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International Journal of Research in Medical Sciences | September 2019 | Vol 7 | Issue 9 Page 3452
International Journal of Research in Medical Sciences
Shrestha S et al. Int J Res Med Sci. 2019 Sep;7(9):3452-3460
www.msjonline.org
pISSN 2320-6071 | eISSN 2320-6012
Original Research Article
A study on the lipid ratios and inflammatory markers in pre-diabetic
and diabetic patients
Shailaza Shrestha1, Preeti Sharma1, Pradeep Kumar1*, Mahendra Prasad2
INTRODUCTION
Diabetes mellitus has become a pandemic globally with
the worldwide prevalence of 8.3% in 2013 which is
predicted to peak at 10.1% by 2035 with almost 80%
incidence only in developing nations. Diabetes incidence
in India is surging rapidly thus making it a diabetic
capital. The incidence of diabetes ranges between 9-12%
in different cities of India with nationwide prevalence of
7.7%.1 With regards to pathogenesis and history of
diabetes progression it is evident that individuals before
developing overt diabetes undergo a prolonged latent
phase known as pre-diabetic phase that confers highest
risk for diabetes.2 It can be defined as the glycemic state
higher than the normal level but below than that required
for diabetes diagnosis.3 ADA, (American diabetic
association) has set up the diagnostic criteria of pre-
diabetes and diabetes as follows: 4
1Department of Biochemistry, Santosh Medical College and Hospital, Ghaziabad, Uttar Pradesh, India
2Department of Biochemistry, Heritage Institute of Medical Sciences, Varanasi, Uttar Pradesh, India
Received: 08 July 2019
Revised: 07 August 2019
Accepted: 13 August 2019
*Correspondence:
Dr. Pradeep Kumar,
E-mail: prcdri2003@yahoo.co.in
Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.
ABSTRACT
Background: One of the leading causes of diabetic mortality is cardiovascular disease. Diabetes progression is
preceded by pre-diabetic phase which is also at higher cardiovascular risk. Both hyperglycemia and atherosclerotic
processes are inflammatory phenomenon. Keeping this in view, it was aimed to evaluate atherogenic indices and
correlate them with inflammatory mediators.
Methods: This study included 80 controls, 80 pre-diabetic and 80 diabetic patients. Anthropometric parameters
(BMI, WHR) and blood parameters like fasting glucose, HbA1c, lipid profile (cholesterol, HDL, LDL TG, VLDL),
adiponectin, IL-6, CRP, fibrinogen and uric acid were analysed.
Results: Significantly high atherogenic indices were observed in pre-diabetic and diabetic subjects compared to
healthy controls. The indices were also significantly correlated with BMI, fasting sugar, HbA1c, cholesterol, HDL,
TG and LDL. The correlation with HDL was negative and with other parameters, the correlation was positive. In pre-
diabetic patients, adiponectin showed significant negative correlation while fibrinogen and CRP showed significant
positive correlation with cardiac risk indices. IL-6 was positively correlated only with AIP while correlation of uric
acid with these indices was insignificant. In case of diabetic patients, the cardiac risk indices were significantly
correlated with adiponectin, IL-6, CRP, fibrinogen and uric acid. The correlation with adiponectin was negative.
Conclusions: The altered atherogenic indices and their significant association with inflammatory markers signify the
direct association of inflammation with CVD risks. Thus, there is requirement of novel approaches that can retard
inflammatory responses and arrest unwanted cardiac health outcomes.
Keywords: Atherogenic indices/cardiac risk indices, Diabetes, Inflammation, Pre-diabetes
DOI: http://dx.doi.org/10.18203/2320-6012.ijrms20193928
Shrestha S et al. Int J Res Med Sci. 2019 Sep;7(9):3452-3460
International Journal of Research in Medical Sciences | September 2019 | Vol 7 | Issue 9 Page 3453
Table 1: Diagnostic criteria of pre-diabetes
and Diabetes.
