being the needed resource for their patients. Physicians could help monitor what their patients use and warn them when problems could exist or develop.

Older patients can be a problem because they think more could be better and if they are experiencing a medical problem, often they will turn to dietary supplements and not communicate with doctors that have played down supplements. So physicians that are against and discourage supplement use are not keeping the lines of communication open for future years when their patients need them for advice on supplements.

For the doctors that believe “trash the vitamins - convince your patients”, they are putting their patients at risk in the future because they have severed the lines of communication. Their patients will never trust them for information about the dangers for some supplements or even supplements in general.

Who Is Paula Deen?

I had stated to another blogger that I was going to stay out of this discussion for now, but with the attacks and attention focused on the attacks, I feel the need to at least make my opinion heard.

Yes, just who is Paula Deen? Is she a celebrity chef? Or is she the celebrity that takes us for fools? I say she is neither. I cannot say she is confused either as she does know how to make money. She is just another person with type 2 diabetes that is still a novice about diabetes. She will make mistakes like all of us do, and she will learn from them.

Where she made her biggest mistake is in not having a doctor she can trust that will tell her like it is. If indeed the one doctor she mentions as being close to and that she trusts says “she puts all her patients on Victoza”, this doctor is not one she should trust. Yes, when it comes to diabetes, it is difficult to trust doctors particularly if they do not specialize in diabetes. Has she been sucked in by the American Diabetes Associations low fat, high carb mantra? Quite possibly, but she will learn.

Dr. Bill Quick is right in his blog here. Victoza is not the first medication people with type 2 diabetes should be considering. Dr. Quick also makes several other well-founded statements about Victoza. Paula Deen is obviously promoting it because of an agreement with Novo Nordisk; however, she has not done her research or learned the risk of the mistakes she is going to be asked to acknowledge.

For someone in her position, she needs an adviser to prep her for her statements in the future. She may get away with a few mistakes, but these will not be allowed by many of her critics.

Even if she has had diabetes for three years, she has not done her homework to be slugging it out with the media. They have been and will continue to hound her into making more mistakes. For a celebrity, she has much to learn both about diabetes and handling the press that is only looking for sensationalism.

Even a type 1 blogger took up the sensationalism idea here to carefully ask her some questions and then point out her mistakes. We do not know for a fact that Paula Deen is taking Victoza, but I am sure in the days and weeks ahead, she will need to say if she is using the medication she is advertising.

For those bloggers that are giving her space and realizing she is still learning – thank you. For the bloggers that are openly critical, how long did it take you to learn some of the lessons diabetes teaches you? I am willing to say that in eight plus years with type 2 diabetes – I am still learning – and making mistakes.

So I would like to thank Dr. Bill Quick for his insightful blog and David Mendosa for his blog. These are worth reading. Then take time to read this blog and remarks by another blogger here. While this is mild in comparison to many in the media, it still rubs me the wrong way. They make it sound like she could have prevented diabetes and that she is to blame for it, although it is not directly stated.

Ms. Torrey apparently does not even know how often a person using Victoza needs to inject it during the day. Where were her proofreaders? Two or three times per day – or more – I think not - the file here on Victoza clearly states it is for injection one (1) time per day. Go to “How Should I Use Victoza”, in the middle column, and the second point under it. Oh my, the mistakes a “Patient Advocate” will make for sensationalism.

I had respect for Ms. Torrey until her tirade about Paula Deen. I could even overlook a few comments that seemed out of line, but for me she crossed the line in her attack. She has lost her credibility as a patient advocate.

Some Blogger Suggestions for Handling Depression

Bloggers do tackle the topic of depression and help educate all of us. Sometimes we write from our personal experiences about depression, but we also read a lot as well.  The first blog I want to bring to your attention is one by Will Ryan at the Joyful Diabetic. Will covers some of the facts about depression and gives several good suggestions to aid in combating and managing depression.

As people with diabetes, we need all the help we can obtain and I always appreciate blogs like Will Ryan's. While I agree with his suggestions, not everyone may. To this I say, find what works for you and discard the rest. I seldom discard things, but bookmark it for later reference in case something changes for me. I also have the habit of having different topic word processor pages, which I copy the URL to and often make notes to the URL to refresh my mind later.

