Journal of hospital medicine最新文献

{"title":"Benefit of using an assistive listening device in a hospital setting","authors":"Marissa Merrifield BS,&nbsp;Sharon A. Brangman MD,&nbsp;Toni Pacioles MD,&nbsp;Karen A. Doherty PhD","doi":"10.1002/jhm.13573","DOIUrl":"10.1002/jhm.13573","url":null,"abstract":"<p>High levels of noise in hospital settings can make communication difficult, especially for older adults. Assistive Listening Devices (ALDs) are personal amplifiers that can improve hearing in background noise. This study investigated the impact of providing ALDs to hospitalized patients 60 years of age and older without using hearing screenings to determine eligibility. Results indicated that 96% of the patients reported that ALD was easy to use and 88% found it helpful. The ALD was used to communicate with family, hospital staff, and physicians. This suggests ALDs can be distributed to patients 60 years and older without any hearing screenings.</p>","PeriodicalId":15883,"journal":{"name":"Journal of hospital medicine","volume":"20 4","pages":"424-429"},"PeriodicalIF":2.4,"publicationDate":"2024-12-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1002/jhm.13573","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142857402","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":"Standardizing imaging practices: An opportunity to leverage modern measurement tools","authors":"Alaina Shine MD,&nbsp;Reto Baertschiger MD, PhD,&nbsp;Samantha A. House DO, MPH","doi":"10.1002/jhm.13579","DOIUrl":"10.1002/jhm.13579","url":null,"abstract":"","PeriodicalId":15883,"journal":{"name":"Journal of hospital medicine","volume":"20 6","pages":"651-652"},"PeriodicalIF":2.4,"publicationDate":"2024-12-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142857404","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":"Optimizing learners on direct care teaching services: A qualitative study of hospitalist clinicians at 26 sites","authors":"Catherine Callister MD,&nbsp;Gopi Astik MD, MS,&nbsp;R. Matthew Atkins MD,&nbsp;Angela Alday MD,&nbsp;Khooshbu Dayton MD,&nbsp;Angela Keniston PhD, MSPH,&nbsp;Anne Linker MD,&nbsp;Lauren McBeth BA,&nbsp;John Merriman MD, MPH,&nbsp;Sara Westergaard MD, MPH,&nbsp;Amy Yu MD,&nbsp;Andrew Auerbach MD, MPH,&nbsp;Marisha Burden MD, MBA","doi":"10.1002/jhm.13561","DOIUrl":"10.1002/jhm.13561","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Background</h3>\u0000 \u0000 <p>Academic medical centers are experiencing rapid clinical growth which has outpaced traditional teaching services. Learners such as medical students, advanced practice provider fellows, and residents may be placed onto direct care teaching services (i.e., inpatient services where attendings provide both direct care to patients and supervise learners) creating potential challenges for attending physicians due to clinical demands.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Objective</h3>\u0000 \u0000 <p>Characterize the hospitalist experience with direct care teaching services.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>Embedded mixed methods study with a 16-question survey and semistructured focus groups using rapid qualitative methods.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Setting and participants</h3>\u0000 \u0000 <p>Virtual focus groups in the Hospital Medicine Reengineering Network (HOMERuN). Main Outcome and measures: Qualitative themes.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>Thirty-eight hospitalist clinicians from 26 hospital systems across five geographic regions participated in the focus groups. Thirty-four (89%) of participants responded to the survey and were predominantly physicians (97%). Most participants preferred traditional teaching services compared with direct care teaching services with 82% replying somewhat or to a great extent. Thematic analysis identified three themes: (1) Hospitalists prefer traditional teaching services in part due to a time and workload mismatch in direct care teaching services; (2) Adaptations can support attending physicians in direct care teaching services such as adjusting workloads based on the level of learners; and (3) Direct care teaching services were perceived to serve an important role by providing direct and personalized teaching, and offering teaching opportunities.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusion</h3>\u0000 \u0000 <p>Direct care teaching services pose challenges given clinical workloads, time constraints for educational activities. Addressing these challenges may make these types of services more sustainable.