{"title":"Anesthesia management for thoracoscopic resection of a huge intrathoracic meningocele: a case report.","authors":"Ryosuke Nakazawa, Kenichi Masui, Takahisa Goto","doi":"10.1186/s40981-024-00697-1","DOIUrl":"10.1186/s40981-024-00697-1","url":null,"abstract":"<p><strong>Background: </strong>Diagnosed intrathoracic meningocele is an uncommon complication of neurofibromatosis type 1. We report an anesthesia management for a rare case undergoing thoracoscopic resection of a huge intrathoracic meningocele.</p><p><strong>Case presentation: </strong>A 51-year-old woman was scheduled for thoracoscopic meningectomy under general anesthesia. We monitored intrathecal pressure during anesthesia to prevent a decrease in intrathecal pressure. During surgery, the intrathecal pressure occasionally increased by around 5 cmH<sub>2</sub>O immediately after the insertion of the drainage tube and occasionally decreased by up to 10 cmH<sub>2</sub>O during the careful slow aspiration of the cerebrospinal fluid (CSF). The pressure rapidly recovered after the interruption of the procedures. She was discharged on postoperative day 4 without major complications.</p><p><strong>Conclusions: </strong>The CSF pressure was fluctuated by procedures during thoracoscopic resection of a huge meningocele. A CSF pressure monitoring was useful to detect the sudden change of CSF pressure immediately, which can cause intracranial hemorrhage.</p>","PeriodicalId":14635,"journal":{"name":"JA Clinical Reports","volume":"10 1","pages":"14"},"PeriodicalIF":0.9,"publicationDate":"2024-02-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10874914/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139899877","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Natsuho Haraguchi, Yoshifumi Naito, Masayuki Shibasaki, Teiji Sawa
{"title":"Tracheal injury diagnosed by a sudden increase in end-tidal carbon dioxide levels during mediastinoscopic subtotal esophagectomy: a case report.","authors":"Natsuho Haraguchi, Yoshifumi Naito, Masayuki Shibasaki, Teiji Sawa","doi":"10.1186/s40981-024-00695-3","DOIUrl":"10.1186/s40981-024-00695-3","url":null,"abstract":"<p><strong>Background: </strong>Mediastinoscopic surgery for esophageal cancer facilitates early postoperative recovery. However, it can occasionally cause serious complications. Here, we present the case of a patient with a tracheal injury diagnosed by a sudden increase in end-tidal carbon dioxide (EtCO<sub>2</sub>) during mediastinoscopic subtotal esophagectomy.</p><p><strong>Case presentation: </strong>A 52-year-old man diagnosed with esophageal cancer was scheduled to undergo mediastinoscopic subtotal esophagectomy. During the mediastinoscopic procedure, the EtCO<sub>2</sub> level suddenly increased above 200 mmHg, and the blood pressure dropped below 80 mmHg. We immediately asked the operator to stop insufflation and found a tracheal injury on the right side of the trachea near the carina by bronchoscopy. The endotracheal tube was replaced with a double-lumen tube, and the trachea was repaired via right thoracotomy. There were no further intraoperative complications. After surgery, the patient was extubated and admitted to the intensive care unit.</p><p><strong>Conclusions: </strong>Monitoring EtCO<sub>2</sub> levels and close communication with the operator is important for safely managing sudden tracheal injury during mediastinoscopic esophagectomy.</p>","PeriodicalId":14635,"journal":{"name":"JA Clinical Reports","volume":"10 1","pages":"11"},"PeriodicalIF":0.9,"publicationDate":"2024-02-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10864238/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139722648","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Successful radiofrequency thermocoagulation of the mandibular nerve for intractable pain associated with medication-related osteonecrosis of the jaw: a case report.","authors":"Sho Shinotsuka, Aiko Maeda, Tomoka Eri, Nozomi Kameyama, Chiaki Yamada, Masako Asada, Ken Yamaura","doi":"10.1186/s40981-024-00696-2","DOIUrl":"10.1186/s40981-024-00696-2","url":null,"abstract":"<p><strong>Background: </strong>Bisphosphonates may cause serious adverse events, including osteonecrosis of the jaw. This article describes a case of successful application of radiofrequency thermocoagulation for pain caused by osteonecrosis of the jaw.