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Li J, Yang N, Chou H, Shi L, Wei M, Li Y. Central diastolic blood pressure, plasma aldosterone and uric acid are associated with microalbuminuria in essential hypertension: a case-control study. BMC Cardiovasc Disord 2023; 23:511. [PMID: 37848834 PMCID: PMC10583460 DOI: 10.1186/s12872-023-03515-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 09/16/2023] [Indexed: 10/19/2023] Open
Abstract
OBJECTIVE To study the development of microalbuminuria (MAU) in essential hypertension (EHT), we investigated the association of MAU with central blood pressure (CBP), direct renin concentration (DRC), plasma aldosterone (PA), and uric acid (UA). METHOD We determined 24 h-urinary albumin excretion (24 h-UAE) in patients with EHT who were hospitalized at TEDA International Cardiovascular Hospital from June 2020 to May 2022. We defined MAU as 24 h-UAE in the range of 30 mg/24 h to 300 mg/24 h. Univariate and multivariate analyses were conducted to determine the associations of MAU with CBP, DRC, PA, and UA in EHT, considering demographic and clinical information. We also plotted receiver operating characteristic curves (ROCs) for predicting MAU using these results. RESULTS More than a quarter of patients (26.5%, 107/404, 95% CI: 22.2-31.1%) were diagnosed with MAU in EHT. A higher body mass index (BMI), longer duration of hypertension, and higher severity were associated with MAU. Also, nearly 10% more creatinine levels were recorded in the MAU group than in the control group (69.5 ± 18.7 µmol/L vs. 64.8 ± 12.5 µmol/L, P = 0.004). The increase was also observed for PA (15.5, 9.7-20.6 ng/dL vs. 12.3, 9.0-17.3 ng/dL, P = 0.024) and UA (419.8 ± 105.6 µmol/L vs. 375.1 ± 89.5 µmol/L, P < 0.001) in the MAU group compared to that in the control group. Several variables were associated with MAU, including central diastolic blood pressure (CDBP) (OR = 1.017, 95% CI: 1.002-1.032, P = 0.027), PA (OR = 1.043, 95% CI: 1.009-1.078, P = 0.012) and UA (OR = 1.005, 95% CI: 1.002-1.008, P < 0.001). For MAU prediction, the area under the curve (AUC) was 0.709 (95% CI: 0.662-0.753; P < 0.001) when CDBP, PA, and UA were used in combination, and the optimal probability of the cut-off value was 0.337. CONCLUSION We found that CDBP, PA, and UA, used for MAU prediction, might be associated with its development during EHT.
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Affiliation(s)
- Jinlong Li
- Department of Hypertension, Clinical School of Cardiovascular Disease, Tianjin Medical University, Tianjin, 300457, China
- Department of Hypertension, TEDA International Cardiovascular Hospital, Tianjin, 300457, China
| | - Ning Yang
- Department of Hypertension, TEDA International Cardiovascular Hospital, Tianjin, 300457, China
| | - Hongda Chou
- Department of Hypertension, TEDA International Cardiovascular Hospital, Tianjin, 300457, China
| | - Leilei Shi
- Department of Hypertension, TEDA International Cardiovascular Hospital, Tianjin, 300457, China
| | - Maoti Wei
- Center for Clinical Epidemiology, TEDA International Cardiovascular Hospital, Tianjin, 300457, China
| | - Yuming Li
- Department of Hypertension, TEDA International Cardiovascular Hospital, Tianjin, 300457, China.