I will point out that Will Ryan and David Mendosa work hard for us and do it in a positive fashion, which makes the information more valuable. With this, here are two previous blogs by David Mendosa that can help you with minor depression and chronic sorrow. This first blog from November 2, 2008 discusses diabetes, depression, and the use of exercise as a possible step in managing both.

In his second blog of January 4, 2010, he lists some of the potential aids he uses to help him manage depression. These can help break out of depression for me and I blogged about using them here and how they have or have not helped me. I do need to make one change about Omega 3. It has given me some help and then I did add vitamin B12 to my supplements about six months later and the two of them seemed to really help in leveling my mood swings and I avoided having depression for the rest of 2010 and well into 2011. I did have a mild bout of sadness or mild depression last September, but it only lasted for a couple of days.

One thing that keeps me going is working for the positive attitude and I really think the power of positive thinking keeps depression out of most of my life, even when I have periods of wondering what I have done wrong in my diabetes management. My blood glucose levels in the first six hours after I wake are right on target. Then in the late PM, they seem to rise more than they should. I have used the same vials of insulin and even rotate the injection locations, but they still rise.

Sometimes they level out in the upper 100's, but I am having some readings over 200 in the late PM. I know the insulin is good and still the readings are climbing. I have been reducing my carbohydrates and still they climb in the late PM. I think I have stopped this for now. Maybe not the best of solutions, but high fat and the rest protein with zero carbs other than what is in fresh lettuce and spinach. Blood glucose has remained under 130 mg/dl for three evenings now.

Dr. R. Centor has something to say that we all need to know. He has two questions for his patients that he uses to see how patients are actually doing. He uses them to detect depression and for some of the underlying issues such as sleep apnea, systolic dysfunction, and other diseases. There are some comments, but nothing as definitive as his two questions. More doctors should use these questions, but many just enter the exam room, check the lab reports and discuss any changes to be made and leave.  They have no interest in checking for anything else and are thinking about the time they will save.

The Depression and Diabetes – A Cycle?

This discussion is not to include the major depressions, but realize they can happen. Mild and short-term depression is the most common for people with diabetes – about double the risk, with approximately two-thirds of people with diabetes at risk for depression. For people with depression, the risk for diabetes is about 20 percent.

Several items came to light in my continuing research on the depression affecting people with diabetes. One person says people may have chronic sorrow rather than clinical depression. Chronic sorrow according this person says it means that people new to diabetes are now coping with new long-term lifestyle changes that they may find stressful.

This condition as it is termed comes from simple things like not being able to join a group for a piece of birthday cake, which can leave the person feeling apart from the group and resentful. For a person to feel sad is a normal reaction about a chronic disease that has taken so much away from you. This make the illness a burden to bear alone and we need to have empathy and support from those around us.

Another piece of advice given is always worth checking out is the thyroid, as it is in the same gland family as the pancreas. Hypothyroidism is a major cause of depression and weight gain. In all cases of diabetes, this should be checked on a regular basis. Another thought is checking for a vitamin deficiency because low levels of vitamins B1 and B12 can cause depression.

Depression – diabetes and the reverse can be a vicious circle for some. As depression gets worse, the complications of diabetes may become worse because the depression causes people to stop or slow their diabetes management. This may cause the people to develop long-term complications like retinopathy, neuropathy, and nephropathy.

It is unfortunate that a large share of the people suffering from depression and diabetes never receive help for the depression. Sometimes it is not recognized by healthcare professionals, and sometimes people with diabetes who are depressed do not communicate to their doctors about their feelings or do not even realize they are depressed.

If you are a person with diabetes, learn the symptoms of depression or chronic sorrow to be able to communicate with your doctor about these. Learn also that people with diabetes can become burned out managing their diabetes. They can often become upset, gloomy, and have the helpless feeling because they cannot control their blood glucose levels.

There are reasons that cause people with diabetes to develop depression or chronic sorrow, and this can vary from one individual to another. Learn as much as you can about what affects you and learn the best way to deal with sorrow or depression.

