Gestational diabetes alters subgingival pathobiont composition.

OC60 Evaluation of perinatal development of offspring born to mothers with gestational diabetes

Background: Gestational diabetes mellitus (GDM) and preeclampsia (PE) significantly increase the risk of adverse pregnancy outcomes. However, the effect on the risk of adverse pregnancy outcomes of GDM in combination with PE remains undetermined. Therefore, this study aimed to investigate the risk of adverse outcomes in pregnant women with GDM and PE. Methods: This retrospective cohort study was conducted at a single center. To explore the correlations between the occurrence of PE and adverse pregnancy outcomes, the enrolled population was divided into two groups: GDM and non-GDM. Risk factors associated with PE were analyzed using a binary logistic regression model. Results: This study comprised 27,181 pregnant women (5412 GDM cases and 21,769 non-GDM cases). The prevalence of PE was significantly higher in the GDM group than in the non-GDM group (p < 0.05). The presence of GDM, pre-pregnancy body mass index (pp-BMI) >24 kg/m2, and excessive gestational weight gain (GWG) were demonstrated to contribute to an increased risk of developing PE (p < 0.05). Pregnant women with GDM exhibited a significantly higher risk of preterm birth. Additionally, the risk of preterm birth, cesarean section, and fetal growth restriction increased further when PE occurred alongside GDM. Conclusions: Overall, pp-BMI >24 kg/m2 and excessive GWG were risk factors for PE. Pregnant women with GDM have a higher risk of developing PE, and co-occurrence of PE further increases the risk of adverse pregnancy outcomes. Therefore, attention and management of this population are needed during pregnancy.

The study aims to analyze the association between gestational diabetes mellitus (GDM) and other risk factors of cesarean delivery using machine learning (ML). The dataset used for the analysis is from the pregnancy risk assessment survey (PRAMS), considered in two scenarios, i.e., all the data is taken, and all the data of the women who developed GDM. Further, the data is developed in two groups Data-I and Data-II by considering multiparous and primiparous women details, respectively. The correlation analysis and major classification algorithms are applied to the data. It is founded that the top risk factors for the first time cesarean delivery are the age, height, weight, race of the women, presence of hypertension and gestational diabetes mellitus. The major risk factor for repeated cesarean delivery is the previous cesarean delivery. The presence of GDM is also one of the risk factors for cesarean delivery.

To examine the effect of maternal characteristics, including advancing maternal age, body mass index (BMI), racial origin and development of gestational diabetes mellitus (GDM), on birthweight and the interactions between these factors. Retrospective analysis of prospectively collected data. Fifteen maternity units in North West London, between 1988 and 2000. A cohort of 130 549 pregnant women. Multivariate regression analysis. Birthweight z-scores in non-GDM and GDM groups within three main racial groups (white European, black and South Asian women). Babies born to women with GDM were heavier compared with those born to women with no GDM in all racial groups. In black women with GDM the birthweight z-scores were 0.805 higher, in South Asian women the scores were 0.618 higher and in white European women the scores were 0.437 higher, compared with the respective non-GDM group (P < 0.001 for both comparisons versus white European women), and these differences were much greater at high rather than at low maternal BMIs. Advancing maternal age, increasing BMI, highest diastolic blood pressure, Castair's index, racial group and presence of GDM or smoking were each, individually, significantly associated with birthweight z-scores (P < 0.001 for all variables). After adjusting for possible confounding factors, BMI was positively associated with birthweight z-scores within all racial groups (P < 0.001 for all), irrespective of glycaemic status, but its effect was much greater in women with GDM, particularly in those of non-White origin. After adjusting for possible confounding factors, advancing maternal age was only positively associated with birthweight in women of white European and South Asian racial origin who did not suffer from GDM (P < 0.001 for both). Gestational diabetes mellitus strongly accentuates the effect of maternal BMI on birthweight, especially within non-white populations.