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Yu LL, Li CN, Fang MY, Ma Y, Wang B, Lin FP, Liu WH, Tu SH, Chen Z, Xie WX, Zhang RY, Huang Y, Zheng CH, Wang Y. Evaluating the effectiveness and safety of acupuncture on serum uric acid in asymptomatic hyperuricemia population: a randomized controlled clinical trial study protocol. Front Endocrinol (Lausanne) 2023; 14:1218546. [PMID: 37900149 PMCID: PMC10611493 DOI: 10.3389/fendo.2023.1218546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 09/01/2023] [Indexed: 10/31/2023] Open
Abstract
Background The clinical dangers of asymptomatic hyperuricemia to human health have become increasingly prominent over the past 20 years. Previous studies have shown the potential benefits of acupuncture on uric acid levels in the body. However, definitive evidence is lacking. Our objective is to evaluate the efficacy and safety of acupuncture on serum uric acid (SUA) in individuals with asymptomatic hyperuricemia. Methods This is a randomized, single-blind, sham-controlled trial. A total of 180 eligible patients with asymptomatic hyperuricemia will be recruited at three hospitals in China. Patients will be randomly assigned in a 1:1 ratio to receive 16 sessions of manual acupuncture or sham acupuncture for 8 weeks. Patients will be followed up for 12 weeks. The primary outcome will be the change in SUA levels at week 8 after randomization. Secondary outcomes will include dynamic changes in SUA levels, efficacy rates, proportion of gout flare, body weight, and acute medication intake. The MGH Acupuncture Sensation Scale and adverse events related to acupuncture will be measured after each treatment. A blinding assessment will be performed on patients who receive at least one session of acupuncture. Data analyses will be performed on a full analysis set and a per-protocol set. Ethics and dissemination Ethics approval has been obtained from the Clinical Trial Ethics Committee of Tongji Medical College, Huazhong University of Science and Technology (approval no. 2021-S135). Written informed consent will be obtained from enrolled patients. The findings will be disseminated in a peer-reviewed journal. Clinical trial registration ClinicalTrials.gov identifier, NCT05406830.
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Affiliation(s)
- Ling-ling Yu
- Institute of Integrated Traditional Chinese and Western Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Chen-nan Li
- The Second School of Clinical Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Meng-yue Fang
- The Second School of Clinical Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Yan Ma
- Department of Rehabilitation Medicine, Wuhan No.1 Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Bo Wang
- Department of Rehabilitation Medicine, Wuhan No.1 Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Feng-ping Lin
- Department of Endocrinology, Xianning Central Hospital, Hubei University of Science and Technology, Xianning, Hubei, China
| | - Wen-hua Liu
- Clinical Research Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Sheng-hao Tu
- Institute of Integrated Traditional Chinese and Western Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Zhe Chen
- Institute of Integrated Traditional Chinese and Western Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Wen-xi Xie
- Institute of Integrated Traditional Chinese and Western Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Rui-yuan Zhang
- Institute of Integrated Traditional Chinese and Western Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Yao Huang
- Institute of Integrated Traditional Chinese and Western Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Cui-hong Zheng
- Institute of Integrated Traditional Chinese and Western Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Yu Wang
- Institute of Integrated Traditional Chinese and Western Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
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Chou H, Wei M, Chen H, Xu Y, Shi L, Duan J, Li L, Yang N, Li Y. The association among uric acid, microalbumin and estimated glomerular filtration rate in hypertensive patients: a case control study. BMC Cardiovasc Disord 2023; 23:68. [PMID: 36740710 PMCID: PMC9899386 DOI: 10.1186/s12872-023-03085-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 01/23/2023] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE To estimate the relationship among uric acid (UA), 24-h microalbumin (24 h-MAU) and estimated glomerular filtration rate (eGFR) in hypertensive patients. METHOD The study enrolled adult patients hospitalized in TEDA International Cardiovascular Hospital. The study was used to explore the correlation among UA, 24 h-MAU and eGFR. Univariate analysis was used to compare continuous or categorical data groups according to data type. Multivariate analysis was used to explore the correlation among UA, Log 24 h-MAU and eGFR by linear regression, and the relationship among UA, 24 h-MAU ≥ 30 mg/24 h (increased 24 h-MAU) and eGFR < 90 ml·min-1·1.73 m-2 (mildly decreased eGFR) by logistic regression. Mediation effect analysis was used to explore the mediating effect of increased 24 h-MAU between UA and mildly decreased eGFR. Subgroup analysis was used to investigate the correlation among UA, 24 h-MAU and eGFR in different gender. RESULT Seven hundred and thirty-three inpatients were enrolled in the study, including 257 patients with hyperuricemia. The level of UA was 377.8 ± 99.9 μmol/L in all patients enrolled, and it was about 50.1% higher in hyperuricemia group (482.3 ± 58.8 μmol/L vs. 321.4 ± 63.5 μmol/L, P < 0.001). The prevalence of hyperuricemia was 35.1% (95%CI 31.6-38.5%). The univariate regression analysis showed that UA was significant related to Log 24 h-MAU, increased 24 h-MAU, eGFR and mildly decreased eGFR. After adjusted confounding factors, UA was significant related to Log 24 h-MAU (β = 0.163, P < 0.001), eGFR (β = - 0.196, P < 0.001), increased 24 h-MAU (quantitative analysis: OR = 1.045, 95%CI 1.020-1.071, P < 0.001; qualitative analysis: OR = 2.245, 95%CI 1.410-3.572, P = 0.001), but had no significant relationship with mildly decreased eGFR. Mediating effect analysis showed that increased 24 h-MAU partially mediated the relationship between UA and mildly decreased eGFR (relative indirect effect: 25.0% and 20.3% in quantitative analysis and qualitative analysis respectively). In the subgroup analysis, the results were stable and similar to the analysis for entry patients. CONCLUSION The prevalence of hyperuricemia was higher in hypertensive inpatients. UA was strongly associated with Log 24 h-MAU, eGFR and increased 24 h-MAU, while the correlation with mildly decreased eGFR was affected by multiple factors. And increased 24 h-MAU might be the intermediate factor between UA and mildly decreased eGFR.