Pre-
diabetes
Fasting
glucose: 100-
125 mg/dL
Post Prandial
glucose: 140-
199 mg/dL
HbA1c:
5.7-
6.4%
Diabetes
Fasting
glucose: ≥126
mg/dL
Post Prandial
glucose:
≥200mg/dL
HbA1c:
>6.4 %
According to several reports, pre-diabetic phase is the last
step to prevent the diabetes progression via lifestyle
modification or treatment. Proper management not only
impedes the diabetes onset by ≥10 years, but also
prevents the disease development.5 The incidence of pre-
diabetes globally is 8% while in India it ranges between
10-14%. If not managed at earlier stage, it is reported that
70% of pre-diabetic patients end to diabetes development
with annual turnover of 5-10%.6
Both pre-diabetes and diabetes act as major risk factors
for CVDs (Cardiovascular diseases). CVD contributes to
almost 70% of mortality in the patients with diabetes. It is
also documented that the risk of cardiovascular mortality
increases by 2-4 times in diabetic patients compared to
healthy controls.7
Both pre-diabetes and diabetes are associated with
dyslipidemia (pro-atherogenic lipid profile) that is
characterized by increased concentration of total
cholesterol, LDL (low density lipoprotein), TG
(triglyceride) and decreased concentration of HDL (high
density lipoprotein). This contributes to atherovascular
events and increases the likelihood of CVD in future.8
Early assessment of CVD risks in diabetic patients can
aid in lowering CV mortality and improving prognosis of
diabetic patients.
Taking this into consideration, continuous efforts are
being made to identify new and easily approachable
techniques so as to improve cardiovascular health in pre-
diabetic and diabetic patients and reduce the rate of
mortality. On this regard various atherogenic indices have
been devised from the parameters of lipid profile in order
to optimise the predictive capability of CV risks. Further,
these indices not only reflect the clear picture of both
metabolic and clinical interactions between different lipid
fractions but also overcome the difficulty encountered on
those risk factors that are not easily accessible on routine
basis e.g. apo-lipoprotein B.9
To mention the names of those indices, important ones
are Cardiac risk ratio or Casteli’s risk index-I (CRR or
CRI-I) which is the ratio of total cholesterol to HDL,
Atherogenic index (AI) which is LDL to HDL ratio,
Atherogenic coefficient (AC) that is a ratio of non HDL
cholesterol to HDL and is the measure of entire
atherogenic lipoprotein fraction of plasma, and
Atherogenic index of plasma (AIP) which is log of ratio
of TG to HDL.10
Further, inflammation is the main phenomenon that leads
to hyperglycemia and associated complications especially
atherosclerosis. Also, there is paucity of studies showing
the association of atherogenic indices with inflammatory
markers especially in Indian scenario. Thus, in this study
it was aimed to assess the atherogenic indices and
determine their association with marker of inflammation
like adiponectin, CRP, IL-6, fibrinogen and uric acid in
pre-diabetic and diabetic patients.
METHODS
With the foresaid aim, 80 controls, 80 pre-diabetic
patients and 80 diabetic patients were enrolled in this
study conducted at department of Biochemistry, Santosh
Medical College and Hospital. The study was conducted
from January 2016-April 2019.
Inclusion criteria
Patients with pre-diabetes and type 2 diabetes
Exclusion criteria
Patients with type 1 diabetes, cardiac diseases, pulmonary
diseases, renal diseases, hepatic diseases, malignancies,
gout and arthritis, and any other conditions that may alter
the levels of inflammatory markers were excluded.
Prior to the commencement, the ethical approval and
written consent were taken from institutional ethical
board and each participant respectively. Basic details of
each participant (age, gender, BMI i.e. body mass index)
were recorded. Fasting blood sample was collected for
quantification of fasting sugar, lipid profile (cholesterol,
HDL, triglyceride) and inflammatory markers
(adiponectin, CRP, fibrinogen, IL-6 and uric acid).
Serum after separation was stored at -80ºC till analysis.
Glycosylated haemoglobin (HbA1c) was assayed in the
whole blood. Standard kit based methods were used for
the estimation of biochemical parameters as follows:
• Fasting blood sugar (FBS): Glucose oxidase
peroxidase (GODPOD) method
• HbA1c: Ion exchange resin method
• Cholesterol (CHO): Cholesterol oxidase peroxidase
(CHODPOD) method
• HDL: CHOD-POD/phosphotungustic acid method
• Triglyceride (TG): GPO-PAP method
• Uric acid (UA): Caraway’s method
• CRP and Fibrinogen (FGN): Immunoturbidimetric
method
• IL-6 and Adiponectin (ADN): Enzyme linked
immunosorbent assay.