Periodontopathic bacteria such as Porphyromonas gingivalis, Aggregatibacter actinomycetemcomitans, Tannerella forsythia, Campylobacter rectus and Treponema denticola play an important role in the initiation and progression of periodontitis. The aim of this investigation was to evaluate the relationship between periodontal clinical parameters and the subgingival profile of periodontopathic bacteria. Twenty-six periodontitis patients (23-62 years of age; mean age, 40.2±13.2) with no systemic disease agreed to participate in the study. Periodontal clinical parameters, including probing depth (PD) and bleeding on probing (BOP) were recorded. Subgingival plaque samples were obtained from deep (PD≥4 mm) and shallow (PD≤3 mm) pockets in each patient for detection of P. gingivalis, A. actinomycetemcomitans, T. forsythia, C. rectus and T. denticola by polymerase chain reaction technique. The relationship between the periodontal pathogens and clinical parameters was determined with the Fisher exact test, and a statistically significant association was found between detection of P. gingivalis, T. forsythia, C. rectus and T. denticola and PD or BOP. T. denticola was the most prevalent pathogen in both shallow PD and deep PD sites. No statistically significant association was found between detection of A. actinomycetemcomitans and the clinical parameters examined. A statistically significant association was found between detection of the red complex bacteria and the clinical parameters. These results suggest that the red complex pathogens and C. rectus play an important role in the initiation and progression of periodontitis.

ObjectiveTo study the combined effect of gestational diabetes mellitus (GDM) and maximum level of maternal serum total bile acid (TBA) on the incidence of adverse pregnancy outcomes in women with intrahepatic cholestasis of pregnancy (ICP).MethodsThis was an observational study with 724 women with ICP. Perinatal outcomes were compared by the presence of GDM. Logistic regression was used to assess the independent and multiplicative interactions of GDM and maximum maternal serum TBA on adverse pregnancy outcomes. Additive interactions were calculated using an Excel sheet developed by Andersson to calculate relative excess risks.ResultsThe incidence of GDM in patients with ICP was 21.55%. Maternal age, pre-pregnancy weight, parity, and gravidity were positively correlated with GDM. Hypertensive disorders of pregnancy (HDP) and fetal distress rates were higher in the GDM vs. non-GDM group. There were no significant differences in biochemical outcomes (i.e., Triglyceride (TG), low density lipoprotein (LDL), alanine aminotransferase (ALT), aspartate aminotransferase (AST) and total bile acid (TBA)) between the two groups. In terms of adverse pregnancy outcomes, GDM was only associated with maximum TBA concentration for cesarean section. No additive or pairwise interactions were detected between GDM and maximum TBA concentration and HDP, PPH, preterm delivery, LGA, SGA, and cesarean section.ConclusionGDM independently contributes to adverse pregnancy outcomes among women with ICP. However, the combined effects of GDM and maximum TBA concentration on adverse pregnancy outcomes do not appear to be multiplicative or additive.

Objective: The purpose of this study was to explore the effect of gestational diabetes mellitus (GDM) on depression and breastfeeding self-efficacy during pregnancy and the postpartum period. Methods: This descriptive study was conducted in Obstetrics and Perinatology clinics of two university hospitals in Turkey between July 2016 and June 2017. Women were followed up two times. The first follow-up was performed face-to-face in the gestational week 34th to 38th and the second one was performed by telephone in the 8th week of the postpartum period. In the first follow-up, 104 pregnant women with GDM and 133 pregnant with non-GDM women were interviewed. In the second follow up, 30 women could not be reached in both groups. Data were collected by the Individual Description Form, Edinburgh Postpartum Depression Scale, and Breastfeeding Self-Efficacy Scale-Short Form. Descriptive statistics, repeated measures analysis of variance and correlation analysis were used in the data analysis. Results: The depression risk of mothers with GDM was found higher compared to non- GDM mothers. No significant difference was found between the depression and breastfeeding self-efficacy mean scores in the antenatal and postpartum period of women by the presence of GDM. There was no significant difference between the depression and breastfeeding self-efficacy mean scores in the antenatal and postpartum period by the presence of GDM and some confounding variables. As the breastfeeding self-efficacy level of mothers with GDM both in the antenatal and postpartum period increased, the depression risk decreased. Conclusion: In the study, it has been concluded that GDM does not have an impact on depression and breastfeeding self-efficacy during pregnancy and in the postpartum period.

