International Journal of STD & AIDS最新文献

{"title":"The diagnosis and management of neurosyphilis in england, 2025: a cross-sectional survey.","authors":"Sarah Keegan, Sarah Alexander, Michelle Cole, Katy Sinka, Helen Fifer","doi":"10.1177/09564624261483244","DOIUrl":"https://doi.org/10.1177/09564624261483244","url":null,"abstract":"<p><p>BackgroundNeurosyphilis remains a challenging diagnosis, and the British Association for Sexual Health and HIV (BASHH) guideline recommends lumbar puncture in patients with clinically suspected neurological syphilis. However, the extent to which this guidance is implemented in routine practice across England is uncertain. This study aimed to characterise current approaches to the diagnosis and management of neurosyphilis in England.MethodsWe conducted an opportunistic cross-sectional, web-based survey of clinicians managing neurosyphilis in England in March 2025. Eligible services had treated at least one case of neurosyphilis within the preceding 12 months. Data were collected on service characteristics, access to and indications for lumbar puncture, laboratory investigations, treatment regimens, and follow-up practices.ResultsForty-two responses representing 66 services across England were included. The majority (93%) were level 3 sexual health services, primarily community-based. Neurosyphilis was infrequently encountered (<10 cases/year in 67% of services). Lumbar puncture practice varied widely: 26% routinely performed lumbar puncture in suspected cases, 21% never performed lumbar puncture, and others reserved lumbar puncture for diagnostic uncertainty or suspected treatment failure. Logistical barriers and perceptions that cerebrospinal fluid (CSF) results would not alter management were common reasons for not performing lumbar puncture. The majority of services (65%) initiated treatment without awaiting CSF results. While 70% used first-line penicillin-based regimens, 23% used ceftriaxone first line, and ceftriaxone was often used in penicillin allergy (18% of services). Follow-up was predominantly serological and clinical; repeat CSF testing was uncommon.ConclusionsThere is substantial variation in neurosyphilis diagnosis and management across England, with frequent divergence from national guidance. Logistical barriers and diagnostic uncertainty contribute to pragmatic, empiric treatment approaches.</p>","PeriodicalId":14408,"journal":{"name":"International Journal of STD & AIDS","volume":" ","pages":"9564624261483244"},"PeriodicalIF":1.6,"publicationDate":"2026-08-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148864710","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Less is more: reconsidering asymptomatic <i>Chlamydia trachomatis</i> and <i>Neisseria gonorrhoeae</i> screening for gay, bisexual and other men who have sex with men in the era of doxycycline post-exposure prophylaxis (DoxyPEP).","authors":"David James Field, Johnny Boylan, Fiona Lyons, Ralph Hurley O'Dwyer, Chantal Den Daas","doi":"10.1177/09564624261481866","DOIUrl":"https://doi.org/10.1177/09564624261481866","url":null,"abstract":"<p><p>Routine high-frequency screening for asymptomatic <i>Chlamydia trachomatis</i> and <i>Neisseria gonorrhoeae</i> among cisgender gay, bisexual and other men who have sex with men (gbMSM) is established despite limited evidence that it reduces population-level incidence or harm. Recent studies support reconsideration but do not settle the balance of benefits and harms. Reducing screening could delay diagnosis and affect transmission or partner notification; continuing screening may increase antimicrobial exposure, possible overdiagnosis, anxiety and stigma. The demonstrated benefits and unresolved long-term stewardship implications of doxycycline post-exposure prophylaxis (DoxyPEP) illustrate why antimicrobial use should be differentiated. We argue for cautious, co-produced, evaluated and reversible de-implementation while maintaining symptomatic, contact-based and otherwise clinically indicated testing, HIV and syphilis screening and HIV pre-exposure prophylaxis (PrEP) care. With transparent communication and community partnership, less screening need not mean less care.