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Affiliation(s)
- Hongda Chou
- grid.265021.20000 0000 9792 1228Department of Graduate School, Tianjin Medical University, Tianjin, 300051 China ,grid.478012.8Department of Hypertension, TEDA International Cardiovascular Hospital, Tianjin, 300457 China
| | - Maoti Wei
- grid.478012.8Center for Clinical Epidemiology, TEDA International Cardiovascular Hospital, Tianjin, 300457 China
| | - Hongxia Chen
- grid.478012.8Intensive Care Unit, TEDA International Cardiovascular Hospital, Tianjin, 300457 China
| | - Yuanyuan Xu
- grid.265021.20000 0000 9792 1228Department of Graduate School, Tianjin Medical University, Tianjin, 300051 China ,grid.478012.8Department of Hypertension, TEDA International Cardiovascular Hospital, Tianjin, 300457 China
| | - Leilie Shi
- grid.478012.8Department of Hypertension, TEDA International Cardiovascular Hospital, Tianjin, 300457 China
| | - Jiajia Duan
- grid.478012.8Department of Hypertension, TEDA International Cardiovascular Hospital, Tianjin, 300457 China
| | - Linlin Li
- grid.478012.8Department of Hypertension, TEDA International Cardiovascular Hospital, Tianjin, 300457 China
| | - Ning Yang
- Department of Hypertension, TEDA International Cardiovascular Hospital, Tianjin, 300457, China.
| | - Yuming Li
- Department of Cardiology, TEDA International Cardiovascular Hospital, Tianjin, 300457, China.
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Du FJ, Huang YQ, Han RF, Huang M, Jia ZY, Shen HM, Yao JJ, Min H, Zhao CH. Prevalence and trends of hyperuricemia among adults over 40 years old in an economically developed region of China from 2017 to 2020. J Public Health (Oxf) 2022. [DOI: 10.1007/s10389-022-01787-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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Shi JC, Chen XH, Yang Q, Wang CM, Huang Q, Shen YM, Yu J. A simple prediction model of hyperuricemia for use in a rural setting. Sci Rep 2021; 11:23300. [PMID: 34857832 PMCID: PMC8639845 DOI: 10.1038/s41598-021-02716-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 11/18/2021] [Indexed: 01/20/2023] Open
Abstract
Currently, the most widely used screening methods for hyperuricemia (HUA) involves invasive laboratory tests, which are lacking in many rural hospitals in China. This study explored the use of non-invasive physical examinations to construct a simple prediction model for HUA, in order to reduce the economic burden and invasive operations such as blood sampling, and provide some help for the health management of people in poor areas with backward medical resources. Data of 9252 adults from April to June 2017 in the Affiliated Hospital of Guilin Medical College were collected and divided randomly into a training set (n = 6364) and a validation set (n = 2888) at a ratio of 7:3. In the training set, non-invasive physical examination indicators of age, gender, body mass index (BMI) and prevalence of hypertension were included for logistic regression analysis, and a nomogram model was established. The classification and regression tree (CART) algorithm of the decision tree model was used to build a classification tree model. Receiver operating characteristic (ROC) curve, calibration curve and decision curve analyses (DCA) were used to test the distinction, accuracy and clinical applicability of the two models. The results showed age, gender, BMI and prevalence of hypertension were all related to the occurrence of HUA. The area under the ROC curve (AUC) of the nomogram model was 0.806 and 0.791 in training set and validation set, respectively. The AUC of the classification tree model was 0.802 and 0.794 in the two sets, respectively, but were not statistically different. The calibration curves and DCAs of the two models performed well on accuracy and clinical practicality, which suggested these models may be suitable to predict HUA for rural setting.