To determine the effect of different bracket designs (conventional brackets and self-ligating brackets) on periodontal clinical parameters and periodontal pathogens in subgingival plaque. The following inclusion criteria were used: requirement of orthodontic treatment plan starting with alignment and leveling, good general health, healthy periodontium, no antibiotic therapy in the previous 6 months before the beginning of the study, and no smoking. The study sample totaled 38 patients (13 male, 25 female; mean age, 14.6 ± 2.0 years). Patients were divided into two groups with random distribution of brackets. Recording of clinical parameters was done before the placement of the orthodontic appliance (T0) and at 6 weeks (T1), 12 weeks (T2), and 18 weeks (T3) after full bonding of orthodontic appliances. Periodontal pathogens of subgingival microflora were detected at T3 using a commercially available polymerase chain reaction test (micro-Dent test) that contains probes for Aggregatibacter actinomycetemcomitans, Porphyromonas gingivalis, Prevotella intermedia, Tannerella forsythia, and Treponema denticola. There was a statistically significant higher prevalence of A actinomycetemcomitans in patients with conventional brackets than in patients with self-ligating brackets, but there was no statistically significant difference for other putative periodontal pathogens. The two different types of brackets did not show statistically significant differences in periodontal clinical parameters. Bracket design does not seem to have a strong influence on periodontal clinical parameters and periodontal pathogens in subgingival plaque. The correlation between some periodontal pathogens and clinical periodontal parameters was weak.

Background: Gestational Diabetes Mellitus (GDM) is a common metabolic complication of pregnancy characterized by glucose intolerance and insulin resistance. Early detection and management of GDM are critical to prevent adverse maternal and foetal outcomes. Cystatin C; traditionally known as a renal marker, has recently been implicated in metabolic dysfunctions such as insulin resistance and hyperglycaemia. Objective: This study aimed to evaluate the association of high serum Cystatin C with glycaemic parameters and insulin resistance in pregnant women with GDM. Methods: This case-control study was conducted at Bangladesh Institute of Research and Rehabilitation in Diabetes, Endocrine and Metabolic Disorders (BIRDEM) General Hospital, Dhaka, from March 2024 to February 2025. Total 160 pregnant women between 24–28 weeks of gestation were enrolled; including 80 diagnosed GDM (cases) and 80 age and gestational week matched healthy pregnant women (controls). Selection was done using convenient and purposive sampling. GDM was diagnosed based on the American diabetes association (ADA) 2023 criteria. Clinical, anthropometric, and biochemical parameters, including fasting plasma glucose, 2-hour post-load plasma glucose, serum insulin, HOMA-IR, and serum Cystatin C, were measured. Data were analysed using SPSS version 26, with p &lt; 0.05 considered statistically significant. Results: The mean BMI was significantly higher in the GDM group (28.97 ± 3.75 kg/m²) compared to controls (27.97 ± 4.04 kg/m², p &lt; 0.002). Fasting plasma glucose (5.92 ± 2.14 mmol/L vs. 4.41 ± 0.40 mmol/L, p &lt; 0.001), 2-hour post load plasma glucose (9.03 ± 2.92 mmol/L vs. 6.53 ± 1.02 mmol/L, p = 0.041), and HOMA-IR (5.87 ± 3.94 vs. 3.99 ± 1.78, p &lt; 0.001) were significantly elevated in the GDM group. Serum insulin was higher among cases but not statistically significant (p = 0.38). Serum Cystatin C level was significantly elevated in the GDM group (0.932 ± 0.23 mg/L vs. 0.734 ± 0.11 mg/L, p &lt; 0.001). The high level (&gt;0.80 mg/dl) serum Cystatin C was strongly associated with GDM (OR-9, CI-5.0 to 16.3, p&lt; 0.001). Cystatin C was positively correlated with fasting plasma glucose (r = 0.321, p &lt;0.05); 2-hour post load plasma glucose (r = 0.303, &lt;0.05) and HOMA-IR (0.323, P&lt; 0.05). Correlations of Cystatin C with serum insulin (r = 0.121, p&gt;0.05) and BMI (r = 0.150, p&gt;0.05)) were positive but not statistically significant. Conclusion: High serum Cystatin C levels exhibit strong, positive, and statistically significant association with the presence of GDM and a positive correlation was found with glycaemic parameters and insulin resistance. So, woman with elevated Cystatin C suggest a higher risk of developing GDM. Bangladesh Medical Res Counc Bull 2025;51(3): 117-122