The following articles are sources for this blog: article 1, article 2, article 3, and article 4.

The Types of Depression

I am writing this blog to give you some information for my two following blogs. I am presenting information about the different types of depression. Many people speak of depression and write about depression, but seldom do they specify what type of depression they are talking discussion. I am guilty of this, and I have read many studies and articles guilty of this. I firmly believe this is because as a layperson, the classification of the different types of depression is not an easy topic to understand.

Feeling sad or what many of us refer to as being depressed can be a form of depression if it lasts for more than a few hours. Being sad for a few hours and then becoming your normal self is generally not considered depression. Can we be in a state of depression for a few days without being clinically depressed? This is a difficult determination and there seems to be few people willing to classify this as a mild form of depression. Most professionals find a way to hide it in technical terms that are hard to understand.

In my own unprofessional understanding, about 67 percent of people with diabetes do suffer from some type of depression; however, most of the time you will see this listed as just depression with no definitive definition. Then about 19 percent of people with diabetes suffer from serious depression and again no accurate definition accompanies this statement.

I must preface the following as being about all types of depression and not just about depression associated with diabetes although it can include depression. When talking about depressions types, understand that some sources will use different terms for the same type. There are several forms or types of depression or depressive disorders. This source says major depressive disorder and dysthymic disorder are the most common. Although this is not clearly stated, I would assume this to be for the more serious forms of depression. However, one source uses dysthymic disorder for mild to moderate depression.

Major depressive disorder is also known as major depression. With this disorder, a patient suffers from a combination of symptoms that undermine his ability to sleep, study, work, eat, and enjoy activities he used to find pleasurable. Experts say that major depressive disorder can be very disabling, preventing the patient from functioning normally. Some people experience only one episode, while others have recurrences.

Dysthymic disorder is also known as dysthymia, or mild chronic depression. The patient will suffer symptoms for a long time, perhaps as long as a couple of years, and often longer. However, the symptoms are not as severe as in major depression, and the patient is not disabled by it. However, he may find it hard to function normally and feel well. Some people experience only one episode during their lifetime, while others may have recurrences.

A person with dysthymia might also experience major depression, once, twice, or more often during his lifetime. Dysthymia can sometimes come with other symptoms. When they do, it is possible that other forms of depression are diagnosed. When severe depressive illness includes hallucinations, delusions, and/or withdrawing from reality, the patient may be diagnosed with psychotic depression.

I will mention postpartum depression in passing because it affects women after giving birth and is not part of the discussion about diabetes although women with diabetes may have this as well.

SAD (seasonal affective disorder) is much more common the further from the equator you live. A person who develops a depressive illness during the winter months might have SAD. The symptoms go away during spring and/or summer. In some countries, where winter can be very dark for many months, patients commonly undergo light therapy - they sit in front of a special light. Light therapy works for about half of all SAD patients. In addition to light therapy, some people may need antidepressants, psychotherapy, or both. Light therapy is becoming more popular in other northern countries, such as Canada and the United Kingdom.

Bipolar disorder (manic-depressive illness) is a mood disorder characterized by chronic mildly depressed or irritable mood often accompanied by other symptoms (as eating and sleeping disturbances, fatigue, and poor self-esteem). It is not as common as major depression or dysthymia. A patient with bipolar disorder experiences moments of extreme highs and extreme lows. These extremes are known as manias.

Some illnesses accompany, precede, or cause depression such as anxiety disorders, and include PTSD (post-traumatic stress disorder), OCD (obsessive-compulsive disorder), social phobia; generalized anxiety disorder and panic disorder often accompany depression. If you are dependent on alcohol or narcotics, you may have a significantly higher risk of having depression.

Depression is more common for people who suffer from HIV/AIDS, heart disease, stroke cancer, diabetes, Parkinson's disease, and many other illnesses. According to studies, if a person has depression as well as another serious illness he or she is more likely to have severe symptoms, and will find it harder to adapt to his medical condition. Studies have also shown that if these people have their depression treated the symptoms of their co-occurring illness improve.

