Journal of Pakistan Medical Association最新文献

{"title":"Interprofessional education: collaborative team work among undergraduate medical students","authors":"None Shumaila Rafi","doi":"10.47391/jpma.10079","DOIUrl":"https://doi.org/10.47391/jpma.10079","url":null,"abstract":"Madam, The last decade has been a global shift towards collaborative learning and practice. A Joint Commission Report noticed that 80% of all medical errors were due to miscommunications during patient handoffs, with 44% occurring in inpatient settings1. Learning Together to Work Together for Health is the essential guide for the working of Interprofessional Education (IPE), the idea presented by WHO and is defined as an experience that “occurs when students from two or more professions learn about, from, and with each other to enable effective collaboration and improve outcomes”2. The core competencies for IPE include collaborative teamwork, communication skills, ethical practice, roles and responsibilities, and conflict resolution2. IPE expects to improve the knowledge, skills, and attitudes towards collaboration to enhance their future clinical practice. Pakistan is a developing country that is strengthening IPE. The Karachi Medical and Dental College launched a training program on research methodology focusing on the principles of IPE to improve primary care delivery2. The Dental Hygiene Program at Aga Khan University is also an example of IPE improving patient healthcare3. These deficiencies can be overcome by vertically and horizontally integrating IPE in the curriculum.  The absence of a formal team-based care programme deprives most students from learning about professional roles. This warrants a need to focus on learning approaches that can be used in undergraduate curricula and thereby create and foster a collaborative learning environment. Case-based learning and team-based learning are valuable approaches resulting in experiential learning and reflection. Simulations allow students to practice and improve their communication and collaboration among medical students. E-learning is worthwhile for enlightening their understanding and cognizance of further profession’s duties and authorities, which is unique to the leading competencies of IPE4. The logistics of setting up IPE activities may be more challenging. The leadership confrontation such as lack of management between the faculties and lack of support by organization, curriculum challenges like IPE courses designing, teaching challenges, such as shortage of faculty members training, skills and competence in interprofessional and resistance to transformation i.e. dearth of resources are the main challenges for the institutions5. The institutions should engage in policies in the best strategies to implement interprofessional education. Hierarchical heads and policymakers need to put forth an effort to advance IPE so that different professions can benefit from each other more easily.","PeriodicalId":16673,"journal":{"name":"Journal of Pakistan Medical Association","volume":"3 3","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-10-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"136105212","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":"Is Pakistan ready to implement Artificial Intelligence?","authors":"None Hamna Tariq, None Areeba Sajid","doi":"10.47391/jpma.9536","DOIUrl":"https://doi.org/10.47391/jpma.9536","url":null,"abstract":"Madam, The phrase \"artificial intelligence\" (AI) refers to the capacity of computers to accomplish activities that humans can typically performed by utilising an Artificial Neural Network (ANN) (1). The Artificial intelligence has become an exceptionally desirable analytical tool in medicine due to its ability to generalise, handle imprecise information, analyse non-linear data, and learn from historical precedents (2). According to Tata Consultancy Services Global Trends Study focusing on artificial intelligence and its impact on the healthcare industry, 86% of healthcare companies use AI\", indicating its significance in improving healthcare (3). AI is employed everywhere, ensuring accuracy and speed in every aspect of a patient's diagnosis to their prognosis and treatment, revolutionising medicine (4) Despite all the benefits of AI, multiple factors need to be kept in mind before it can be successfully applied. AI works on software that is designed in accordance with data sets. If the data used in programming is not diverse, it will inevitably result in prejudice worsening the discriminatory outcomes in healthcare. There are numerous examples of AI being biased. For example, gender