Humanin (MT-RNR2) is an endogenous polypeptide that is involved in many diseases, including T2DM. Gestational diabetes mellitus (GDM) is defined as hyperglycemia during pregnancy. The aim of this study was to evaluate serum humanin levels in women with or without GDM and to elucidate possible correlations with anthropometric parameters, metabolic parameters and the incidence of GDM. Eighty-four women with GDM and 73 control women were enrolled in this study. The clinical and biochemical parameters of all subjects were determined. Serum humanin levels were measured by an ELISA. Serum humanin levels were significantly lower in women with GDM than in control women. Moreover, humanin levels were significantly negatively correlated with the presence of GDM, body weight, BMI at 24 weeks of gestation, TG, FPG, 1 hPG, 2 hPG, FINS, and HOMA-IR. In contrast, humanin levels were significantly positively correlated with FT3 and FT4. A binary logistic analysis showed that humanin levels were associated with the incidence of GDM. Additional follow-up studies are needed to highlight whether and how decreased humanin levels play an important role in GDM.

Objective: To compare presence of gestational diabetes mellitus in women with short inter pregnancy interval vs women with normal pregnancy interval in two hospitals of northern and southern regions of Pakistan. Study Design: Case Control study. Setting and Duration of Study: Gynecology and Obstetrics Department, Combined Military Hospital, Malir and Gilgit Pakistan, from Jun 2022 to Feb 2023. Methodology: This case control study was conducted in two military hospitals of Pakistan. Cases were women with short inter pregnancy interval and controls were equal number of pregnant women who had normal inter pregnancy interval. Both the groups were followed up for whole period of pregnancy to look for presence of gestational diabetes mellitus or other relevant metabolic abnormalities. Results: A total 304 cases of short interval pregnancy were studied along with equal number of controls. Mean age of the total study participants was 30.29±5.90 years. When cases and controls were compared for presence of gestational diabetes mellitus, 7(2.3%) controls had this disease while 78(25.6%) cases developed gestational diabetes mellitus during the course of pregnancy (p-value&lt;0.001). Pregnancy induced hypertension, Antiphospholipid antibody syndrome and preeclampsia were not statistically significant among cases and controls (p-value&gt;0.05). Conclusion: Women with short inter pregnancy interval were found more at risk of having gestational diabetes mellitus as compared to control group which comprised of women with normal inter pregnancy interval.

Aim. To study biochemical markers of endothelial dysfunction associated with placental insufficiency and fetal growth restriction (FGR) in pregnant women with gestational diabetes mellitus (GDM). Design. A longitudinal, prospective case-control study. Materials and methods. The study included 110 pregnant women from the first trimester of gestation, including 75 women with GDM (study group) and 35 patients with uncomplicated pregnancies (control group). Pregnant women with GDM were divided into two subgroups: 23 women with FGR (including those with impaired maternal-placental-fetal blood flow) and 52 women with normal-weight fetuses without impaired uteroplacental, fetoplacental, or fetal blood flow. All subjects were tested for the level of methylated derivatives of L-arginine in the blood: monomethylarginine (MMA), asymmetric dimethylarginine (ADMA), symmetric dimethylarginine (SDMA) and their calculated ratios: (ADMA + SDMA)/MMA, ADMA/MMA, SDMA/MMA, ADMA/SDMA, using high-performance liquid chromatography with tandem mass spectrometric detection. Results. According to the results of the study of ADMA indices, its elevated level was noted in 39 (52%) patients in the main group, including 18 of 23 (78.3%) women with GDM and IGR, and 20 of 52 (38.5%) pregnant women with GDM and normal fetal weight. Thus, it was found that an increase in ADMA is associated with the development of IGR in GDM (odds ratio (OR) = 5.7). The MMA values in the blood of the studied patients did not differ statistically significantly: an increase in MMA was noted in 15 (20.0%) pregnant women in the main group, including 5 (21.7%) women with GDM and 10 (19.2%) women with GDM without IGR; among patients in the control group, an elevated MMA level was found in 8 (22.9%) women (p = 0.45). The SDMA index was elevated in 19 (82.6%) pregnant women with GDM and IUGR, in 41 (78.8%) patients with GDM without IUGR, and in 5 (14.3%) women in the control group. A statistically significant relationship between an increase in the SDMA level and the presence of GDM was revealed (p &lt; 0.001, OR = 26.1), while a significantly lower proportion of SDMA increase was observed in the group of women without GDM. ROC analysis was performed to determine the diagnostic value of the ADMA/SDMA ratio. At a cutoff value of &gt; 1.2, the ratio demonstrated a sensitivity of 69.6% (16 true positive cases out of 23) and a specificity of 82.7% (43 true negative results out of 52). The area under the ROC curve (AUC) was 0.76 (95% confidence interval: 0.68–0.84), indicating a moderate prognostic value of this indicator. Conclusion. In pregnant women with GDM, ADMA and SDMA levels are statistically significantly elevated, indicating severe endothelial dysfunction and correlating with the development of placental insufficiency and intrauterine growth restriction (IGR). An ADMA/SDMA ratio &gt; 1.2 is a significant prognostic marker for IGR in GDM. The study results highlight the need to revise clinical guidelines for the management of GDM to include assessment of endothelial dysfunction. Keywords: gestational diabetes mellitus, fetal growth restriction, placental insufficiency, endothelial dysfunction, blood biochemistry.