</p><p><strong>Case presentation: </strong>An 86-year-old woman who had received alendronate sodium hydrate for osteoporosis was diagnosed with osteonecrosis of the right mandible after dental treatment. Despite repeated conservative and debridement treatments, the patient could not eat due to intractable pain; accordingly, her condition was debilitated. The patient was referred to our pain management clinic for radiofrequency thermocoagulation of the right mandibular nerve. Immediately after the procedure, her pain drastically improved and she could eat; moreover, the pain has not recurred for 3 years.</p><p><strong>Conclusion: </strong>Our findings demonstrate that minimally invasive radiofrequency thermocoagulation may have long-term effects in patients with chronic pain caused by osteonecrosis of the jaw that is refractory to conservative treatment.</p>","PeriodicalId":14635,"journal":{"name":"JA Clinical Reports","volume":"10 1","pages":"12"},"PeriodicalIF":0.9,"publicationDate":"2024-02-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10864227/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139722647","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Analgesic effect of neuromodulation using the AT-04 portable magnetic field-generating device in a patient with neuropathic pain: a case report.","authors":"Atsushi Sawada, Michiaki Yamakage","doi":"10.1186/s40981-024-00694-4","DOIUrl":"10.1186/s40981-024-00694-4","url":null,"abstract":"<p><strong>Background: </strong>Neuromodulation by magnetic field through the AT-04 (ait® (AT-04); Peace of Mind Co., Ltd., Kumamoto, Japan) has improved allodynia in neuropathic pain model rats. This report focuses on neuromodulation through magnetic field exposure using the AT-04 that provided an analgesic effect in a patient with neuropathic pain.</p><p><strong>Case presentation: </strong>A 47-year-old man presented with flaccid paralysis and extensive neuropathic pain and scored 7 on the 11-point Numerical Rating Scale (NRS) for his left upper limb. The patient was treated with neuromodulation by magnetic field exposure using the AT-04. Baseline NRS scores were obtained three times daily during the baseline period (days 1-5). Magnetic field exposure was then performed for 30 min three times daily (morning, noon, and evening) at home for 36 days, which was termed the intervention period (days 6-41). During the baseline period, the median NRS score was 7 and the baseline NRS score for calculating the percentage of nonoverlap data (PND) was 6. During the intervention period, the median NRS score was 4 and the PND value of the NRS score was 77.8% (28/36). Neuromodulation by magnetic field exposure using the AT-04 effectively decreased the patient's NRS score. The patient had no adverse effects during the intervention period.</p><p><strong>Conclusions: </strong>Neuromodulation by magnetic field exposure using the AT-04 was effective in decreasing the NRS score in a patient with neuropathic pain. The AT-04 portable magnetic field-generating device shows potential as a therapeutic option for refractory neuropathic pain.</p>","PeriodicalId":14635,"journal":{"name":"JA Clinical Reports","volume":"10 1","pages":"10"},"PeriodicalIF":0.9,"publicationDate":"2024-02-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10857986/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139712236","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Vulnerability to bending and occlusion of distal lumen of the 17G triple-lumen central venous catheter","authors":"Tomohiro Yamamoto","doi":"10.1186/s40981-024-00691-7","DOIUrl":"https://doi.org/10.1186/s40981-024-00691-7","url":null,"abstract":"<p>To the Editor</p><p>The risk of central venous catheter (CVC)-related venous thrombosis [1, 2] should always be kept in mind. It is a critical issue, particularly in pediatric patients with congenital heart diseases, because of the possible impact on subsequent surgical treatment. The risk of CVC-related venous thrombosis is reportedly greater when CVC is larger than one-third the diameter of the target vein [3]. Cardinal Health™ has recently developed a 17-gauge (G) triple-lumen CVC (ARGYLE™ Fukuroi SMAC<sup>TM</sup> Plus), of which the cross-sectional area of lumens and flow rate are comparable to those of a 15G triple-lumen CVC (Fig. 1).