discrimination was a problem with facial recognition algorithms developed by Microsoft, IBM, and Face++; these AI systems were better at identifying the gender of white males than those with a darker complexion (5). When an advanced company like Amazon faces such issues, do we think a developing country like Pakistan will be equipped to successfully implement AI in a vast field like medicine? In Pakistan, women are typically responsible for the care of the home and are restricted in their capacity to travel alone and prioritise the health of their male family members (6). So will women be able to contribute their confidential information for AI data sets while they are confined to their houses? This could result in data that is weighted towards men (6). Conducting surveys is a crucial part of data collection (7). We must be cognizant that not all of Pakistan is accessible and that people there have a variety of objections and obstinate attitudes (7). The most recent COVID-19 outbreak was the ideal illustration of their ignorant behaviour (7). This demonstrates how unlikely it is to obtain data from the Pakistani population, which means only limited data can be collected. Since AI data sets heavily rely on Volume, variety and velocity so it is natural for AI not to prevail in Pakistan (7). ---Continue","PeriodicalId":16673,"journal":{"name":"Journal of Pakistan Medical Association","volume":"55 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-10-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"136104921","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":"The breastfeeding effect on the tear film of women: an observational study","authors":"Mana Alafri Alanazi, Gamal Abdel-Rahman El-Hiti, Amjad Ali Alshamrani, Mashaaer Abdulwahhab Baashen, Raied Fagehi, Ali Mohammed Masmali","doi":"10.47391/jpma.8049","DOIUrl":"https://doi.org/10.47391/jpma.8049","url":null,"abstract":"Objective: To assess the tear film parameters in breastfeeding women. Method: The observational study was conducted at the College of Applied Medical Sciences, Riyadh, Saudi Arabia, from December 15, 2021, to February 12, 2022, and comprised healthy women aged 18-40 years who had no ocular diseases. Breastfeeding women were in group A and non-breastfeeding women formed the control group B. Ocular surface disease index, phenol red thread, and tear ferning tests were used in that order to assess the tear film for all the subjects. A gap of 5 minutes was allowed between phenol red thread and tear ferning tests. Data was analysed using SPSS, version 22. Results: Of the 50 subjects, 25(50%) were in group A with mean age 30.4 ± 5.9 years having a mean breastfeeding period of 5.4±5.0 months. The remaining 25(50%) women were in group B with mean age 28.5±2.1 years. Significant differences were found between the groups for ocular surface disease index, phenol red thread, and tear ferning (p<0.05). Significant moderate correlation was found between tear ferning grades and breastfeeding duration (p<0.05). Conclusion: Breastfeeding was found to increase dry eye symptoms in women. Key Words: Dry eye, Tear film, Tear ferning test, Breastfeeding, Risk factor.","PeriodicalId":16673,"journal":{"name":"Journal of Pakistan Medical Association","volume":"49 3","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-10-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"136105073","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":"Effectiveness of treatment of tralokinumab in treatment of atopic dermatitis in adolescents","authors":"None Sameen Tahira, Fiza Mushtaq","doi":"10.47391/jpma.9995","DOIUrl":"https://doi.org/10.47391/jpma.9995","url":null,"abstract":"Respected Madam, Atopic dermatitis (AD) is a prevalent inflammatory skin condition that affects people of all ages and can cause significant distress based on the severity of the condition. Researchers have examined focussed therapies that rely on a better understanding of the underlying pathophysiology of AD. While some therapies that target specific molecules, such as IL-13, IL-31, and OX40 (CD134), have been assessed, there is still much to be done regarding narrow-acting agents which act on a single molecule only.1 Tralokinumab, targeting interleukin-13 in patients with moderate-to-severe atopic dermatitis, was found to be an effective treatment hence beneficial in enhancing health-related quality of life (QoL) in adults.2 Paller et al. recently conducted a clinical trial focussing on adolescents (aged 12-17) with moderate to severe atopic dermatitis, finding that tralokinumab was both effective and safe, showcasing its potential as a treatment option for