BACKGROUND: The prevalence of gestational diabetes mellitus has increased significantly and has become a global health problem, affecting 9.325.5% of pregnant women worldwide. Violation of the interaction of various body systems with the intestinal microbiota can be the cause of the development of insulin resistance. The study of the state of the intestinal microbiota based on the results of the study of the species composition of microorganisms in feces by the polymerase chain reaction method is necessary to understand the mechanisms of gestational diabetes mellitus development.&#x0D; AIM: The aim of this study was to evaluate the intestinal microbiota status in women with normal pregnancy and pregnancy complicated by gestational diabetes mellitus.&#x0D; MATERIALS AND METHODS: We examined 51 pregnant women in the period 2020-2022. The average age of women with normal pregnancy (n = 20) and pregnancy complicated by gestational diabetes mellitus (n = 31) was 29 (27.0; 32.5) and 31 (27.0; 35.0) years, respectively. The intestinal microbiota status was assessed based on the microbial species composition in feces using real-time polymerase chain reaction. All women underwent a test for carbohydrate metabolism at various gestation periods.&#x0D; RESULTS: We have established a positive relation between Bacteroides thetaiotaomicron and Body Mass Index before pregnancy (r = 0.42). The number of Bacteroides thetaiotaomicron in the 1st, 2nd and 3rd trimesters of gestation positively correlated with the initial weight of women before pregnancy (r = 0.60, r = 0.52, r = 0.47, respectively; p 0.05). The Bacteroides spp. / Faecalibacterium prausnitzii ratio in women with gestational diabetes mellitus was negatively correlated with the average blood glucose level in the 3rd trimester of pregnancy (r = 0.81; p 0.05). Parvimonas micra positively correlated with venous plasma glucose levels in the presence of gestational diabetes mellitus (r = 0.58; p 0.05). A positive relationship was obtained between the number of Escherichia coli in pregnant women in the 1st trimester and the average glucose level in the 3rd trimester of pregnancy (r = 0.41; p 0.05). It was demonstrated that the growth of Bacteroides fragilis in the large intestine of pregnant women with gestational diabetes mellitus in the 3rd trimester of pregnancy correlated with subnormal blood glucose levels (r = 0.77; p 0.05), which may be due to a diet disorder (insufficient carbohydrate intake) or insulin overdose, which can lead to hypoglycemic conditions. In the group of women with gestational diabetes mellitus, a positive correlation was obtained between glycated hemoglobin level and the opportunistic pathogen Klebsiella pneumoniae representative amount in the 1st trimester of pregnancy (r = 0.46; p 0.05). In addition, we have found positive relations between the Citrobacter spp. / Enterobacter spp. ratio and the maximum blood glucose level in women with gestational diabetes mellitus in the 1st, 2nd and 3rd trimesters of pregnancy (r = 0.49, r = 0.43, r = 0.47, respectively; p 0.05). The difference in the intake of dietary fiber in the control group and in the group of pregnant women with gestational diabetes mellitus was obtained: 2 (1; 3) and 1 (1; 1), respectively (p 0.05).&#x0D; CONCLUSIONS: Data have been obtained confirming the relationship between disorders of the colon microbiocenosis and carbohydrate metabolism in pregnant women with gestational diabetes mellitus. A relationship has been found between insufficient intake of dietary fiber and the risk of developing gestational diabetes mellitus.