</p><figure><figcaption><b data-test=\"figure-caption-text\">Fig. 1</b></figcaption><picture><source srcset=\"//media.springernature.com/lw685/springer-static/image/art%3A10.1186%2Fs40981-024-00691-7/MediaObjects/40981_2024_691_Fig1_HTML.png?as=webp\" type=\"image/webp\"/><img alt=\"figure 1\" aria-describedby=\"Fig1\" height=\"380\" loading=\"lazy\" src=\"//media.springernature.com/lw685/springer-static/image/art%3A10.1186%2Fs40981-024-00691-7/MediaObjects/40981_2024_691_Fig1_HTML.png\" width=\"685\"/></picture><p>Cross-section of central venous catheters (CVCs). Cross section of the 17-gauge (G) double-lumen (left), 17G triple-lumen (center), and 15G triple-lumen (right) CVCs (ARGYLE™ Fukuroi SMAC™ Plus, Cardinal Health™), side by side with ruler scale for size comparison. Note the semicircular-shaped distal (largest) lumen of the 17G triple-lumen CVC (center) in contrast with the circular-shaped distal lumens of the 17G double-lumen (left) and of the 15G triple-lumen (right) CVCs. The outer diameters of the 17G double-lumen (left), 17G triple-lumen (center), and 15G double-lumen CVC (right) are 1.35 mm, 1.45 mm, and 1.70 mm, respectively</p><span>Full size image</span><svg aria-hidden=\"true\" focusable=\"false\" height=\"16\" role=\"img\" width=\"16\"><use xlink:href=\"#icon-eds-i-chevron-right-small\" xmlns:xlink=\"http://www.w3.org/1999/xlink\"></use></svg></figure><p>The distal lumen is generally thought to be the least susceptible to catheter bending and the least vulnerable to occlusion because it has the largest lumen and is located in the middle of the catheter. However, uncommonly, we have encountered several cases in our hospital wherein the pressure alarm sounded on the syringe pump connected to the distal lumen or no blood backflow was obtained from the distal lumen of the 17G triple-lumen CVC, whereas the other two smaller lumens had no problems. We found that the CVCs were bent at the site just distal to the junction hub (Fig. 2), which was common in all catheter obstruction cases. However, 17G double-lumen CVCs had been used in our hospital without similar problems. The cross-sectional structure of the CVCs is shown in Fig. 1, where the lumens of the 17G triple-lumen CVC have a semicircular or fan-shaped structure. Additionally, the distal lumen, which has a semicircular structure, is the most vulnerable to bending, while","PeriodicalId":14635,"journal":{"name":"JA Clinical Reports","volume":"296 2 1","pages":""},"PeriodicalIF":0.9,"publicationDate":"2024-02-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139664201","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"In-reply to the comment by Poling et al","authors":"Kyosuke Takahashi, Kotaro Sakurai, Izumi Hamaya","doi":"10.1186/s40981-023-00681-1","DOIUrl":"https://doi.org/10.1186/s40981-023-00681-1","url":null,"abstract":"<p>To the editor</p><p>We thank Poling et al. for their interest in our report [1]. They raised the importance of a new disease concept and optimal management according to the diagnosis.</p><p>As they pointed out, the diagnosis of Freeman-Sheldon syndrome (FSS) (What they call Freeman-Burian syndrome [FBS]) is difficult due to similar physical characteristics between FSS/FBS and Sheldon-Hall syndrome. We think our case was not typical of FSS/FBS. Although she had multiple arthrogryposes and prominent nasolabial folds, microstomia was not severe, midface hypoplasia was mild, and tracheal intubation was easy during anesthesia. However, this does not exclude the diagnosis of FSS/FBS.