Journal of Burn Care & Research最新文献

{"title":"Vasoactive Agents in Burn Patients - Perspectives on Angiotensin-II.","authors":"Scott W Mueller, Nicolas M Tran, Kevin D Betthauser, Mitchell S Buckley, Jeffrey Shupp, Arek J Wiktor, David M Hill","doi":"10.1093/jbcr/irae208","DOIUrl":"https://doi.org/10.1093/jbcr/irae208","url":null,"abstract":"<p><p>Severe burn injury poses significant clinical challenges, often necessitating the use of vasoactive agents to maintain perfusion. This narrative review explores the current landscape of vasoactive agents in acute burn shock resuscitation and severe burn-injured patients who develop septic shock, with a particular focus on the potential role of the novel vasoactive agent, synthetic angiotensin-II (AT-II), in these settings. While catecholamines and vasopressin remain cornerstone therapies, adverse effects, variable patient response, and a new understanding of burn injury pathophysiology highlight the potentially evolving role of vasoactive agents in these clinical scenarios. A key system involved in blood pressure regulation, the renin-angiotensin-aldosterone system (RAAS), is often dysregulated in acute burn and septic shock. Contributory mechanisms and potential benefits of synthetic AT-II are discussed here within and form the physiologic rationale behind exogenous administration of synthetic AT-II in the context of available safety and efficacy data. To date, administration of synthetic AT-II administration has shown promise in improving hemodynamics and clinical outcomes in distributive shock populations; however, data in acute burn shock and burn patients who develop septic shock are lacking. In addition, a comprehensive understanding of the potential and future areas of research in burn shock and severe burn-injured patients is provided.</p>","PeriodicalId":15205,"journal":{"name":"Journal of Burn Care & Research","volume":" ","pages":""},"PeriodicalIF":1.5,"publicationDate":"2024-12-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142818062","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":"Enoxaparin 40mg Twice Daily with Peak Anti-Xa Adjustments is Safe and Necessary to Achieve Therapeutic Chemoprophylaxis in Burn-Injured Patients.","authors":"Desiree N Pinto, Sophia Lee, Cory Johnson, Rola Halabi, Tuan D Le, Lauren T Moffatt, Bonnie C Carney, Shane K Mathew, Melissa McLawhorn, Shawn Tejiram, Taryn E Travis, Jeffrey W Shupp","doi":"10.1093/jbcr/irae201","DOIUrl":"https://doi.org/10.1093/jbcr/irae201","url":null,"abstract":"<p><p>Burn injury results in hypercoagulability and an increased venous thromboembolism risk. However, the most effective chemoprophylaxis for burn-injured patients has yet to be elucidated. Therefore, this study aims to identify the safety and efficacy of a burn center's venous thromboembolism protocol modification which increased the dose of enoxaparin from 40mg daily to 40mg twice daily with peak anti-Xa level adjustments. It was hypothesized that this change would not increase bleeding complications and would decrease venous thromboembolism rates. All adult, burn-injured patients admitted to a regional burn center were retrospectively reviewed one year before and after the implementation of this protocol modification. There were no differences in demographics, injury characteristics, or hospital length of stay between the pre- (n=432) and post-protocol modification (n=407) groups. Bleeding complications did not increase in the post-protocol group, including intraoperative blood loss (50 vs 25cc), the total number of transfusions (9.0 vs 6.0 units), and GI bleeding events (0.7 vs 0.2%) (all p>0.05). Most patients receiving enoxaparin 40mg twice daily achieved an initial therapeutic level based on peak anti-Xa measurements (46.5%), yet the rate of venous thromboembolisms between pre- and post-protocol groups was not statistically different (1.4 vs 0.7%, p=0.5072). Factors associated with an initial sub- or supratherapeutic peak anti-Xa level were percent total body surface area, weight, body mass index, and creatinine clearance. Overall, this study demonstrated that a higher dose of enoxaparin (40mg twice daily) with peak anti-Xa level adjustments was safe in burn-injured patients and necessary to obtain therapeutic levels of chemoprophylaxis.