Aim To determine neonatal outcome in women with gestational diabetes mellitus (GDM) diagnosed using Diabetes in Pregnancy Study Group of India (DIPSI) recommended method. Materials and methods Out of 487 antenatal women, 52 were diagnosed with GDM using DIPSI test. All women were followed up until delivery and evaluated for neonatal outcome and managed accordingly. The appropriate statistical tests for various variables were applied by using Epi Info 7 software and evaluated at the level below than 5%. Results Apgar score of &lt;6 at 5 minutes was found in 10 (20%) neonates of GDM mothers as compared with 18 (4.1%) in non-GDM group (p-value of 0.00001). Respiratory distress was present in 19 (38%) neonates in GDM group, while it was 48 (11.1%) in non-GDM group (p-value of 0.00002). Association of GDM and hyperbilirubinemia was nonsignificant in 2 (4%) neonates among GDM group, while it was 6 (1.4%) in non-GDM group. Hypoglycemia was 5 (10%) in GDM group, while 3 (0.7%) in non-GDM group (p-value of &lt;0.0003). A total of 3 (6%) among GDM group had hypocalcemia, while 3 (0.7%) had hypocalcemia in non-GDM group (p-value of 0.02). The neonatal intensive care unit admissions were 29 (58%) in GDM group, while it was 96 (22.1%) neonates belonging to non-GDM group (p-value of 0.00001). No neonatal deaths were reported in GDM group, while there were 2 (0.5%) in non-GDM group. Anomalies were found in 6 (11.5%) in GDM group as compared with 5 (1.1%) in non-GDM (p-value of 0.00001). About 44.2% women with GDM had hemoglobin (Hb)A1c levels between 6 and 6.9%. Among GDM women, 4 (7.7%) had pregnancy losses as compared with 7 (1.6%) in non-GDM group. Conclusion The GDM is associated with significant fetal and neonatal morbidity; hence, preconceptional counseling, early diagnosis, and proper treatment are recommended. Clinical significance Preconceptional correction of HbA1c is also recommended based on risk of anomalies in fetus of GDM mother. How to cite this article Jain P, Somalwar S, Jain P. Neonatal Outcome and Its Correlation with Hemoglobin A1c in Gestational Diabetes Mellitus. J South Asian Feder Obst Gynae 2017;9(3):216-220.

Crohn's disease (CD) was reported to have oral manifestations. However, data on periodontal parameters and oral microbiology in CD are rare. Recent studies showed associations of variants in the caspase recruitment domain (CARD)15 gene with CD that are involved in the immune response toward bacterial products. Our aim is to investigate the periodontal status and prevalence of periodontal pathogens in patients with CD under consideration of the CARD15 polymorphism. Oral soft tissue alterations and periodontal parameters of 147 patients with CD were assessed. Subgingival plaque samples were analyzed for the periodontal pathogens Aggregatibacter actinomycetemcomitans (Aa; previously Actinobacillus actinomycetemcomitans), Porphyromonas gingivalis (Pg), Tannerella forsythia (Tf; previously T. forsythensis), Prevotella intermedia (Pi), and Campylobacter rectus (Cr ) using dot-blot hybridization. CARD15 genotyping was performed with the a polymerase chain reaction (PCR) based assay. A total of 36.7% of patients had oral manifestations predominated by gingival swellings (27.2%) and hyperplastic lesions of the buccal mucosa (20.4%). The mean probing depth and mean clinical attachment level were 3.6 and 3.8 mm, respectively. A total of 57.8% of the patients had a Community Periodontal Index of Treatment Needs (CPITN) score 3, and 31.3% of had a CPITN score 4. The prevalence of Aa, Pg, Pi, Tf, and Cr was 76.9%, 62.6%, 79.6%, 64.6%, and 94.6%, respectively. Pi was significantly less frequent in carriers of CARD15 mutations compared to the wild type (69.7% versus 87.7%; P = 0.008). All other pathogens and clinical periodontal parameters did not differ significantly as to the CARD15 polymorphism. Our findings suggest that patients with CD have an increased prevalence and moderate severity of periodontitis. The colonization of periodontal pathogens, in particular Cr, might be of particular value for the periodontal manifestation of CD. Although a modulating impact on periodontal microbiota can be supposed, our data do not support the role of CARD15 in oral symptoms and periodontal lesions in patients with CD.