</p><p>The association between distal arthrogryposis and malignant hyperthermia remains uncertain. An observational study that investigated 73 individuals referred with the diagnosis of FSS revealed that 3 out of 10 patients developed malignant hyperthermia when they had surgery [2]. On the other hand, a study reported no association between malignant hyperthermia and distal arthrogryposis [3]. Considering the mixed findings of past studies, it is still safe to avoid inhalation anesthetics because we have many alternative options without them. Hence, our strategy using propofol, opioids, and dexmedetomidine was a reasonable choice for the patient who underwent cardiac surgery. Further studies with large sample sizes are needed to determine the association between malignant hyperthermia and this syndrome. Until this question is resolved, providing malignant-hyperthermia-safe anesthesia for patients with FSS/FBS is warranted.</p><p>Not applicable.</p><dl><dt style=\"min-width:50px;\"><dfn>FBS:</dfn></dt><dd>\u0000<p>Freeman Burian Syndrome</p>\u0000</dd><dt style=\"min-width:50px;\"><dfn>FSS:</dfn></dt><dd>\u0000<p>Freeman Sheldon Syndrome</p>\u0000</dd></dl><ol data-track-component=\"outbound reference\"><li data-counter=\"1.\"><p>Takahashi K, Sakurai K, Hamaya I. Anesthetic management of a pediatric patient with Freeman-Sheldon syndrome undergoing atrial septal defect closure: a case report. JA Clin Reports Springer, Berlin Heidelberg. 2023;9:9–12. https://doi.org/10.1186/s40981-023-00633-9.</p><p>Article Google Scholar </p></li><li data-counter=\"2.\"><p>Stevenson DA, Carey JC, Palumbos J, Rutherford A, Dolcourt J, Bamshad MJ. Clinical characteristics and natural history of Freeman-Sheldon syndrome. Pediatrics. 2006;117:754–62.</p><p>Article PubMed Google Scholar </p></li><li data-counter=\"3.\"><p>Gleich SJ, Tien M, Schroeder DR, Hanson AC, Flick R, Nemergut ME. Anesthetic Outcomes of Children with Arthrogryposis Syndromes: No Evidence of Hyperthermia. Anesth Analg. 2017;124:908–14.</p><p>Article PubMed Google Scholar </p></li></ol><p>Download references<svg aria-hidden=\"true\" focusable=\"false\" height=\"16\" role=\"img\" width=\"16\"><use xlink:href=\"#icon-eds-i-download-medium\" xmlns:xlink=\"http://www.w3.org/1999/xlink\"></use></svg></p><p>Not applicable.</p><p>Not applicable.</p><h3>Authors and Affiliatio","PeriodicalId":14635,"journal":{"name":"JA Clinical Reports","volume":"10 1","pages":""},"PeriodicalIF":0.9,"publicationDate":"2024-02-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139664324","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Remimazolam in perioperative management of Eisenmenger syndrome: a case report","authors":"Kazuya Hashimoto, Tsuguhiro Matsumoto, Toshiyuki Mizota, Shinichi Kai, Moritoki Egi","doi":"10.1186/s40981-024-00692-6","DOIUrl":"https://doi.org/10.1186/s40981-024-00692-6","url":null,"abstract":"Eisenmenger syndrome (ES) is characterized by severe and irreversible pulmonary hypertension stemming from an uncorrected intracardiac shunt of significant size. The imbalance between systemic and pulmonary artery pressures predisposes patients with ES to the risk of cardiac arrest. Remimazolam has caused less circulatory depression, which may be advantageous for ES. However, no studies reported the use of remimazolam in perioperative ES management. A 45-year-old female patient with ES derived from a ventricular septal defect was scheduled to undergo bilateral adnexectomy for an ovarian tumor. Her oxygen saturation was 80% with 3 L/min oxygen at rest, and her pulmonary and systemic flow ratio was 0.53. She underwent general anesthesia with remimazolam, and intraoperative hemodynamics was stable without hypotension or reduced oxygen saturation. Our successful management of ovarian tumor surgery in a patient with ES using remimazolam reveals its potential effectiveness in perioperative care.","PeriodicalId":14635,"journal":{"name":"JA Clinical Reports","volume":"46 1","pages":""},"PeriodicalIF":0.9,"publicationDate":"2024-02-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139664213","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Andexanet alpha-induced heparin resistance treated by nafamostat mesylate in a patient undergoing total aortic arch repair for Stanford type A acute aortic dissection: a case report.","authors":"Yasuhito Suzuki, Mutsuhito Kikura, Shingo Kawashima, Tetsuro Kimura, Yoshiki Nakajima","doi":"10.1186/s40981-024-00690-8","DOIUrl":"10.1186/s40981-024-00690-8","url":null,"abstract":"<p><strong>Background: </strong>Andexanet alfa, an anti-Xa inhibitor antagonist, induces heparin resistance. Here, we report a case of successful management of cardiopulmonary bypass with andexanet alfa-induced heparin resistance using nafamostat mesylate.