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Affiliation(s)
- Jia-Cheng Shi
- Department of Nephrology, Haining People’s Hospital, No. 2 West Qianjiang Road, Jiaxing, 314400 Zhejiang China
| | - Xiao-Huan Chen
- Department of Endocrinology and Rheumatology, The First People’s Hospital of Linping District, No. 369 Yingbin Road, Hangzhou, 311100 Zhejiang China
| | - Qiong Yang
- grid.452806.d0000 0004 1758 1729Department of Endocrinology, The Affiliated Hospital of Guilin Medical University, No. 15 Lequn Road, Guilin, 541001 Guangxi China
| | - Cai-Mei Wang
- grid.452806.d0000 0004 1758 1729Department of Laboratory Medicine, The Affiliated Hospital of Guilin Medical University, No. 15 Lequn Road, Guilin, 541001 Guangxi China
| | - Qian Huang
- grid.452806.d0000 0004 1758 1729Department of Endocrinology, The Affiliated Hospital of Guilin Medical University, No. 15 Lequn Road, Guilin, 541001 Guangxi China
| | - Yan-Ming Shen
- grid.452806.d0000 0004 1758 1729Department of Endocrinology, The Affiliated Hospital of Guilin Medical University, No. 15 Lequn Road, Guilin, 541001 Guangxi China
| | - Jian Yu
- Department of Endocrinology, The Affiliated Hospital of Guilin Medical University, No. 15 Lequn Road, Guilin, 541001, Guangxi, China.
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Should we be more aware of gender aspects in hyperuricemia? Analysis of the population-based German health interview and examination survey for adults (DEGS1). Maturitas 2021; 153:33-40. [PMID: 34654526 DOI: 10.1016/j.maturitas.2021.08.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 06/02/2021] [Accepted: 08/04/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVES While gout is a well-known entity, little research has been conducted on its pathophysiology. There is growing evidence that women with hyperuricemia are at higher cardiovascular risk than men with hyperuricemia. We aim to evaluate whether gender-specific cut-offs should be considered. STUDY DESIGN Cross-sectional study (the German Health Interview and Examination Survey for Adults; DEGS1). MAIN OUTCOME MEASURES Self-reported gout or hyperuricemia and uric acid level. RESULTS Of 6,918 participants (mean age 47.2 years; 50.5% females), 9.7% had had a diagnosis of hyperuricemia or gout at least once in their lifetime. Men were nearly twice as often affected as women (12.9 vs. 6.5%). In women, the prevalence of cardiovascular and renal diseases increased with higher uric acid level to a much greater extent than in men. This association remained in multivariate analyses. CONCLUSIONS No commonly accepted cut-off value for uric acid has been established. Overall, women were at lower risk of hyperuricemia. However, women were at higher risk of having cardiovascular and renal comorbidities, even at lower uric acid levels. Our results are in line with the accumulating evidence that we should consider gender in gout and hyperuricemia.
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Ma M, Wang L, Huang W, Zhong X, Li L, Wang H, Peng B, Mao M. Meta-analysis of the correlation between serum uric acid level and carotid intima-media thickness. PLoS One 2021; 16:e0246416. [PMID: 33571245 PMCID: PMC7877574 DOI: 10.1371/journal.pone.0246416] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Accepted: 01/20/2021] [Indexed: 12/13/2022] Open
Abstract
Objective Recently, increasing epidemiological evidence has shown that there is a correlation between serum uric acid level (SUA) and carotid intima-media thickness (CIMT). This paper explored the relationship between them through meta-analysis. Methods PubMed, Cochrane Library, EMBASE, Web of Science and Google Scholar were searched to obtain literature. The keywords used to retrieve the literature were carotid intima thickness, intima-media thickness, carotid atherosclerosis, carotid stenosis, carotid artery, uric acid, blood uric acid, and hyperuricaemia. The retrieval time was from the establishment of the database through July 2020. Stata15.0 and RevMan5.3 software were used for statistical analysis. The standardized mean difference (SMD) and 95% confidence interval (95% CI) were calculated by a random effect model to estimate the correlation. Publication bias was assessed using the Begg and Egger tests. The stability of these results was evaluated using sensitivity analyses. Results Fifteen studies were included with a total sample size of 11382, including 7597 participants in the high uric acid group and 3785 in the control group, on the basis of the inclusion and exclusion criteria. According to the evaluation of the JBI scale, the literature was of high quality. The average age ranged from 42 to 74. Meta-analysis showed that CIMT in the high uric acid group was significantly higher than that in the control group (SMD = 0.53, 95% CI: [0.38, 0.68]), and the difference was significant (z = 6.98, P < 0.00001). The heterogeneity among the 15 articles was obvious (I2 = 89%, P < 0.00001). Subgroup analysis by disease status illustrated a positive relationship between SUA and CIMT in healthy people and people with diseases. SUA was shown to be positively correlated with CIMT in people aged 45–60 years and ≥60 years by subgroup analysis by age. SUA was also found to be positively correlated with CIMT in a population with BMI>24 kg/m2 by subgroup analysis by BMI. In addition, subgroup analysis of other risk factors for CIMT, including TC, SBP, DBP, triglycerides, and LDL-C, all showed a positive correlation between SUA and CIMT. Conclusions There is a significant correlation between serum uric acid level and carotid intima-media thickness, and a high concentration of serum uric acid is related to carotid artery intima-media thickness.