Other types or sub-types of depressions I include here are:

• atypical depression (sub-type of major depression or dysthymia
• chronic depression is a major depressive episode that lasts for at least two years
• endogenous depression is defined as feeling depressed for no apparent reason
• situational or reactive depression (also known as adjustment disorder with depressed mood) that develops in response to a specific stressful situation or event like job loss, end of a relationship, death in family, etc.
• agitated depression which is a type of major depressive disorder
• psychotic depression is a major depressive disorder with psychotic symptoms like hallucination and delusions
• melancholic and catatonic depression which are sub-types of major depressive disorder

There are obviously many more subtypes, but finding anything descriptive of the short-lived or short-term depressive nature is very difficult to find. So what other than the term of mild depression are we left with for describing what many of us feel that we have or are we just feeling sad and let down.

Two of the above types do come close to being mild and not serious – SAD and situational or reactive depression. The first generally only last for the winter months and the second for about three months and then not until about three months following the cause of the depression. While not in the category of major depression, the short time can be very depressive and symptoms can vary from mild to deep.

The articles used in this blog include article 1, article 2, article 3 and article 4.

Diabetic Neuropathy – Part 5

In the last blog, alternative treatments for diabetic neuropathy were mentioned. Now it is time to discuss the alternative treatments as some are quite effective, but again it is worth pointing out that not everything will work for everyone.

Capsaicin is the chemical that gives hot peppers their bite. When applied to the skin, capsaicin creams can reduce pain sensations in some people. Side effects may include a burning feeling and skin irritation. Alpha-lipoic acid (ALA) is one of the most interesting developments in pain research is the discovery that alpha-lipoic acid, a powerful antioxidant found in food, may be effective at relieving the symptoms of peripheral neuropathy.

Your doctor may prescribe transcutaneous electrical nerve stimulation (TENS) therapy, which can help prevent pain signals from reaching your brain. TENS delivers tiny electrical impulses to specific nerve pathways through small electrodes placed on your skin. Although safe and painless, TENS does not work for everyone or for all types of pain. TENS may be prescribed in addition to other treatments.

Acupuncture may help relieve the pain of neuropathy, and generally does not have any side effects. Keep in mind that you may not get immediate relief with acupuncture and will likely require more than one session. Biofeedback therapy uses a special machine to teach you how to control certain body responses that reduce pain. You then learn how to control these same responses yourself. Biofeedback techniques are often taught in medical centers and hospitals.

The above are all worth investigating and may be of value for you. You may need to use a combination or use in combination with prescription medications. If one treatment does not work in a reasonable time, try another treatment.

The best way to control diabetic neuropathy, and what it does, is to keep your blood glucose tightly managed, taking good care of your feet, and maintaining a healthy lifestyle. Yes, maintaining tight management of your diabetes requires a big commitment on your part, but the rewards are worth it. Whether you are on oral medications or insulin, by watching the foods you eat and monitoring your blood glucose levels is the only way to help avoid or prevent neuropathy and other complications of diabetes.

I would like to remind everyone to reread part one of this series about the four main types of neuropathy. This is because peripheral neuropathy is the most common form, but also because it is the most talked about. Foot care of foot problems is so important I want everyone to know how important this is. I do not wish to seen people needing an amputation because they did not take care of their feet.

First, have a comprehensive foot examination at least a minimum of once a year and more often if possible. Check your feet daily. No, do not just take a glance at them, but really look and examine them. If you are unable the bottoms of your feet, use a mirror or ask a family member or even a friend to examine your feet for blisters, cuts, bruises, cracked and peeling skin, redness and swelling.

Please wash your feet everyday with lukewarm water and mild soap. If you cannot tell the temperature of the water with your feet, use a dampened washcloth and touch it to an area of your body that is still sensitive to temperature. Wash thoroughly and rinse before drying. Be careful when drying as rubbing too vigorously can damage your skin. Dry between your toes and if necessary moisturize your skin liberally, but it is not good to put the lotion between your toes. This applies especially to men to avoid fungal growth.

Trim your toenails regularly and carefully to avoid cutting into the skin. Use a toenail clipper and with an emery board round off the corners not filing into the skin. If you are unable to reach your feet, ask a family member to assist or schedule a regular appointment with your podiatrist to get this done.