</p>","PeriodicalId":15205,"journal":{"name":"Journal of Burn Care & Research","volume":" ","pages":""},"PeriodicalIF":1.5,"publicationDate":"2024-12-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142807184","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":"Hand Burn Injuries and Occupational Impairment: A Study on the Impact of Burn Injuries on Return-to-Work Outcomes from the Burn Model System research program.","authors":"Nikhitha Thrikutam, Charles M Kopp, Caitlin Orton, Alyssa M Bamer, Jeffrey C Schneider, Kyra Solis-Beach, Lewis E Kazis, Haig A Yenikomshian, Karen Kowalske, Barclay T Stewart","doi":"10.1093/jbcr/irae203","DOIUrl":"10.1093/jbcr/irae203","url":null,"abstract":"<p><p>Return to work (RTW) after burn injury is dependent on many variables, including type and location of burn injury, access to care, and pre-injury mental and physical health. Noting that prior studies were limited by small sample sizes, we aimed to use a large database to explore the associations between hand burn severity, functional hand outcomes, and RTW post-injury. Data from a multicenter longitudinal study were analyzed. Adults with burn injuries were classified into 6 groups ranking in severity of hand injury: (0) no hand burns, (1) single hand burn no grafting, (2) bilateral hand burn no grafting, (3) single hand burn requiring grafting, (4) bilateral hand burn requiring unilateral graft, (5) bilateral hand burn requiring bilateral grafts. Grafting was used as a proxy for burn severity. Self-reported employment status, Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE) scores and reported request for work accommodations were collected at discharge, 6-, 12-, and 24-months post-injury. Descriptive statistics and analysis of variance (ANOVA) with post-hoc Tukey Test were completed to examine differences in outcomes by hand injury severity. A total of 4,621 participants met inclusion criteria. Group 5, those with most severe burns, had significantly longer RTW times than Groups 0-3 (p< 0.005). Group 5's (bilateral burn/unilateral graft) average RTW was greater, however not significantly, compared to group 4. At 6 months, the mean PROMIS UE scores for grafted groups (Group 3, 40.6; Group 5, 35.4) were significantly worse than non-grafted groups (Group 1, 46.8; Group 2, 45.0; (p< 0.0001). At 12 and 24 months, mean PROMIS UE scores were worse for grafted groups, though differences were no longer significant compared to non-grafted groups. At every time point, the majority of respondents did not request accommodations for their injuries from their employers, regardless of severity. Burn severity plays a significant role in both RTW and hand function for participants with hand burns. Additionally, the lack of correlation between burn severity and request for work accommodations hints at the baseline vulnerability of these populations. These findings suggest a need for systematic improvements in the way these patients are cared for and re-integrated into the workforce.</p>","PeriodicalId":15205,"journal":{"name":"Journal of Burn Care & Research","volume":" ","pages":""},"PeriodicalIF":1.5,"publicationDate":"2024-11-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142668086","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":"Analysis of Burn Casualties in the Swords of Iron War.","authors":"Dafna Shilo Yaacobi, Yehiel Hayun, Daniel Hilewitz, Dean D Ad-El, Sagit Meshulam-Derazon, Irina Radomislensky, Cole D Bendor, Yehonatan Noyman, Ofer Almog, Asaf Olshinka","doi":"10.1093/jbcr/irae207","DOIUrl":"https://doi.org/10.1093/jbcr/irae207","url":null,"abstract":"&lt;p&gt;&lt;p&gt;The Swords of Iron (SOI) War is an armed conflict between Israel and Hamas, which has been taking place in Gaza from October 2023 until the present time of writing this article. This war is characterized by urban close contact combat. The combat equipment, weaponry, and protective measures employed, differ markedly from those in previously documented major conflicts, significantly impacting the types of injuries sustained by soldiers. This study examines the number of injured soldiers in combat, field mortality rates, incidence of burns and trauma, demographic details of the injured, causes and distribution of injuries, burn characteristics, hemodynamic status, and injury severity. This is a retrospective, registry-based cohort study. Military personnel treated by IDF medical teams with burn injuries from the ground maneuver in Gaza between October 27th, 2023 to April 2024 were included in the analysis. Diagnosis of burn injuries was made in the prehospital setting and recorded in the patient's casualty cards and the IDF trauma registry and/or in the hospitals, and then recorded by the Israel National Trauma Registry. A total of 2,627 documented military personnel were included. Of