</p>","PeriodicalId":14408,"journal":{"name":"International Journal of STD & AIDS","volume":" ","pages":"9564624261481866"},"PeriodicalIF":1.6,"publicationDate":"2026-08-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148828555","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"British association for sexual health and HIV UK national guideline for the management of infection with <i>Chlamydia trachomatis</i>, 2026.","authors":"John Saunders, Nathan Burley, Susie Brice, Luke Cannon, Sarah Cochrane, Alice Milligan, Rachel Pitt-Kendall, Vicki Sellors, Cara Saxon","doi":"10.1177/09564624261475950","DOIUrl":"https://doi.org/10.1177/09564624261475950","url":null,"abstract":"<p><p>This guideline provides details on the pathology and clinical features of <i>Chlamydia trachomatis</i> infection and makes recommendations for diagnostic tests, treatment regimens and the health promotion principles needed for the effective management of chlamydia, in people aged 16 years or older attending sexual health services. The guideline is primarily aimed at level 3 sexual health services in the UK, although it could also serve as a reference guide for sexually transmitted infection services at other levels. This guideline is an update of the previous one published in 2015.</p>","PeriodicalId":14408,"journal":{"name":"International Journal of STD & AIDS","volume":" ","pages":"9564624261475950"},"PeriodicalIF":1.6,"publicationDate":"2026-08-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148812842","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Acute kidney injury among hospitalized people living with HIV.","authors":"Alice Doubinsky, Aude Theunissen, Rita Ghaleb, Marc Delforge, Maria Garjau, Nicolas Dauby","doi":"10.1177/09564624261483248","DOIUrl":"https://doi.org/10.1177/09564624261483248","url":null,"abstract":"<p><p>ObjectivesTo describe the clinical characteristics, aetiologies, severity, and short-term outcomes of acute kidney injury (AKI) among hospitalized people living with HIV in a European tertiary HIV referral center.MethodsThis cross sectional analysis included adults living with HIV who developed AKI during hospitalization at Saint-Pierre University Hospital, Brussels, between 2007 and 2016. AKI was defined according to Kidney Disease: Improving Global Outcomes (KDIGO) serum creatinine criteria. Aetiologies, clinical characteristics, and outcomes were recorded, including intensive care unit admission, renal replacement therapy, renal recovery, chronic kidney disease (CKD) progression, in-hospital mortality, and one-year rehospitalization.ResultsAmong 206 patients with AKI, 64% had KDIGO stage 1, 21% stage 2, and 15% stage 3 AKI. Pre-renal AKI was the most frequent aetiology (45%), followed by intrinsic (25%) and mixed AKI (16%). Intensive care unit admission occurred in 36% of patients and renal repolacement therapy was required in 12%. In-hospital mortality was 16%. Among survivors, 77% achieved renal recovery, 5% progressed to chronic kidney disease, and 38% were rehospitalized within 1 year.ConclusionsAKI remains a clinically important complication among hospitalized people living with HIV, with substantial short-term morbidity and mortality. Early recognition and management of reversible causes and avoidance of nephrotoxic exposures remain important.</p>","PeriodicalId":14408,"journal":{"name":"International Journal of STD & AIDS","volume":" ","pages":"9564624261483248"},"PeriodicalIF":1.6,"publicationDate":"2026-08-24","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148812251","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Towards patient-centered HIV drug resistance testing services in China: A discrete choice experiment.","authors":"Qingxian Song, Qianqian Shen, Tengxiao Long, Yingni Yu, Shu Su","doi":"10.1177/09564624261480307","DOIUrl":"https://doi.org/10.1177/09564624261480307","url":null,"abstract":"<p><p>BackgroundHIV drug resistance testing plays an important role in optimizing antiretroviral therapy, yet routine testing remains limited in China. This study applied a discrete choice experiment to evaluate patient preferences and willingness-to-pay for HIV drug resistance testing; to inform patient-centered implementation strategies for HIV drug resistance testing.MethodsBetween April and June 2025, people living with HIV were recruited from community healthcare centers in China. Mixed logit models and latent class analysis were used to quantify attribute trade-offs, identify preference heterogeneity, and estimate willingness-to-pay across clinical and demographic subgroups.ResultsAmong 204 participants, out-of-pocket cost was the dominant barrier to uptake, accounting for 62.3% of overall decision importance. Testing after treatment failure (<i>β</i> = 