Level of LDL was computed from Friedwald’s equation
11 i.e. LDL=Total Cholesterol-(HDL+VLDL) where
VLDL=TG/5
Shrestha S et al. Int J Res Med Sci. 2019 Sep;7(9):3452-3460
International Journal of Research in Medical Sciences | September 2019 | Vol 7 | Issue 9 Page 3454
Calculation of cardiac risk indices/atherogenic indices
was done as:12
Statistical analysis
The data was analysed using ANOVA and post hoc t-test.
The association of atherogenic indices with inflammatory
markers was determined by Pearson’s correlation
coefficient.
The difference in level and association was considered
statistically significant if p<0.05 was obtained.
RESULTS
The result of ANOVA was statistically significant for all
the studied variables (p<0.05). The comparison between
the groups was done by post hoc t test (Figures 1-17).
The age of the control group was significantly lower
compared to pre-diabetic and diabetic subjects; however,
the age of pre-diabetic and diabetic subjects was similar
(Figures. 1).
Figure 1: Comparison of age among the study groups.
In case of BMI, diabetic subjects had significantly high
BMI compared to control group (Figure 2). Similarly,
both fasting blood sugar and HbA1c showed sequential
increase from control group to pre-diabetic group and
then to diabetic group. The difference of mean was
significant in each group comparisons (Figures 3-4).
Figure 2: Comparison of BMI among the
study groups.
Figure 3: Comparison of FBS among the
study groups.
Figure 4: Comparison of HbA1c among the
study groups.
Further pre-diabetic and diabetic patients had
significantly high cholesterol (Figures 5) and LDL
(Figures 8) levels compared to control group while in
0
10
20
30
40
50
60
70
Control Pre-diabetes Diabetes
Age (years)
Group
A* B*
C*
Anova (p)=<0.0001*
0
5
10
15
20
25
30
Control Pre-diabetes Diabetes
BMI
Group
A
CB*
Anova (p)=0.016*
0
50
100
150
200
250
Control Pre-diabetes Diabetes
Fasting glucose (mg/dL)
Group
A*
C*
B*
Anova(p)=<0.0001*
0
1
2
3
4
5
6
7
8
Control Pre-diabetes Diabetes
HbA1c (gm%)
Group
B*
C*
A*
Anova(p)=<0.0001*
Shrestha S et al. Int J Res Med Sci. 2019 Sep;7(9):3452-3460
International Journal of Research in Medical Sciences | September 2019 | Vol 7 | Issue 9 Page 3455
case of HDL, the levels was significantly low in diabetic
group compared to control and pre-diabetic groups
(Figures 6). The level of TG was high in diabetic patients
compared to control and pre-diabetic groups, but the
significant result was not found in case of control versus
pre-diabetic comparison (Figure 7). Both pre-diabetic and
diabetic patients had significantly high cardiac risk
indices compared to controls. The indices were further
significantly increased in diabetic individuals when
comparison was made between pre-diabetic and diabetic
patients, but the level of statistical significance could not
be established between pre-diabetes versus diabetes (in
case of AI) and control versus pre-diabetes comparisons
(in case of AC) (Figures. 9-12).
Figure 5: Comparison of CHO among the
study groups.
Figure 6: Comparison of HDL among the
study groups.
The level of adiponectin was high in control group
compared to patient groups, but the significant result was
seen only in case of control versus diabetes and pre-
diabetes versus diabetes groups (Figure13).
The concentrations of CRP and IL-6 were significantly
high in both pre-diabetes and diabetes compared to
controls. The levels were further higher in diabetes (pre-
diabetes vs diabetes) (Figures. 15-16). Similar was the
case with fibrinogen and uric acid but the significant
results were not observed in these parameters when
compared between control and pre-diabetes groups.
(Figure 16-17).
Figure 7: Comparison of TG among the study groups.
Figure 8: Comparison of LDL among the
study groups.
Figure 9: Comparison of CRR among the
study groups.
