Journal of pediatric surgery最新文献

{"title":"National Trends of Common Gynecologic Procedures Among Pediatric Hospitals: A National Surgical Quality Improvement Program Pediatric (NSQIP-P) Database Analysis","authors":"Tambu Kudze ,&nbsp;Elizabeth R. Boskey ,&nbsp;Ava Scatoni ,&nbsp;Frances W. Grimstad ,&nbsp;Jessica Y. Shim","doi":"10.1016/j.jpedsurg.2024.162068","DOIUrl":"10.1016/j.jpedsurg.2024.162068","url":null,"abstract":"<div><h3>Background</h3><div>Gynecologic surgeries have in general been performed in pediatric hospitals by both gynecologists and other surgical specialists. This study assessed current practices and outcomes using a national database.</div></div><div><h3>Methods</h3><div>Procedures performed by gynecologists in the National Surgical Quality Improvement Program Pediatric database (NSQIP-P) from 2012 to 2021 were reviewed and used to identify a set of common gynecologic procedures for which outcomes could be compared across specialties. Categorical data were analyzed using Pearson’s Chi² or a one-sided Fisher’s exact test where cell sizes were smaller than 5, and continuous data were analyzed using linear regression. This study was exempt from IRB review.</div></div><div><h3>Results</h3><div>There was a total of 3870 cases performed by gynecologists, of which 2872 were categorized as common gynecology procedures. The median age of patients operated on by gynecologists was 15.0 years (S.D. 2.9) compared to 13.2 years (S.D. 5.0) for other specialties. The proportion of common gynecologic cases performed by gynecologists increased from 19% in 2012 to 30% in 2021 (<em>p</em> &lt; 0.001). Gynecologists were more likely to use only a minimally invasive approach (<em>p</em> &lt; 0.001) and operate with elective case status (<em>p</em> &lt; 0.001) compared to other surgeons performing these procedures. There was no significant difference in the risk of postoperative complications for common gynecology procedures performed by gynecologists vs. other specialties. Gynecologists were less likely to perform an oophorectomy than pediatric surgeons as part of surgeries involving the pelvic adnexa (5% vs 10%, p ≤ 0.002).</div></div><div><h3>Conclusion</h3><div>Pediatric and adolescent gynecologic surgeries have been increasingly performed by gynecologists over the past decade. These cases have substantiated national databases, which can help in guiding quality improvement efforts.</div></div><div><h3>Level of Evidence</h3><div>III.</div></div>","PeriodicalId":16733,"journal":{"name":"Journal of pediatric surgery","volume":"60 2","pages":"Article 162068"},"PeriodicalIF":2.4,"publicationDate":"2024-11-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142720751","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Announcements of Future Meetings","authors":"","doi":"10.1016/S0022-3468(24)00990-4","DOIUrl":"10.1016/S0022-3468(24)00990-4","url":null,"abstract":"","PeriodicalId":16733,"journal":{"name":"Journal of pediatric surgery","volume":"59 12","pages":"Article 162035"},"PeriodicalIF":2.4,"publicationDate":"2024-11-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142651163","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Diagnosing Hirschsprung Disease in Children Older than Six Months of Age: Complications After Rectal Biopsy, Insight in Final Diagnoses and Factors Associated With Hirschsprung Disease","authors":"H. Labib ,&nbsp;I.J. Shirinskiy ,&nbsp;J.J.T.H. Roelofs ,&nbsp;J.P. van der Voorn ,&nbsp;J. van Schuppen ,&nbsp;J. Oosterlaan ,&nbsp;L.W.E. van Heurn ,&nbsp;M.A. Benninga ,&nbsp;J.P.M. Derikx","doi":"10.1016/j.jpedsurg.2024.162066","DOIUrl":"10.1016/j.jpedsurg.2024.162066","url":null,"abstract":"<div><h3>Introduction</h3><div>It is challenging to distinguish between patients with Hirschsprung disease (HD) and patients with other causes of defecation problems based on clinical presentation in patients older than six months. Pathological examination of the rectal biopsy is the gold standard for the diagnosis of HD. The aim of this study was to gain insight into 1) the prevalence and severity of complications following rectal biopsy, 2) the final diagnoses of patients referred for biopsy, and 3) clinical factors associated with HD in patients older than six months.</div></div><div><h3>Methods</h3><div>Children suspected of HD above the age of six months referred for biopsies were analyzed retrospectively. Severity of complications of rectal suction biopsy (RSB) and full thickness biopsy (FTB) were assessed using Clavien-Madadi (CM) grading. Factors associated with HD were tested using multivariate logistic regression analysis.</div></div><div><h3>Results</h3><div>From 2000 to 2022, 234 children older than six months of age underwent biopsies because of defecation problems (median age of 47.2 months (IQR = 17.2–87.2)). Of these, 130 out of 234 children underwent RSB and 112 out of 234 children underwent FTB. One patient (0.4 %) developed a complication following RSB (CM1-A): fever without evident cause. Two patients (0.9 %) had ongoing rectal bleeding following FTB. One patient did not require an intervention (CM1-A), the other received rectal spongostan to stop the bleeding and erythrocyte transfusion (CM2). The most frequent final diagnoses were functional constipation (n = 179, 76.5 %), HD (n = 25, 10.6 %) and food intolerance (n = 5, 2.1 %). Associated factors for HD were distended abdomen (OR 5.41, CI 2.05–14.31), vomiting (OR 4.14, CI 1.64–11.85) and no abdominal pain (OR 0.14, CI 0.03–0.65) (model R² = 0.278).