0.862), and doctor recommendation (<i>β</i> = 0.519) were primary determinants of choice (all <i>p</i> < 0.001). Combined testing (<i>p</i> = 0.037), shorter waiting time (3 days: <i>p</i> = 0.008), and high accuracy (<i>p</i> = 0.031) also significantly increased testing preference. Latent class analysis identified two distinct subgroups. Class 1 (failure-driven) prioritized testing after treatment failure (<i>β</i> = 3.547) but showed a negative preference for combined testing and high accuracy (all <i>p</i> < 0.05). Class 2 (service-oriented) strongly valued doctor recommendation and high accuracy (all <i>p</i> < 0.01). Older participants (≥50 years old) had a higher willingness-to-pay for doctor recommendation than the younger (240.2 vs 115.7 CNY), while younger showed higher WTP for combined testing and high accuracy.ConclusionsReducing financial barriers, strengthening provider recommendations, and tailoring testing services to different patient preference patterns may improve HIV drug resistance testing uptake. These findings support patient-centered implementation strategies to promote earlier and more routine HIV drug resistance testing in China.</p>","PeriodicalId":14408,"journal":{"name":"International Journal of STD & AIDS","volume":" ","pages":"9564624261480307"},"PeriodicalIF":1.6,"publicationDate":"2026-08-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148808665","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Disclosure, stigma, and HIV care among sex workers and men who have sex with men living with HIV in Jamaica.","authors":"Carmen H Logie, Frannie MacKenzie, Kandasi Levermore, Patrick Lalor, Lesley Gittings, David J Kinitz, Julien Brisson","doi":"10.1177/09564624261476362","DOIUrl":"https://doi.org/10.1177/09564624261476362","url":null,"abstract":"<p><p>BackgroundHIV-related stigma remains a barrier to HIV care cascade engagement among key populations globally. In Jamaica, men who have sex with men (MSM) and female sex workers (FSW) living with HIV experience intersecting stigma that complicates disclosure decision-making and HIV care engagement. Guided by the Disclosure Processes Model, this study examined how approach and avoidance-focused goals shaped disclosure-related outcome aims, affective responses, and coping strategies related to HIV care engagement among MSM and FSW living with HIV in Jamaica.MethodsThis community-based qualitative study was conducted with an AIDS Service organization across Kingston, St Ann, and Montego Bay, Jamaica (2020-2022). We conducted six focus groups with MSM and FSW living with HIV (n = 46), followed by comic-guided in-depth individual interviews (n = 31). We conducted codebook thematic analysis informed by the antecedent goals component of the Disclosure Processes Model. Analyses explored how approach and avoidance-focused goals shaped outcome aims, affect, and coping strategies related to HIV disclosure and care engagement.ResultsParticipants (n = 28 FSW, n = 49 MSM) described disclosure decision-making was shaped by competing aims to achieve positive outcomes and avoid stigma-related harms. Approach-focused goals related to disclosure focused on pursuing positive outcomes (preserving health; sustaining family responsibilities; building a meaningful future), positive affect (peace of mind; hopefulness), and coping (accessing social support; self-acceptance). Avoidance-focused disclosure related goals centered prevention of negative outcomes (confidentiality breaches; social rejection), negative affect (fear; worry; isolation), and avoidance coping (concealment; social withdrawal). Participants described healthcare settings, pharmacies, workplaces, and family environments as spaces of potential disclosure risk.ConclusionHIV disclosure decision-making among MSM and FSW participants was a complex process shaped by stigma, distress, and institutional mistrust, and also access to social support. Findings underscore the need for trauma-informed and stigma reducing HIV services that support safe disclosure and HIV care engagement with key populations in Jamaica.