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Affiliation(s)
- Mingzhu Ma
- School of Public Health and Management, Chongqing Medical University; Research Center for Medicine and Social Development, Chongqing, China
| | - Liangxu Wang
- School of Basic Medicine, Kunming Medical University, Kunming, China
| | - Wenjing Huang
- School of Public Health and Management, Chongqing Medical University; Research Center for Medicine and Social Development, Chongqing, China
| | - Xiaoni Zhong
- School of Public Health and Management, Chongqing Medical University; Research Center for Medicine and Social Development, Chongqing, China
| | - Longfei Li
- School of Public Health and Management, Chongqing Medical University; Research Center for Medicine and Social Development, Chongqing, China
| | - Huan Wang
- Department of Development planning, Chongqing Medical University, Chongqing, China
| | - Bin Peng
- School of Public Health and Management, Chongqing Medical University; Research Center for Medicine and Social Development, Chongqing, China
| | - Min Mao
- Department of Cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
- * E-mail:
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Zhang C, Li L, Zhang Y, Zeng C. Recent advances in fructose intake and risk of hyperuricemia. Biomed Pharmacother 2020; 131:110795. [PMID: 33152951 DOI: 10.1016/j.biopha.2020.110795] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Revised: 09/17/2020] [Accepted: 09/19/2020] [Indexed: 12/17/2022] Open
Abstract
With the widespread popularity of hyperuricemia, it has become a severe threat to human public health. Accumulating evidence suggests that dietary fructose has a close relationship with hyperuricemia, but the role of fructose intake in hyperuricemia remains unclear. Hyperuricemia is characterized by excessive production and deposition of urate crystals. Metabolism of fructose leads to the increased serum concentration of urate. In this review, we depict an update of fructose consumption worldwide and the epidemiology of hyperuricemia and summarize the progress in studying the relationship between fructose intake and the risk of hyperuricemia. This review highlights the metabolic process of fructose in the liver, small intestine, and kidney. Furthermore, we discuss molecular insights on fructose metabolism to reveal the underlying mechanism of fructose metabolism. Additionally, we elaborate on the effect of fructose metabolism on hyperuricemia to deeply understand the pathogenesis of hyperuricemia caused by fructose intake. Fructose consumption has a close correlation with an enhanced risk of developing hyperuricemia. More prospective studies are inevitable to understand the role of fructose intake in the development of hyperuricemia.
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Affiliation(s)
- Congwang Zhang
- Department of Medical Laboratory, Shenzhen Longhua District Central Hospital, Guangdong Medical University, Shenzhen, Guangdong, 518110, PR China
| | - Lijun Li
- Department of Quality Control, Shenzhen Longhua District Central Hospital, Guangdong Medical University, Shenzhen, Guangdong, 518110, PR China
| | - Yipeng Zhang
- Clinical Laboratory, Shenzhen Longhua District Central Hospital, Guangdong Medical University, Shenzhen, Guangdong, 518110, PR China
| | - Changchun Zeng
- Department of Medical Laboratory, Shenzhen Longhua District Central Hospital, Guangdong Medical University, Shenzhen, Guangdong, 518110, PR China.
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