0
50
100
150
200
250
Control Pre-diabetes Diabetes
Cholesterol (mg/dL)
Group
A* CB*
Anova(p)=<0.0001*
0
10
20
30
40
50
60
Control Pre-diabetes Diabetes
HDL (mg/dL)
Group
AC* B*
Anova(p)=0.0002*
0
20
40
60
80
100
120
140
160
180
Control Pre-diabetes Diabetes
TG (mg/dL)
Group
AC* B*
Anova(p)<0.0001*
0
20
40
60
80
100
120
140
160
180
Control Pre-diabetes Diabetes
LDL (mg/dL)
Group
A* CB*
Anova(p)=<0.0001*
0
1
2
3
4
5
6
Control Pre-diabetes Diabetes
CRR
Group
A* C* B*
Anova(p)=<0.0001*
Shrestha S et al. Int J Res Med Sci. 2019 Sep;7(9):3452-3460
International Journal of Research in Medical Sciences | September 2019 | Vol 7 | Issue 9 Page 3456
Figure 10: Comparison of AI among the study groups.
Figure 11: Comparison of AC among the
study groups.
Figure 12: Comparison of AIP among the
study groups.
The Table 2 shows the correlation of cardiac indices
(CRR, AI, AC, AIP) with basic parameters in pre-
diabetic and diabetic individuals.
Figure 13: Comparison of ADN among the
study groups.
Figure 14: Comparison of CRP among the
study groups.
Figure 15: Comparison of IL-6 among the
study groups.
Similarly, in Table 3 and Table 4 the correlation of
cardiac risk indices with inflammatory markers was
shown.
0
0.5
1
1.5
2
2.5
3
3.5
4
Control Pre-diabetes Diabetes
AI
Group
A* CB*
Anova(p)=<0.0001*
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
Control Pre-diabetes Diabetes
AC
Group
A* C* B*
Anova(p)=<0.0001*
0
0.1
0.2
0.3
0.4
0.5
0.6
Control Pre-diabetes Diabetes
AIP
Group
AC*
B*
Anova(p)=<0.0001*
0
2
4
6
8
10
12
Control Pre-diabetes Diabetes
Adiponectin (μg/mL)
Group
AC*
B*
Anova(p)=<0.0001*
0
1
2
3
4
5
6
7
8
Control Pre-diabetes Diabetes
CRP (mg/L)
Group
A*
C*
B*
Anova(p)=<0.0001*
0
2
4
6
8
10
12
Control Pre-diabetes Diabetes
IL-6 (pg/mL)
Group
A*
C*
B*
Anova(p)=<0.0001*
Shrestha S et al. Int J Res Med Sci. 2019 Sep;7(9):3452-3460
International Journal of Research in Medical Sciences | September 2019 | Vol 7 | Issue 9 Page 3457
Figure 16: Comparison of FGN among the
study groups.
In pre-diabetic patients, adiponectin showed significant
inverse correlation while CRP and fibrinogen showed
significant linear association with the cardiac risk indices.
IL-6 demonstrated significant positive correlation only
with AIP while for uric acid authors could not
demonstrate any significant association.
Among diabetic patients, significant negative correlation
was observed between the cardiac risk indices and
adiponectin while for IL-6, CRP, fibrinogen and uric acid
the correlation was significantly positive.
In figures 1-17:
A→Comparison between Control and Pre-diabetes
B→Comparison between Control and Diabetes
C→Comparison between Pre-diabetes and Diabetes
*→Statistically significant
Figure 17: Comparison of UA among the
study groups.
DISCUSSION
Diabetes is associated with CVD which is the main cause
of mortality in these patients. Therefore, earlier detection
of cardiovascular risk in diabetic patients can reduce the
CVD associated mortality rate. Several techniques have
been developed to predict the cardiovascular risk in
diabetic patients.
Table 2: Correlation of cardiac risk indices with basic parameters in pre-diabetic and diabetic groups
Parameters
Pre-diabetes
Diabetes
CRR
AI
AC
AIP
CRR
AI
AC
AIP
Age
0.13
0.11
0.15
0.12
0.06
0.04
0.06
0.25**
BMI
0.25**
0.25**
0.26**
0.16
0.28**
0.22*
0.26**
0.41**
Glucose
0.21*
0.17*
0.19*
0.31**
0.37**
0.33**
0.37**
0.28**
HbA1c
0.18*
0.16
0.18*
0.29**
0.45**
0.43**
0.45**
0.30**
CHO
0.91**
0.90**
0.91**
0.24**
0.93**
0.93**
0.93**
0.49**
HDL
-0.78**
-0.72**
-0.78**
-0.6**
-0.74**
-0.7**
-0.74**
-0.60**
TG
0.11
0.02
0.11
0.9**
0.5**
0.36**
0.5**
0.93**
LDL
0.93**
0.95**
0.93**
0.18*
0.92**
0.96**
0.92**
0.39**
Statistically significant: *→p<0.05, **→p<0.01.