Wear clean and dry sock and preferably ones that have a cushion on the bottom to assist in keeping the moisture away from your feet. Avoid socks that are too tight or have a tight elastic at the top or thick seams. You will only harm your feet with this type of sock.

The last, and I want to emphasize this, is to wear shoes that fit your feet properly, are cushioned and comfortable. A podiatrist can be very helpful in teaching you how to buy properly fitting shoes that will help in preventing problems such as corns and calluses. Never buy new shoes in the morning. Wait until later in the afternoon when your feet are more swollen to ensure the shoes are not too tight. Shoes that fit well can be costly. If you are on Medicare, your plan may cover one pair of shoes per year. Your doctor and possibly your diabetes educator may be able to help you. Never buy shoes that pinch your toes or that do not support your feet. Just because it may be the latest fashion, does not mean they are for you.

Please read these articles for additional information, article 1 and article 2.  Part 5 of 5.

Diabetic Neuropathy – Part 4

In case you are not aware of this, diabetic neuropathy has no known cure. Treatment focuses on slowing the progression of the disease, relieving the pain, and managing the complications.

As you should know, management of your blood glucose readings is important. Maintaining these in a narrow range is the best solution for slowing the progression of neuropathy. I will give you the American Diabetes Association's (ADA's) recommendations, which I think are too lax.

They claim this is intense management.

Time                                                           ADA                       Rest of the World

Blood glucose level before meals               70 to 130 mg/dl          3.9 to 7.2 mmol/L

Blood glucose level two hours after meals  less than 180 mg/dl    10 mmol/L

after meals

Hemoglobin A1c less than                          7 percent

People that do not have diabetes generally maintain an A1c between 4 and 6 percent. To help slow nerve damage be sure to follow the recommendations of your doctor for good foot care and keep your blood pressure where it should be. Also, follow a healthy food plan, get plenty of exercise, if needed, get to a healthy weight, and avoid smoking and alcohol.

How do you effectively get pain relief from diabetic neuropathy? There are several medications that are used to relieve nerve pain, but they do not work for everyone. They also have to be weighed against the side effects and balanced to the benefits offered. This is the most difficult part of finding what works for you most efficiently and may require some trial and error.

Some of the prescription medications that may be prescribed include the following: anti-seizure medications, antidepressants, lidocaine patch, and opioids. You may read about them here. There are a few alternative therapies, such as capsaicin cream and acupuncture that may help with pain relief. Doctors do use them with prescribed medications, but some can be effective on their own.

Other neuropathy complications can have specific treatments for restoring functions. Urinary tract problems for both men and women have specific treatments and can have a combination of therapies that can be the most effective. Digestive problems can be treated and gastroparesis, diarrhea, constipation, and nausea may be helped with dietary changes and medications.

Low blood pressure on standing can often be helped with lifestyle measures. Medications can also be used alone in combination to treat orthostatic hypertension. There are many alternative medications and devices to help men with erectile dysfunction and women may get help with vaginal lubricants.

There are also lifestyle and home remedies that may help reduce the risk of diabetic neuropathy. First, people with diabetes generally have high blood pressure and with diabetes can greatly increase your risk of complications. It is important to maintain your blood pressure in the range that your doctor recommends. Read the advice of the Mayo Clinic here.

Second, regardless of whether you think your current food choices are healthy, many people find out once they have diabetes that the foods are not as healthy as thought. Make sure that you attempt to eat a balanced diet. Third, if possible, achieve a healthy weight and stay as active as your condition permits. Select an activity that you enjoy and can continue. If possible, try to do at least 30 minutes per day five days per week or 15 minutes seven days per week. Fourth, if you smoke, realize that with diabetes you are more likely to suffer a heart attack or stroke. Find ways to stop smoking as this increases your chances of neuropathy.

Finally, do all you are able to tightly manage your diabetes. This will help prevent or delay complications for many years.  Part 4 of 5.