</p>","PeriodicalId":14408,"journal":{"name":"International Journal of STD & AIDS","volume":" ","pages":"9564624261476362"},"PeriodicalIF":1.6,"publicationDate":"2026-08-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148706399","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Screening for asymptomatic <i>Chlamydia trachomatis</i> and <i>Neisseria gonorrhoeae</i> in gay, bisexual and other men who have sex with men: A scoping review.","authors":"Thomas Munday, Himani Jayasinghe, Helen Fifer, John Saunders","doi":"10.1177/09564624261476607","DOIUrl":"https://doi.org/10.1177/09564624261476607","url":null,"abstract":"<p><p>BackgroundThe balance of benefits and harms associated with frequent asymptomatic testing for <i>Chlamydia trachomatis</i> and <i>Neisseria gonorrhoeae</i> in gay, bisexual and other men who have sex with men (GBMSM) remains uncertain. While many guidelines recommend three-monthly testing for those perceived to be at higher risk, the evidence supporting this frequency is unclear. We reviewed existing evidence on testing frequency for <i>C. trachomatis and</i> <i>N. gonorrhoeae</i> in asymptomatic GBMSM and synthesised what is known about its impact on infection incidence and prevalence, symptomatic disease, and antimicrobial consumption.MethodsWe conducted a review of studies published between 2005 and 2025 across EMBASE, MEDLINE, CINAHL, Web of Science and Scopus. Quantitative, qualitative and mixed-methods studies evaluating outcomes associated with repeated asymptomatic screening in GBMSM were included.ResultsFifteen studies met eligibility criteria. More frequent screening increases detection of asymptomatic infections with limited evidence of reducing incidence, symptomatic presentations, or population-level prevalence. More frequent screening was associated with higher antimicrobial consumption. A single randomised controlled trial found modest reductions in <i>C. trachomatis</i>incidence with three-monthly screening but no clear benefit for <i>N. gonorrhoeae</i>. Frequent screening is closely tied to GBMSM's sense of responsibility, reassurance and community norms, and both GBMSM and clinicians express discomfort with reduced screening despite limited awareness of the natural clearance of <i>C. trachomatis or</i> <i>N. gonorrhoeae</i> or implications for antimicrobial resistance.ConclusionsThe current evidence base provides limited support for three-monthly asymptomatic <i>C. trachomatis and</i> <i>N. gonorrhoeae</i>screening among GBMSM, and highlights the potential harms of increased antimicrobial use. A move to less frequent screening may offer a more balanced public health approach, but change will require careful engagement, transparent communication and attention to social and behavioural dimensions. More rigorous trials, especially in the context of emerging prevention strategies such as doxyPEP are needed to inform optimal screening intervals.</p>","PeriodicalId":14408,"journal":{"name":"International Journal of STD & AIDS","volume":" ","pages":"9564624261476607"},"PeriodicalIF":1.6,"publicationDate":"2026-08-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148706402","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"HIV-related bladder cancer: A ten-year experience.","authors":"Mengmeng Zhang, Hui Liu, Yanyan Zhang, Zhiqiang Zhu, Yu Zhang","doi":"10.1177/09564624261449133","DOIUrl":"10.1177/09564624261449133","url":null,"abstract":"<p><p>BackgroundReports on bladder cancer among people living with HIV (PLWH) are very limited. In this case series, we investigated the clinical characteristics, pathology, treatments, adjuvant therapy, and survival of bladder cancer in PLWH.MethodsThis case series identified all PLWH treated for bladder cancer at our institution between 2013 and 2023 through review of medical records. Clinical data were presented as descriptive statistics. We estimated median and 1-, 3-, and 5-years cancer-specific survival using the Kaplan-Meier method and conducted univariate Cox analyses to evaluate variables associated with cancer-specific survival.ResultsTwenty PLWH underwent treatment for bladder cancer during the study period. All patients were male with a median age of 56 years. Radical cystectomy was performed in four patients (20%) and transurethral resection of bladder tumor in sixteen (80%). Adjuvant immunotherapy (tislelizumab) combined with chemotherapy (gemcitabine and cisplatin) was used in six patients after radical cystectomy. In the Kaplan-Meier analysis, the 1-, 3-, and 5-years cancer-specific survival rates of the cohort were 85%, 65%, and 60%, respectively. In univariate analysis, higher tumor stage (stage >T1 vs T1) was significantly associated with cancer-specific survival.ConclusionsGiven the relatively young age and aggressive pathological features observed in this case series, further research is warranted to determine whether targeted screening in PLWH could be beneficial. Limited data preliminarily suggest that intravesical chemotherapy with pirarubicin and adjuvant immunotherapy combined with chemotherapy may be safe and effective options for PLWH with bladder cancer; however, these observations require validation in larger studies. PLWH with muscle-invasive bladder cancer appear to have poorer cancer-specific survival.