</p>\u0000 </section>\u0000 </div>","PeriodicalId":15883,"journal":{"name":"Journal of hospital medicine","volume":"20 6","pages":"562-572"},"PeriodicalIF":2.4,"publicationDate":"2024-12-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142831464","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":"The SafeTy And Resource (STAR) Clinician: Improving care and hospitalist satisfaction with a novel support role","authors":"Amy W. Baughman MD, MPH,&nbsp;William C. Hillmann MD,&nbsp;Emily Hughes MD,&nbsp;Zachary Ranta MD,&nbsp;Cindy Yu MD,&nbsp;Denisa Gace DO, MPH,&nbsp;Meghan Meehan CNP,&nbsp;Candice Couture RN,&nbsp;Holly Jackson RN,&nbsp;Kerry Maloney MPH,&nbsp;Melissa L. P. Mattison MD","doi":"10.1002/jhm.13563","DOIUrl":"10.1002/jhm.13563","url":null,"abstract":"","PeriodicalId":15883,"journal":{"name":"Journal of hospital medicine","volume":"20 6","pages":"642-644"},"PeriodicalIF":2.4,"publicationDate":"2024-12-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142804171","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":"Waiting to be seen: Understanding the experience of waiting in hospital settings through a patient-created digital story","authors":"Michael Lang PhD,&nbsp;Daniel Piller,&nbsp;Christopher Roach BSc","doi":"10.1002/jhm.13566","DOIUrl":"10.1002/jhm.13566","url":null,"abstract":"&lt;p&gt;Few healthcare experiences are as ubiquitous as waiting. Conversations at any social gathering will unearth stories of wait times and waiting rooms, waiting for referrals, appointments, test results, treatments, or medications. A common quip in patient advocacy circles is that the experience of waiting is why “people” become “patients” when they interact with the healthcare system.* After an accident at the age of 20 led to quadriplegia, Daniel is “good at waiting” as a recurrent user of the acute care system. His years of lived experience provided extensive material to draw upon as he created a short-film titled, &lt;i&gt;Waiting to be Seen&lt;/i&gt;, on which this interpretive article is based (Click Here to View).&lt;/p&gt;&lt;p&gt;In Canada, provincial healthcare systems across the country are infamous for their time-to-treatment metrics, with surgery and emergency department (ED) wait times being challenges in acute care.&lt;span&gt;&lt;sup&gt;1&lt;/sup&gt;&lt;/span&gt; As a result, improving patient flow in hospital contexts is a focus of many quality improvement (QI) initiatives, including the “Know Your Data” Physician Audit and Feedback pilot project with Alberta Health Services. Audit and feedback (AF) is a method of providing performance data to physicians to help them translate knowledge into practice&lt;span&gt;&lt;sup&gt;2&lt;/sup&gt;&lt;/span&gt; and this particular initiative aimed to help hospitalists and internal medicine physicians understand their practices using operational data.&lt;/p&gt;&lt;p&gt;Led by the Hospital Medicine Section of the Medicine Strategic Clinical Network, the pilot project used physician AF literature&lt;span&gt;&lt;sup&gt;3&lt;/sup&gt;&lt;/span&gt; and internal data and analytics to provide individual and service-level data to physicians and highlight data availability in the new province-wide Clinical Information System, called Connect Care. Data provision (e.g., acute length of stay:expected length of stay ratio, readmission rates, etc.) was coupled with QI approaches to cultivate change at the individual physician level, through self-reflection on their own data, and by reviewing data at an aggregated level in facilitated physician group discussions. It was noted during the initial phase of this project that these group conversations lacked context, specifically, the impact that patient flow had on the lives of patients and their families. In other words, &lt;i&gt;why did the numbers matter&lt;/i&gt;? It was clear that lived experiences were needed to contextualize the AF group conversations, and five patient advisors were recruited to create their own short-film, called a Digital Story, about their acute care encounters. The remainder of this interpretive article will explore three ideas that emerge from the story Daniel created for the Know Your Data project.&lt;/p&gt;&lt;p&gt;The imagery emphasizes these words with a slowly dissolving image of Daniel in his wheelchair that reappears as the doctor apologizes and Daniel “feels seen.” By admitting a mistake and accepting responsibility, the ED physician demonstrated that he un","PeriodicalId":15883,"journal":{"name":"Journal of hospital medicine","volume":"20 4","pages":"430-432"},"PeriodicalIF":2.4,"publicationDate":"2024-12-05","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1002/jhm.13566","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142788183","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":"Evaluating the impact of patient–staff interactions on sleep opportunities using the electronic health record","authors":"Sullafa Kadura MD, MBA,&nbsp;Lisa Pink MS,&nbsp;Diego R. Mazzotti PhD,&nbsp;Kathleen Fear PhD","doi":"10.1002/jhm.13568","DOIUrl":"10.1002/jhm.13568","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Background</h3>\u0000 \u0000 <p>Hospitalized patients often experience disrupted sleep due to nighttime patient–staff interactions (PSIs). This study evaluates how PSIs impact sleep opportunities in neurology inpatients using electronic health record (EHR) data and introduces surrogate measures of sleep such as longest uninterrupted sleep opportunity (LUSO) and interruptive episodes.