the said age group.3 Tralokinumab is a fully human monoclonal immunoglobulin G4 antibody that binds with remarkable affinity to the IL-13 cytokine, blocking its interaction with the IL-13 receptor and thus preventing downstream signalling and its ensuing inflammatory effects.4 Atopic dermatitis can be treated with the use of Janus Kinase inhibitors; however, these treatments have shown to result in unexpected adverse effects (AEs) due to the interaction of unintended pathways as well as the target ones; the most common being acne.5 Dupilumab, another therapeutic agent for atopic dermatitis, has been observed to cause conjunctivitis in adolescent patients. The study revealed that Tralokinumab (150mg/300mg) demonstrated to be an effectual treatment for atopic dermatitis, as the primary and secondary endpoints of the trial between Tralokinumab and placebo were statistically significant (p<0.05) while the frequency of conjunctivitis in adolescents was numerically lower than that reported with Dupilumab and the frequency of acne was numerically lower than that reported with Janus kinase inhibitors. As safe and efficient treatment of acute dermatitis for adolescents is already limited, Tralokinumab’s narrow focus on IL-13 molecule provides a more precise approach to treat atopic dermatitis in adolescents with fewer complications. Hence, it is imperative to look into this discovery for more effective treatment of the disease.","PeriodicalId":16673,"journal":{"name":"Journal of Pakistan Medical Association","volume":"3 2","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-10-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"136105214","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":"Raman Spectroscopy: Can it change the future of Brain Tumour Surgery?","authors":"None Qurat-Ul-Ain Virani, None Hafiza Fatima Aziz, None Shahzad Shamim","doi":"10.47391/jpma.23-96","DOIUrl":"https://doi.org/10.47391/jpma.23-96","url":null,"abstract":"Raman Spectroscopy (RS) is one of several techniques being used to identify tumour tissue during brain surgery. It is emerging as a novel investigative and diagnostic tool. The application of RS in cancer treatment has displayed promising results. This review centers around its clinical implication in brain tumours. Keywords: Raman spectroscopy, brain tumour, neurosurgery","PeriodicalId":16673,"journal":{"name":"Journal of Pakistan Medical Association","volume":"7 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-10-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"136105215","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":"Flexible bronchoscopy combined with videolaryngoscope for tracheal intubation in a child with Hunter syndrome: a case report","authors":"Faisal Shamim, Amber Gulamani, Abdullah Nisar, Saima Rashid, Humayun kaleem Siddiqui","doi":"10.47391/jpma.8635","DOIUrl":"https://doi.org/10.47391/jpma.8635","url":null,"abstract":"Hunter syndrome (mucopolysaccharidosis type II) has the highest reported prevalence of difficult tracheal intubation among the seven known types of mucopolysaccharidoses. Despite improved difficult airway guidelines and equipment, conventional approaches may fail in some cases. A 10-year-old child with Hunter syndrome, was scheduled for multiple dental extractions. On the first visit, failed intubation was declared as per Difficult Airway Society guidelines in the surgical day-care suite of our institute and the procedure was postponed. The case was then planned to be handled in the main operating room with additional preparation and input from the paediatric otolaryngologist for possible tracheostomy, paediatric intensive care for postoperative need for ventilation, and difficult airway resource faculty for an unconventional approach—videolaryngoscope combined with fibreoptic bronchoscope—which resulted in safe administration of anaesthesia. This case illustrates the importance of meticulous planning in the management of previously failed airway.","PeriodicalId":16673,"journal":{"name":"Journal of Pakistan Medical Association","volume":"32 2","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-10-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"136105378","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":"Rising Antimicrobial Resistance in Pakistan, a call for an urgent action","authors":"Faisal Rasheed, Sameer Almas","doi":"10.47391/jpma.10013","DOIUrl":"https://doi.org/10.47391/jpma.10013","url":null,"abstract":"Madam, Antibiotic resistance is a growing global concern. Pakistan is a developing nation in South Asia with a high rate of antibiotic resistance, posing a serious