Table 3: Correlation of cardiac risk indices with inflammatory markers in pre-diabetic group.
Parameter
Adiponectin (r)
CRP (r)
IL-6 (r)
Fibrinogen (r)
Uric acid (r)
CRR
-0.32**
0.24**
0.09
0.25**
0.11
AI
-0.29**
0.20**
0.04
0.26**
0.15
AC
-0.30**
0.27**
0.16
0.38**
0.13
AIP
-0.29**
0.19*
0.34**
0.2*
0.09
Statistically significant: *→p<0.05 , **→p<0.01.
0
50
100
150
200
250
300
350
400
450
500
Control Pre-diabetes Diabetes
Fibrinogen (mg/dL)
Group
AC* B*
Anova(p)=<0.0001*
0
1
2
3
4
5
6
7
8
9
Control Pre-diabetes Diabetes
Uric caid (mg/dL)
Group
AC*
B*
Anova(p)=<0.0001*
Shrestha S et al. Int J Res Med Sci. 2019 Sep;7(9):3452-3460
International Journal of Research in Medical Sciences | September 2019 | Vol 7 | Issue 9 Page 3458
Table 4: Correlation of cardiac risk indices with inflammatory markers in diabetic group.
Parameter
Adiponectin (r)
CRP (r)
IL-6 (r)
Fibrinogen (r)
Uric acid (r)
CRR
-0.48**
0.71**
0.46**
0.31**
0.29**
AI
-0.42**
0.65**
0.43**
0.33**
0.27**
AC
-0.45**
0.71**
0.46**
0.33**
0.30**
AIP
-0.55**
0.58**
0.49**
0.20*
0.22*
Statistically significant: *→p<0.05 **→p<0.01
The most authentic and economically reliable measures
with high predictive capabilities include atherogenic
indices or cardiac risk indices namely CRR, AI, AC and
AIP. Not only diabetes but the pre-diabetic patients are
also at a greater threat to develop cardiovascular diseases.
Thus, in this study the cardiac risk indices among control,
pre-diabetic and diabetic groups were assessed.
Compared to control group, the pre-diabetic and diabetic
patients had significantly high cardiac risk indices. The
indices were further elevated in diabetic patients. Similar
to this study, previous studies conducted by Mahat R et
al, and Ranjit PM et al, found significantly high
atherogenic indices in pre-diabetic patients.13,14 In this
study, the level of CRR, AI, AC and AIP were 3.92±0.84,
2.48±0.8, 2.61±0.53 and 0.32±0.09 respectively in pre-
diabetic patients while for diabetic patients they were
respectively 4.29±1.06, 2.76±0.94, 3.31±1.06 and
0.41±0.14. Chakraborty M et al, reported higher CRR
(i.e.>5), AI (i.e>3.5) and AC values (i.e.>4) in pre-
diabetic patients. In case of diabetic patients, the authors
reported these values to be >11, >9 and >10 respectively.4
The reported levels of cardiac risk indices were higher
than that observed in this study. In contrast Miyazaki Y et
al, could not document any significant difference in the
level of AI in their study.15
In the present study presence of dyslipidemia, a major
cause of CVD, in the patients involved was documented.
Significantly high values of cholesterol, TG and LDL
were observed in the patient groups while the level of
HDL was significantly low.
These results were in accordance with the previous
studies.13,16,17 LDL is the chief atherogenic lipoprotein
while HDL is an anti-atherogenic lipoprotein.