Diabetic Neuropathy – Part 3

Seeing a doctor is very difficult for many people. They do not like to admit something is wrong that they cannot handle. Others just will not see a doctor until they have to. Neuropathy is not something to take lightly and does need to be seen by a doctor. It is better to see a doctor sooner than later with neuropathy. I hate to say this, but if you can manage your diabetes, neuropathy may be managed as well. Neuropathy is still possible whether we like it or not.

If you have a cut or sore on your foot or lower legs that does not seem to be healing, is infected or is getting worse, seek medical care. If you have a burning sensation, a tingling, weakness, or pain in your hands or feet that bothers you doing your daily tasks, be sure to see a doctor. If you have dizziness, or changes in your digestion, urination, or sexual function, seek medical care quickly.

These symptoms do not always mean nerve damage, as they may indicate other problems needing medical care. Regardless of the symptoms, record them and get an appointment with your doctor, as this is your best opportunity to prevent more serious complications. If fact, any problems with your feet should be seen by a doctor. This is the best method to prevent any problems from becoming severe enough to cause amputation.

Anyone can develop neuropathy, but people with diabetes are more susceptible if they have these risk factors. Number one is poor blood glucose management as this is the greatest risk factor for every complication of diabetes. Keeping your blood glucose levels consistently within goals is the best way to protect the health of your nerves and blood vessels.

Another factor is just the length of time you have had diabetes. This is especially true if your blood glucose levels are poorly managed. Peripheral neuropathy is most common in people who have had diabetes for 25 years. Others who are successful in their management of their diabetes may never develop peripheral neuropathy.

Kidney disease is another factor that can be caused by poor management of diabetes and can increase the toxin in your blood and contribute to nerve damage. Finally, smoking causes your arteries to narrow and harden, reducing the blood flow to your legs and feet. This makes it more difficult for cuts and wounds to heal.

People with type 2 diabetes should prepare for their appointments by being prepared. Your preparation will depend on the doctor you are seeing. Unless your doctor is very knowledgeable about diabetes, expect to be referred to an endocrinologist as they specialize in treating metabolic disorders, such as diabetes. You may also be referred to a doctor who specializes in treating the nervous system (neurologist). Here are some tips to help make the best use of the time you have to spend with the doctor.

When you make the appointment, be sure to ask about special preparations necessary, such as fasting or diet restrictions. Next write down any symptoms you are experiencing. Be sure to include any symptoms even if they seem unrelated to the reason for seeing this doctor. Make a list of all (this is important) medications you are taking and include all vitamins and supplements you are taking. While this may seem unimportant, record any major stresses or recent life changes that have happen, such as illnesses, family deaths, major accidents, etc.. Depending on what you can find out, it may be wise to take your blood glucose meter with you as well as your daily log of blood glucose readings.

If possible, ask a family member or a friend to come with you. Instruct them to record potential important information to assist you in remembering everything all the information you will receive during the appointment. Also write down the questions for your doctor. List the most important one first in case time expires before all are asked. Some doctors will accept a list of questions and send a follow-up letter with answers, but this is not to be expected.

If you cannot get a referral to a neurologist, check with your medical insurance company to see what they will allow or suggest. Some will offer a list of two or three that are in proximity to you. A neurologist will give you an examination to check your muscle strength and tone, tendon reflexes, and sensitivity to touch, temperature and vibration.

Other tests may include a filament test using a monofilament and electromyography (EMG) which measures the electrical discharges produced in your muscles. Other tests may be a quantitative sensory testing to assess how your nerves respond to vibration and temperature changes and a nerve conduction studies that measures how quickly the nerves in your arms and legs conduct electrical signals. Finally autonomic testing may be done if you have symptoms of autonomic neuropathy to determine your blood pressure in different positions and assess your ability to sweat.

The American Diabetes Association recommends all people with diabetes have a comprehensive foot exam, either by a doctor or by a foot specialist (podiatrist), at least once a year. In addition, your feet should be checked for sores, cracked skin, calluses, blisters, and bone and joint abnormalities at every office visit. If you already have diabetic neuropathy, you will likely be referred to a podiatrist or other specialist for monitoring and treatment.

The next blog will be on treatment. Part 3 of 5.