them, there was a total of 249 burn casualties. They were all male combat soldiers and their mean age was 22 years. Most of the burn injuries were combined with other injuries, only 12% were defined as in shock state, and 14% received whole blood in the field. The burn degree was second and third degree for most cases. A third (34%) of burn injured soldiers had surgery (Table 2), and half of the total were sent to rehabilitation departments following their initial hospitalization. An analysis of total body surface area (TBSA)% affected by burns among SOI War casualties reveals a higher proportion of severe burns exceeding 20% TBSA, compared to previous conflicts. Additionally, a higher proportion of personnel suffered from second and third degree burns. This is likely attributed to the operational mode of the IDF in Gaza, where urban close-contact warfare exposes soldiers to heightened risks of explosive and blast injuries. A significant percentage of live casualties had TBSA percentages that were not life-threatening, which underscores the importance of updating emergency burn treatment protocols and employing rapid evacuation and medical response systems in the field. Most of the wounded that suffer from significant burns had other significant and life-threatening injuries, making the appropriate protective measures and the preparation for rapid evacuation the best way to improve burn casualty survival. The significance of this research lies in the timely analysis of accumulated combat data to derive lessons and conclusions relevant to ongoing and future conflicts, and to understand the clinical implications arising from combat situations. Given the relatively high prevalence of burn injuries, understanding their etiology, severity, and consequences is essentia","PeriodicalId":15205,"journal":{"name":"Journal of Burn Care & Research","volume":" ","pages":""},"PeriodicalIF":1.5,"publicationDate":"2024-11-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142648252","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":"Evidence Supporting Conservative Scar Management Interventions Following Burn Injury: a review article.","authors":"Zoë Edger-Lacoursière, Mengyue Zhu, Stéphanie Jean, Elisabeth Marois-Pagé, Bernadette Nedelec","doi":"10.1093/jbcr/irae204","DOIUrl":"https://doi.org/10.1093/jbcr/irae204","url":null,"abstract":"<p><p>Conservative management for hypertrophic scars (HSc) and scar contractures is of utmost importance to optimally reintegrate burn survivors into society. Many conservative treatment interventions have been described in the literature for the management of HSc. Recent advancements in the literature pertaining to post-burn scarring and HSc formation, have advanced our understanding of the mechanisms that support or refute the use of common rehabilitation treatment modalities after burn injury. This is particularly relevant for recent advancements in the fields of mechanotransduction and neurogenic inflammation resulting in the need for rehabilitation clinicians to reflect upon commonly employed treatment interventions. The aim of this review article is to summarize and clinically apply the evidence that supports or refutes the use of common conservative treatment interventions for scar management employed after burn injury. The following treatments are discussed and mechanotransduction and neurogenic inflammation concepts are highlighted: 1) edema management (compression, positioning/elevation, pumping exercises, retrograde massage, manual edema mobilization), 2) pressure therapy (including custom fabricated pressure garments, inserts, face masks, and other low-load long duration orthotic devices), 3) gels or gel sheets, 4) combined pressure therapy and gels, 5) serial casting, 6) scar massage, and 7) passive stretching. This review supports the following statements: 1) Compression for edema reduction should be initiated 48-72 hrs post-injury and continued for wounds that require longer than 21 days to heal until scar maturation; 2) Elevation, pumping exercises and retrograde massage/MEM should be used in combination with other edema management techniques; 3) Custom fabricated pressure garments should be applied once the edema is stabilized and adequate healing has occurred. Garments should be monitored on a regular basis to ensure that optional pressure, >15 mm Hg, is maintained, adding inserts when necessary. The wearing time should be >16 hrs/day; 4) Gels for post-burn scar management should extend beyond the scar; 5) Serial casting should be applied when contractures interfere with function; 6) Forceful scar massage should be avoided early in the wound healing process or when the scar is inflamed or breaks down; 7) Other treatment modalities should be prioritized over passive stretching for scar management.