</p>","PeriodicalId":14408,"journal":{"name":"International Journal of STD & AIDS","volume":" ","pages":"1013-1019"},"PeriodicalIF":1.6,"publicationDate":"2026-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148005220","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Perceptions of acceptability and preferences surrounding a hypothetical syphilis vaccine in Lima, Peru.","authors":"Valeria Fulqui, Wendy Hamasaki, Jessica Perez, Gilbert A Orta Portillo, Jeffrey D Klausner, Kelika A Konda","doi":"10.1177/09564624261459952","DOIUrl":"10.1177/09564624261459952","url":null,"abstract":"<p><p>BackgroundNo vaccine is currently available for syphilis. Research efforts to inform vaccine development are underway. In parallel, understanding factors that would influence willingness to receive a future vaccine can provide useful information for vaccine design and future implementation. This study explored attributes of interest in a hypothetical syphilis vaccine using focus group discussions in Lima, Peru.MethodsIn early 2025, we conducted ten virtual focus group discussions, among five population groups in Lima, Peru: health professionals, sexual/gender minorities, general population, cisgender female sex workers, and parents of minors. Semi-structured guides explored barriers and facilitators to preventive care, attitudes toward vaccines, syphilis knowledge, and desired attributes of a potential syphilis vaccine. Audio recordings were analyzed thematically.ResultsEighty-five participants took part in the discussions. Despite limited syphilis knowledge among many participants, there was interest in a hypothetical vaccine. Acceptability was shaped by three factors including, vaccine attributes, structural conditions and the healthcare provider-user relationship. In vaccine attributes, participants desired high effectiveness, safety, and a single-dose schedule, while expressing concerns about vaccine-induced persistent seropositivity related to stigma about STI prevention. Structural conditions: free vaccination, endorsement from respected health institutions, information environment and health education were viewed as essential for uptake. Third, the healthcare provider-user relationship emerged as a central mediator influencing how individuals interpreted vaccine information and navigated structural barriers.ConclusionsAcceptability of a future syphilis vaccine depends not only on its attributes, but also on structural enablers and the quality of provider-user interactions. Strengthening provider communication, addressing structural barriers, and ensuring transparent information dissemination will be essential for equitable implementation.</p>","PeriodicalId":14408,"journal":{"name":"International Journal of STD & AIDS","volume":" ","pages":"1026-1034"},"PeriodicalIF":1.6,"publicationDate":"2026-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148239132","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"A case of transient hepatocellular injury in an HIV monoclonal antibody trial.","authors":"Ishana Harkoo, Parveen Sobia, Derseree Archary, Nigel Garrett, Sharana Mahomed","doi":"10.1177/09564624261458750","DOIUrl":"10.1177/09564624261458750","url":null,"abstract":"<p><p>The diagnosis and management of acute hepatocellular injury continue to pose significant challenges. Clinicians depend on both clinical and laboratory findings, alongside the exclusion of other potential aetiologies, to make a diagnosis. We describe a case of transient marked hepatocellular injury in a phase 1 clinical trial participant exposed to anti-HIV monoclonal antibodies. The trial was registered with the Pan African Clinical Trial Registry (PACTR 201808919297244) on 29 August 2018.</p>","PeriodicalId":14408,"journal":{"name":"International Journal of STD & AIDS","volume":" ","pages":"1051-1054"},"PeriodicalIF":1.6,"publicationDate":"2026-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13498743/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148175706","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}