</p><p><strong>Case presentation: </strong>An 84-year-old female, with Stanford type A acute aortic dissection, underwent an emergency surgery for total aortic arch replacement. Andexanet alfa 400 mg was administered preoperatively to antagonize edoxaban, an oral Xa inhibitor. Heparin 300 IU/kg was administered before cardiopulmonary bypass, and the activated clotting time (ACT) was 291 s. The ACT was 361 s after another administration of heparin 200 IU/kg. According to our routine therapy for heparin resistance, an initial dose of nafamostat mesylate 10 mg was administered intravenously, followed by a continuous infusion of 20-30 mg/h. The ACT was prolonged to 500 s, and cardiopulmonary bypass was successfully established thereafter.</p><p><strong>Conclusions: </strong>This case report presents the successful management of cardiopulmonary bypass with andexanet alfa-induced heparin resistance using nafamostat mesilate. This report presents the successful management of cardiopulmonary bypass with andexanet alfa-induced heparin resistance using nafamostat mesilate.</p>","PeriodicalId":14635,"journal":{"name":"JA Clinical Reports","volume":"10 1","pages":"6"},"PeriodicalIF":0.8,"publicationDate":"2024-01-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10825097/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139570289","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
{"title":"Association between intraoperative blood salvage and coagulation disorder after cardiopulmonary bypass.","authors":"Masahiro Morinaga, Kenji Yoshitani, Soshiro Ogata, Satsuki Fukushima, Hitoshi Matsuda","doi":"10.1186/s40981-024-00689-1","DOIUrl":"10.1186/s40981-024-00689-1","url":null,"abstract":"<p><strong>Background: </strong>This study investigated whether intraoperative blood salvage was associated with coagulation disorder diagnosed by conventional coagulation tests and thromboelastography (TEG) after cardiopulmonary bypass (CPB).</p><p><strong>Study design and methods: </strong>This was a prospective, observational study. Ninety-two patients who underwent cardiovascular surgery with CPB were enrolled. We evaluated coagulation function in patients with or without cell salvage blood transfusion at the following time points: before CPB, just after protamine administration, and 1 h after protamine administration. We evaluated platelet count, fibrinogen concentration, and TEG parameters. Patients were considered to have coagulation disorder if one or more of the following criteria were present: (1) residual heparin, (2) low platelet count, (3) low fibrinogen level, (4) low clotting factor level, and (5) hyperfibrinolysis.</p><p><strong>Results: </strong>Fifty-three of 92 patients (57.6%) received intraoperative cell salvage. Coagulation disorder was observed in 56 of 92 patients (60.9%) after CPB. There was no significant difference between patients with or without intraoperative blood salvage in terms of the incidence of coagulation disorder (p = 0.542) or the total volume of blood from the drain after CPB (p = 0.437). Intraoperative blood salvage was not associated with coagulation disorder diagnosed by either TEG or conventional coagulation tests (odds ratio 1.329, 95% confidence interval: 0.549-3.213, p = 0.547). There were no significant interactions between patients with or without intraoperative blood salvage regarding coagulation parameters derived from TEG.</p><p><strong>Conclusions: </strong>The incidence of coagulation disorder and the total blood volume from the drain after CPB did not differ significantly between patients with or without intraoperative blood salvage.</p>","PeriodicalId":14635,"journal":{"name":"JA Clinical Reports","volume":"10 1","pages":"5"},"PeriodicalIF":0.8,"publicationDate":"2024-01-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10810763/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139546187","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}