concern on a global and regional scale1 In Pakistan in recent years, both extensively drug-resistant (XDR) and multi-drug-resistant. (MDR) microorganisms have been found2.From January 2017 to June 2021, a total of 14,360. XDR-TF cases were reported in Karachi, according to the National Institute of Health (NIH) Islamabad's Weekly Field Epidemiological Report2.Only three antimicrobials: azithromycin, carbapenems, and tigecycline(parenteral) are effective against the XDR strains3. However, after Covid-19, the misuse of Azithromycin has increased manifold, which is worrisome. Pakistani public’s lack of awareness about the harms of antibiotic self-prescription and the widespread presence of quacks in the society has posed a great threat to rational use of antimicrobials4. According to a cross-sectional survey of pharmacy staff’s opinion ,approximately 81.5% of participants declared that dispensing non-prescribed antibiotics is a common practice in community pharmacies, and 51.1% considered themselves to be authorized to dispense these drugs5. The chicken industry of Pakistan is excessively using important antimicrobials in their bird feed6. According to a surveillance survey done in 2019 in Pakistan; among the antimicrobials used for therapeutic or prophylactic purposes in animals; colistin, tylosin, enrofloxacin, and doxycycline were the most frequently used6.This calls for an urgent action in Pakistan to prevent a public health crisis. It is a dire need of the hour to implement the National Drug Policy (NDP) of Pakistan. There should be a national action plan on how to curb this menace of the misuse of therapeutically important antimicrobials in Pakistan. Special units should be devised by Drug regulatory Authority of Pakistan (DRAP) and The Ministry of Health (MoH) to rein back those chemist stores involved in selling of prescription only antimicrobials without the advice of a medical doctor. These teams should catch quacks working in all provinces of Pakistan. Quackery should be made illegal. The sale of large flocks of antimicrobials to animal keepers and broiler industry people should be immediately stopped and the involved people should be fined and their licenses cancelled. Talks and sessions should be held in schools, colleges and public places about the correct use of antibiotics. A medical doctor’s stamp with a registration number should be mentioned on each prescription of an antimicrobial. ---Continue","PeriodicalId":16673,"journal":{"name":"Journal of Pakistan Medical Association","volume":"7 5","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-10-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"136105381","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":"Medical Gastronomy and Glucofriendly Gastronomy: Tools for Chronic Disease and Diabetes Care","authors":"None Sanjay Kalra, None Atul Dhingra, None Nitin Kapoor","doi":"10.47391/jpma.23-95","DOIUrl":"https://doi.org/10.47391/jpma.23-95","url":null,"abstract":"In this communication, we introduce and describe the concepts of medical gastronomy, glucofriendly gastronomy, and gastronomic phenotypes. We discuss the clinical relevance of these frameworks in chronic disease management, including obesity and diabetes care. We propose the use of the phrase ‘medical gastronomy’ to describe the practice of choosing, cooking and consuming food, which is not only appealing or tasty, but nutritious and healthy as well. ‘Glucofriendly gastronomy’ conceptualizes the art and science of choosing, cooking and consuming food, which is not only safe for persons living with diabetes, but appealing and tasty, too. The term ‘gastronomic phenotype’ is the sum of all attributes related to the practice or art of choosing, cooking and consuming food. This includes the individual’s likes (dislikes), preferences and choices related to meal frequency, meal composition, meal quantity and meal sequencing. Keywords: Culinary medicine, diabetes, diet, nutrition, obesity, person centred care","PeriodicalId":16673,"journal":{"name":"Journal of Pakistan Medical Association","volume":"3 5","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-10-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"136105382","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":"Effect of Graston technique versus ischaemic compression in students who developed neck pain during distance learning in Covid-19: a pilot study preceding the randomised clinical trial","authors":"Mushyyaida Iqbal, Hafsa Noreen, Tuba Ureeda Tasawar, Khansa Tajammul","doi":"10.47391/jpma.8178","DOIUrl":"https://doi.org/10.47391/jpma.8178","url":null,"abstract":"Many people