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Objective</h3>\u0000 \u0000 <p>To develop a methodology leveraging time-stamped EHR data to quantify and visualize the impact of PSIs on inpatient sleep opportunities.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>We analyzed 3305 patient nights in an inpatient neurology unit, categorizing PSIs into six types: vital signs, neurological checks, medication administration, bedside diagnostic testing, off-unit diagnostic testing, and bed changes. We calculated LUSO and interruptive episodes and used a linear mixed model to assess the relationship between PSIs and LUSO.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>PSIs occurred in 92% of patient nights, averaging 2.81 interruptive episodes and 4.06 h of LUSO per night. Vital signs and medication administrations were the most frequent PSIs. Neurological checks and off-unit diagnostic testing were associated with the largest reductions in LUSO (approximately 40 min), followed by bed changes (−33.79 min).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusion</h3>\u0000 \u0000 <p>This study demonstrates the utility of LUSO and interruptive episodes as EHR-based measures to link PSIs to sleep opportunities. While vital signs and medications were the most frequent PSIs, neurological checks and off-unit testing were associated with the largest impact on reducing LUSO. The predominance of single-PSI interruptive episodes underscores that the bundling of PSIs is not occurring. These findings highlight that PSIs impact sleep opportunities in distinct ways, supporting the use of this methodology to evaluate and address EHR-linked disruptions to patient sleep.</p>\u0000 </section>\u0000 </div>","PeriodicalId":15883,"journal":{"name":"Journal of hospital medicine","volume":"20 6","pages":"581-587"},"PeriodicalIF":2.4,"publicationDate":"2024-12-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142782205","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":"Impact of alcohol use disorder on inpatient hospitalizations: A comparison of outcomes between urban and rural Veterans Affairs hospitals","authors":"James Willey MD,&nbsp;Peter Kaboli MD, MS,&nbsp;Andrea Holcombe PhD,&nbsp;Amy M. J. O'Shea PhD,&nbsp;Tong Yu MD,&nbsp;Kelby Rewerts BS,&nbsp;George Bailey BS,&nbsp;Anindita Bandyopadhyay MS,&nbsp;Thad Abrams MD, MS,&nbsp;Jeydith T. Gutierrez MD, MPH","doi":"10.1002/jhm.13544","DOIUrl":"10.1002/jhm.13544","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Background</h3>\u0000 \u0000 <p>Alcohol use disorder (AUD) is a leading cause of morbidity and mortality that disproportionately affects rural residents and Veterans.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Objective</h3>\u0000 \u0000 <p>To evaluate the burden of AUD in admissions at rural and urban hospitals within the Veterans Health Administration (VHA) comparing patient characteristics, clinical outcomes, and 1-, 3-, and 5-year mortality rates.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>Retrospective cross-sectional study of patients admitted to VHA hospitals from 2016 to 2020, with a primary or secondary diagnosis related to AUD. Follow-up mortality data was collected through September 30, 2023.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>From 2.9 million qualifying admissions, AUD-related diagnoses were present in 14.3% of admitted patients (427,375 admissions among 190,152 unique patients in 129 facilities). Rural hospitals (<i>n</i> = 22) had a significantly higher overall admission rate for AUD-related diagnoses (21.6% vs. 14.8%, <i>p</i> = .011), higher 30-day readmission rates (17.8% vs. 15.3%, <i>p</i> &lt; .001), but lower hospital-level average length of stay (median = 4.3 vs. 5.6, <i>p</i> &lt; .001). Mortality in rural hospitals was lower than urban at 1 year (9.6% vs. 11.4%, <i>p</i> &lt; .001), 3 years (20.7% vs. 23.1%, <i>p</i> &lt; .001), and 5 years (30.4% vs. 32.9%, <i>p</i> &lt; .001).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>Rural VHA hospitals have a higher proportion of patients admitted with AUD-related diagnoses and higher readmission rates, but lower mortality rates. Approximately, one in three patients admitted with an AUD-related diagnosis died within the 5-year follow-up period. The mortality rates observed are extraordinary and deserve urgent attention. A comprehensive plan to address AUD in the Veteran population, including how we approach and engage patients in treatment during hospitalizations with any primary or secondary AUD diagnoses, is needed.