</p>","PeriodicalId":15205,"journal":{"name":"Journal of Burn Care & Research","volume":" ","pages":""},"PeriodicalIF":1.5,"publicationDate":"2024-11-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142644312","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":"Needs assessment for a new military burn care educational curriculum focused on prolonged field care: The Burns for Providers Program (BP2).","authors":"Logan J Hornung, L T C Ret Mario Rivera-Barbosa, James E Johnson, Jeffrey E Carter, Jonathan E Schoen, C O L Ret Leopoldo C Cancio, M A J Angela B Samosorn, Herb A Phelan","doi":"10.1093/jbcr/irae206","DOIUrl":"https://doi.org/10.1093/jbcr/irae206","url":null,"abstract":"<p><p>We performed a needs assessment to determine the essential elements for a curriculum teaching burn care during Large Scale Combat Operations against peer/near-peer adversaries within multi-domain contested combat environments. Virtual and face-to-face site visit meetings were conducted with 20 stakeholders at 3 levels: 1) Subject Matter Experts (SMEs) in military burn casualty care at the U.S. Army Institute of Surgical Research (USAISR), the Joint Trauma System (JTS), and the U.S. Army Medical Center of Excellence (US Army MedCOE) in Joint Base San Antonio (JBSA) - Fort Sam Houston, TX; 2) Course Directors, Instructors, Curriculum Innovators and Writers for the Combat Paramedic Branch and the Critical Care Flight Paramedic Program (CCFPP) at JBSA; and 3) regulatory administrators providing education, research and IRB administration for USAISR and US Army MEDCOE. The identified terminal learning objectives consisted of training in: burn casualty monitoring and principles of burn wound care according to available resources; best practices during PCC for pain, nutrition, and infection control; specific management of inhalation, chemical, radiation, electrical, pediatric, and mass casualty burn injuries; and procedural skill training for patient decontamination, debridement, dressings, and escharotomy. Additionally, needs were identified for novel technology that provides asynchronous individual learning opportunities using interactive role play simulations, immersive simulation, or virtual reality simulation as well as hands-on procedure simulators. Stakeholder engagement resulted in identification of sixteen terminal learning objectives that were subsequently used as the basis for a military curriculum we are calling the \"Burns for Providers Program\" (BP2).</p>","PeriodicalId":15205,"journal":{"name":"Journal of Burn Care & Research","volume":" ","pages":""},"PeriodicalIF":1.5,"publicationDate":"2024-11-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142644313","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":"Correction to: Burn Registries: From Observation to Intervention.","authors":"","doi":"10.1093/jbcr/irae167","DOIUrl":"10.1093/jbcr/irae167","url":null,"abstract":"","PeriodicalId":15205,"journal":{"name":"Journal of Burn Care & Research","volume":" ","pages":"1651"},"PeriodicalIF":1.5,"publicationDate":"2024-11-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142143074","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":"Navigating the Ethical Challenges of Clinical Decision-Making for Patients with Mental Illness Presenting with Self-Inflicted Burns.","authors":"Rebekka DePew, Ashima Lal, Elizabeth Sivertsen, Ashley Smith, Laura S Johnson, Emily Pinto Taylor","doi":"10.1093/jbcr/irae176","DOIUrl":"10.1093/jbcr/irae176","url":null,"abstract":"<p><p>Complex ethical considerations can arise when patients with severe, persistent mental illness (SPMI) present with critical illness resulting from self-injury. This article presents 2 clinical cases in which a patient with SPMI was admitted with severe injuries following self-inflicted burns, with a substantial impact on their anticipated quality of life and challenges directing their medical care. In both cases, the medical teams held discussions with surrogate decision-makers in order to evaluate the patient's minimal acceptable quality of life and make medical decisions that best reflected the patient's voice and goals. These cases underscore the importance of advance care planning in SPMI, particularly the appointment of a surrogate decision-maker, and highlight the moral distress that can arise among surgical teams and trainees while caring for patients with illness resulting from self-harm. This article offers a framework for approaching decision-making in critical illness resulting from self-harm for patients with SPMI.