experienced neck pain during COVID-19 quarantine period due to prolonged use of electronic devices for academic activities and work from home. The aim of this study was to determine the effects of Graston Technique versus Ischaemic Compression on pain, range of movement (ROM), and functional performance in students with neck pain, due to distance learning during COVID-19 pandemic. A pilot study (randomised clinical trial) was performed. Fifty-four subjects were included in the study on the basis of sample selection criteria and were divided into two groups, Group A and Group B. The outcome measures were pain, range of movement (ROM), and disability assessed by Numeric pain rating scale (NPRS), goniometry and Neck disability index (NDI) respectively. Group A received treatment with hot pack and Graston technique, while Group B received a hot pack and Ischaemic compression. Three sessions per week on alternate days for four weeks were given to each patient. Both groups were reassessed after four weeks of treatment. Data was analysed using SPSS 26. There was a statistically significant change within both the groups in NPRS, NDI, and cervical ROM (p< 0.05). Both were effective but the group using Graston Technique showed more improvement.","PeriodicalId":16673,"journal":{"name":"Journal of Pakistan Medical Association","volume":"56 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-10-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"136105879","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":"Hyftor – An emerging therapy for Facial Angiofibromas: A letter to the editor","authors":"Muhammad Hassan Zulfi, None Zainab Abbas, None Elahi Sana Jilani","doi":"10.47391/jpma.9781","DOIUrl":"https://doi.org/10.47391/jpma.9781","url":null,"abstract":"Tuberous Sclerosis Complex (TSC) is a rare autosomal dominant genetic disease caused by a deactivating mutation in one of the two tumour suppressor genes, TSC1 or TSC2.1,2 These mutations can lead to hyperactivation of the mammalian Target of Rapamycin (mTOR) signalling pathway, which in turn mediates cellular growth and proliferation. As the mTOR pathway is usually responsible for stimulating the synthesis of protein, cells' survival, and cell cycle progression.1,3 This causes the formation of multiple benign non-invasive tumours, called hamartoma, in different body tissues and organs.1,3 Facial Angiofibroma (FA) is the most prevalent skin manifestation of TSC.4 These are multiple, erythematous, small hamartomatous papules of around 1 to 3 mm in size formed by the excessive production of skin cells coupled with angiogenesis.3,4 The most classical sites of occurrence include the center of the face, alar grooves, cheeks, nose, and chin.3 FA has increased chances of bleeding; it can damage the eyesight and can cause psychological distress due to aesthetic disfiguration.4 Physical removal of FA is associated with pain, hyperpigmentation, scarring, bleeding, and recurrence of the lesions.4 Therefore, recently, on March 22, 2022, the FDA approved the topical use of Hyftor (Sirolimus, also known as Rapamycin mTOR inhibitor) for the treatment of FA.5 Hyftor has earned its position as the most appropriate treatment for FA in TSC due to its anti-tumour, anti-angiogenic and immunosuppressive properties, which highly favours this drug’s effectiveness and safety profile.1 It binds to the FK-binding protein-12 (FKBP-12), which in turn impedes the hyperactivity of mTOR, eventually causing the down-regulation of cellular growth. It also reduces levels of vascular endothelial growth factor levels depriving the tumour cells of their blood supply. Furthermore, it also halts the progression and proliferation of the cell cycle by blocking the response of T and B cell activation by cytokines.3 Long-term serious systematic side effects of mTOR inhibitors were overcome by the topical formulation of sirolimus.3,4 All concentrations of this drug are very well-tolerated with minor adverse effects, which include dry skin, application site irritation, burning sensation, and pruritis.3 Hyftor has proven to be a practical therapeutic innovation in the medical field due to its high specificity for mTOR and meager adverse effects profile. However, this drug requires additional large population-based studies and trials to substantiate further its efficacy and safety in patients with FA.","PeriodicalId":16673,"journal":{"name":"Journal of Pakistan Medical Association","volume":"18 1","pages":"0"},"PeriodicalIF":0.0,"publicationDate":"2023-10-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"136104925","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}