Abnormality in lipid metabolism in hyperglycemic state
is induced by insulin resistance. In insulin resistant state
there is increased lipolysis causing increased free fatty
acid flux from adipose tissue and release of VLDL from
hepatocytes which further increases the TG and reduces
HDL levels.18
Elevation in TG facilitates the increase in small and
dense LDL particles that have strong atherogenic
potential and increases the risk of atherosclerosis via lipid
peroxidation and free radical generation.19 On the
contrary HDL promotes reverse cholesterol transport and
exhibit anti-oxidant function due to presence of anti-
oxidant enzyme paroxonase. Thus, decreased level of
HDL and increased level of LDL and TG are strongly
associated with CVD in hyperglycemic patients.
Compared to the individual lipid parameters, cardiac risk
indices are considered more specific and sensitive marker
of cardiovascular risk prediction. However, Da Luz PL et
al, regarded AIP to be the more convenient marker
compared to CRR, AI and AC especially for myocardial
infarction and stroke.20 It may be due to positive
association of AIP with FERHDL (Fractional
esterification rate of HDL) and inverse association with
LDL particle size. AIP also acts as surrogate marker of
apo-lipoprotein B which is not easily available, and it
accurately reflects the status of atherogenic LDL and
anti-atherogenic HDL particles.21 The AIP values
observed in this study was significantly high in pre-
diabetic and diabetic patients. Similar to this study Regmi
P et al, and Thiyagajarajan R et al, also reported high
AIP values in pre-diabetic patients suggesting increased
CVD risks in future. According to Miric DJ et al, AIP
was significantly high in diabetic patients with
neuropathy than those who did not have. However,
Akdogan M et al, could not document such significant
difference in AIP among diabetic patients with and
without retinopathy.22-25 Since both hyperglycemia and
associated CVD are linked with inflammatory
mechanisms, the correlation of atherogenic indices with
inflammatory mediators (adiponectin, IL-6, CRP,
fibrinogen and uric acid) were also assessed. Adiponectin
showed significant negative correlation while CRP and
fibrinogen showed significant positive correlation with
atherogenic indices in pre-diabetic patients. In this study
positive association of IL-6 could be documented only
with AIP while in case of uric acid any significant
association with the indices could not be documented.
With regards to diabetic patients, all the inflammatory
mediators were significantly correlated with atherogenic
indices. The association was negative with adiponectin
and positive with IL-6, CRP, fibrinogen and uric acid.The
atherogenic indices were also significantly correlated
with basic parameters. The correlation was negative with
HDL and positive with other parameters (BMI, fasting
sugar, HbA1c, cholesterol, TG and LDL). Zhen Li et al,
reported significant association of AIP with BMI, WHR,
glucose and HbA1c similar to that of Juarez CA et al, and
Nansseu JRN et al, Likewise Nimmanapalli HD et al,
elucidated significant correlation of CRR, AC and AIP
Shrestha S et al. Int J Res Med Sci. 2019 Sep;7(9):3452-3460
International Journal of Research in Medical Sciences | September 2019 | Vol 7 | Issue 9 Page 3459
with age, BMI, fasting sugar, HbA1c and lipid
parameters.11,26-28 Previous studies have also reported
significant positive correlation between AIP and uric
acid.29,30
CONCLUSION
Cardiac risk indices can be generated simply by
measuring the level of lipid parameters (total cholesterol,
LDL, HDL, VLDL and TG) and they are the most
reliable and economic method for screening as they
surpass the expensive laboratory methods (like estimation
of apolipoproteins). In this study, there was increase in
values of cardiac risk indices in pre-diabetic and diabetic
patients thereby increasing the susceptibility of CVD in
these patients in future. Also, these indices were
significantly correlated with the inflammatory mediators
like adiponectin (cardio-protective cytokine) and IL-6,
CRP, fibrinogen and uric acid (cardiac risk factors).
Hence, it is recommended that screening must be
conducted among pre-diabetic and diabetic patients, so
that the propensity of future development of CVD can be
arrested by encouragement of healthy lifestyle or
pharmacotherapy that not only improve cardiac risk
factors but also increase the level of cardio-protective
molecules and decrease the level of those which thrives
cardiovascular risks.
Funding: No funding sources
Conflict of interest: None declared
Ethical approval: The study was approved by the
Institutional Ethics Committee
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Cite this article as: Shrestha S, Sharma P, Kumar P,
Prasad M. A study on the lipid ratios and
inflammatory markers in pre-diabetic and diabetic
patients. Int J Res Med Sci 2019;7:3452-60.