</p>","PeriodicalId":15205,"journal":{"name":"Journal of Burn Care & Research","volume":" ","pages":"1641-1644"},"PeriodicalIF":1.5,"publicationDate":"2024-11-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142288090","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":"Managing Long-term Orofacial Contractures and Microstomia Through Intraoral Stretching.","authors":"Lori Ann Arguello, Kathleen Mary Kerr","doi":"10.1093/jbcr/irae123","DOIUrl":"10.1093/jbcr/irae123","url":null,"abstract":"<p><p>Microstomia and orofacial contractures continue to garner interest regarding the effectiveness of treatment methodologies utilized to impact functional change. Oral splints are an accepted tool in the management of microstomia. However, the concepts of which oral splints to use, timing of initiation, and duration of treatment have not gained a consensus. This article reviews approaches to oral splinting and an alternative intraoral approach using splints designed to provide a graded, low load, multidirectional, and prolonged stretch specifically in facial burn survivors including those with mature scars. Two participants participated in a trial using oral splints placed inside the mouth at established contracture points. Participants were requested to use the splints for 1 h twice daily. Participants were photographed weekly producing 9 facial expressions, and distance between 13 facial landmarks was measured to evaluate change in tissue length. Numerical changes observed from beginning to end of the trial indicate positive and negative alterations, signifying lengthening or shortening of tissue. Negative changes denote reduction in distance between endpoints, while positive changes signify an increase. Participants verbalized functional improvements in oral motor and psychosocial function posttreatment. To date, oral splints can be custom fabricated for each individual patient. However, few oral splints are created to provide multidirectional stretch focusing on problem areas across the mid and lower face. The intraoral splints and regimen described here have the capability of providing a stretching intervention that could be applicable in various stages of burn recovery.</p>","PeriodicalId":15205,"journal":{"name":"Journal of Burn Care & Research","volume":" ","pages":"1454-1463"},"PeriodicalIF":1.5,"publicationDate":"2024-11-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11565195/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141788132","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}

{"title":"Revision of an Adult Burn Center's Resuscitation Guideline Leads to Lower Resuscitation Requirements.","authors":"Dominick Curry, Kimberly Wray, Brandon Hobbs, Susan Smith, Howard Smith","doi":"10.1093/jbcr/irae098","DOIUrl":"10.1093/jbcr/irae098","url":null,"abstract":"<p><p>In 2018, the institutional burn resuscitation guideline was updated to remove the use of high-dose ascorbic acid (HDAA) therapy, to lower 24-hour resuscitation fluid estimations from 4 to 2 mL/kg/TBSA, and to optimize guidance around appropriate colloid resuscitation. This retrospective study compared the incidence of a composite safety outcome (acute kidney injury, or intra-abdominal hypertension requiring intervention) between the pre-guideline update to post-guideline update. Secondarily, 24-hour resuscitation volumes, hourly urine output, vasopressor use, and mechanical ventilation duration were compared as well. The composite safety outcome was similar between the 2 groups (40% vs 29%; P = .27), but the post-group showed significantly lower 24-hour resuscitation volumes (3.74 vs 2.94 mL/kg/TBSA; P < .01), as well as lower urine output (1.26 vs 0.75 mL/kg/h; P < .01). There was no difference between the groups with respect to vasopressor use, mechanical ventilation duration, or mortality. This study suggests that a simplified resuscitation protocol without HDAA, combined with a lower starting fluid rate, led to significantly lower 24-hour resuscitation volumes without an increase in adverse safety events.</p>","PeriodicalId":15205,"journal":{"name":"Journal of Burn Care & Research","volume":" ","pages":"1499-1504"},"PeriodicalIF":1.5,"publicationDate":"2024-11-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141186492","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}