</p>\u0000 </section>\u0000 </div>","PeriodicalId":15883,"journal":{"name":"Journal of hospital medicine","volume":"20 5","pages":"463-470"},"PeriodicalIF":2.4,"publicationDate":"2024-12-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.1002/jhm.13544","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142775937","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":"Identifying opportunities to reduce imaging overuse in hospitalized children","authors":"Sanyukta Desai MD, MSc,&nbsp;Jennifer Treasure MD, MSc,&nbsp;Troy Richardson PhD,&nbsp;Matt Hall PhD,&nbsp;Samir S. Shah MD, MSCE,&nbsp;Joanna E. Thomson MD, MPH","doi":"10.1002/jhm.13562","DOIUrl":"10.1002/jhm.13562","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Background</h3>\u0000 \u0000 <p>Radiologic imaging is routinely performed to aid in diagnosis for hospitalized children. Identifying and reducing variability in imaging practices can improve care while reducing harms and costs.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Objectives</h3>\u0000 \u0000 <p>To identify common inpatient pediatric conditions with high prevalence of imaging and variation in imaging practices and imaging-related costs across hospitals.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Methods</h3>\u0000 \u0000 <p>We conducted a cross-sectional study of children 0–18 years old admitted to 50 children's hospitals in the Pediatric Health Information Systems database between 2017 and 2019. We excluded patients with complex chronic conditions, pregnancy, newborn, or neonatal intensive care charges, and those who died or who were discharged to hospice or rehabilitation facilities. Conditions with at least 2500 discharges and in which ≥30% of patients received imaging were included. Outcomes included imaging frequency, standardized imaging-related costs (including all modalities across all encounters), and hospital-level variation in imaging costs using the intraclass correlation coefficient (ICC).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>Of the 56 included conditions, imaging was most frequently conducted in patients with pectus excavatum (97.8%), scoliosis (96.2%), and intestinal obstruction (96%). Fracture ($21.4 million), trauma ($15.7 million), and appendicitis ($8.6 million) had the highest total imaging-related costs. Conditions with the highest geometric mean standardized imaging costs were nervous system disorders ($507), osteomyelitis ($494), vesicoureteral reflux/hydronephrosis ($468). Scoliosis (ICC = 0.49) and preseptal cellulitis (ICC = 0.48) had the highest variation in imaging-related costs.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusion</h3>\u0000 \u0000 <p>To reduce imaging overuse in hospitalized children, conditions with frequent imaging, high imaging-related costs, and high hospital-level variation in imaging practices should serve as priorities for future evidence generation, guideline development, and/or improvement initiatives.</p>\u0000 </section>\u0000 </div>","PeriodicalId":15883,"journal":{"name":"Journal of hospital medicine","volume":"20 6","pages":"573-580"},"PeriodicalIF":2.4,"publicationDate":"2024-12-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142775932","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":"Postoperative pain treatment in children with severe neurological impairment: We must do better","authors":"Sarah K. Luthy MD, MSCS,&nbsp;Stefan J. Friedrichsdorf MD, FAAP","doi":"10.1002/jhm.13567","DOIUrl":"10.1002/jhm.13567","url":null,"abstract":"<p>\u0000 <figure>\u0000 <div><picture>\u0000 <source></source></picture><p></p>\u0000 </div>\u0000 </figure></p>","PeriodicalId":15883,"journal":{"name":"Journal of hospital medicine","volume":"20 5","pages":"526-527"},"PeriodicalIF":2.4,"publicationDate":"2024-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142775942","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":"Airway clearance in hospitalized children with neurological impairment: Does it work?","authors":"Leah N. Jones MD,&nbsp;Erin Shaughnessy MD, MSHCM","doi":"10.1002/jhm.13564","DOIUrl":"10.1002/jhm.13564","url":null,"abstract":"<p>\u0000 <figure>\u0000 <div><picture>\u0000 <source></source></picture><p></p>\u0000 </div>\u0000 </figure></p>","PeriodicalId":15883,"journal":{"name":"Journal of hospital medicine","volume":"20 5","pages":"530-531"},"PeriodicalIF":2.4,"publicationDate":"2024-11-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142741882","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}