</div></div><div><h3>Conclusion</h3><div>In children older than six months suspected of HD, presenting with distended abdomen, vomiting and no abdominal pain, we advise obtaining a rectal biopsy in case other causes of constipation are ruled out, because a rectal biopsy is a safe procedure with only minor complications. The most common diagnosis in patients older than six months of age referred for rectal biopsy was functional constipation.</div></div><div><h3>Level of Evidence</h3><div>Level III.</div></div>","PeriodicalId":16733,"journal":{"name":"Journal of pediatric surgery","volume":"60 3","pages":"Article 162066"},"PeriodicalIF":2.4,"publicationDate":"2024-11-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142748438","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"A Novel Endoscopic Approach to Fibroadipose Vascular Anomaly","authors":"Chong Xie,&nbsp;Huaijie Wang,&nbsp;Zhengtuan Guo,&nbsp;Peihua Wang,&nbsp;Weilong Lin,&nbsp;Weijia Yang","doi":"10.1016/j.jpedsurg.2024.162064","DOIUrl":"10.1016/j.jpedsurg.2024.162064","url":null,"abstract":"<div><h3>Background</h3><div>Open surgery is the standard treatment for fibroadipose vascular anomalies (FAVA). This study evaluated an endoscopic approach for FAVA, assessing its safety and feasibility.</div></div><div><h3>Methods</h3><div>Data from October 1, 2019, and May 1, 2024, were analyzed from the Vascular Anomalies Center database at our institution. Patients with FAVA Stage I (pain stage) or II (contracture stage) were included and divided into the endoscopic surgery group (ESG) and open surgery group (OSG).</div></div><div><h3>Results</h3><div>In total, 101 patients underwent 110 procedures. In ESG, 42 patients (16 males and 26 females; 31 with Stage I and 11 with Stage II) underwent radical excision (with tendon lengthening in 2 patients). Ten patients underwent an open surgery. In OSG, 63 patients (18 males and 45 females; 30 with Stage I and 33 with Stage II) underwent radical excision (with tendon lengthening in 12 patients). The OSG had significantly shorter operative time than the ESG (<em>p</em> = 0.009). Furthermore, The OSG had longer hospitalization time (<em>p</em> = 0.022) than the ESG. The blood loss in the OSG was greater than that in the ESG, but without statistical difference (<em>p</em> = 0.069). During follow-up, the incidence of wound complications (<em>p</em> = 0.121) and residual symptoms (<em>p</em> = 0.179) were slightly higher in the OSG.</div></div><div><h3>Conclusions</h3><div>Endoscopic surgery is a safe and effective treatment for FAVA, promoting faster habilitation and improved patient satisfaction. This method may also serve as a reference for the excision of other benign muscle and soft tissue masses.</div></div>","PeriodicalId":16733,"journal":{"name":"Journal of pediatric surgery","volume":"60 2","pages":"Article 162064"},"PeriodicalIF":2.4,"publicationDate":"2024-11-13","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142743893","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Precise Thoracoscopic Pneumonectomy Using Fluorescence Imaging After Aerosolized Indocyanine Green Inhalation: A Novel Strategy for Treating Congenital Pulmonary Airway Malformation","authors":"Tianqi Zhu ,&nbsp;Yanan Li ,&nbsp;Jiaxin Zhang ,&nbsp;Xiaofeng Xiong ,&nbsp;Ye Yin ,&nbsp;Didi Zhuansun ,&nbsp;Ying He ,&nbsp;Jiexiong Feng","doi":"10.1016/j.jpedsurg.2024.162063","DOIUrl":"10.1016/j.jpedsurg.2024.162063","url":null,"abstract":"<div><h3>Background</h3><div>Lobectomy resection is the standard treatment for patients with congenital pulmonary airway malformation (CPAM). However, accurate localization of CPAM lesions and avoiding excessive resection of normal lung tissue are one of the critical issues that can impact postoperative pulmonary function. Indocyanine green (ICG) can be adopted in lung preservation surgery, to minimize damage to normal lung tissue during thoracoscopic pneumonectomy.</div></div><div><h3>Objective</h3><div>To demonstrate the potential benefits of aerosol inhalation of ICG followed by thoracoscopic precision pneumonectomy for the treatment of CPAM.</div></div><div><h3>Methods</h3><div>From January 2023 to March 2024, we prospectively collected clinical data from 34 pediatric patients diagnosed with CPAM and treated with thoracoscopic surgery. Patients inhaled ICG aerosol solution (0.5 mg/kg) approximately 30–60 min before the operation. During surgery, fluorescence thoracoscopy was used to clearly locate the lesion boundaries and achieve precise resection.</div></div><div><h3>Results</h3><div>All patients successfully underwent thoracoscopic precise resection of CPAM lesions without conversion to open surgery. The mean operation time was 100.3 ± 24.6 min, and the mean intraoperative blood loss was 30.5 ± 25.6 mL. The mean total length of hospital stay (tLOS) was 6.6 ± 3.2 days. No adverse reactions to ICG were observed. Postoperative complications included one case of pneumothorax (5.9 %) and three cases of subcutaneous emphysema (17.6 %), all of which resolved without special intervention. Follow-up CT scans and pulmonary function tests conducted 6 months post-surgery demonstrated the absence of residual or recurrent lesions and notable enhancement in pulmonary function.</div></div><div><h3>Conclusion</h3><div>Preliminary results indicated that the treatment of CPAM with aerosolized ICG followed by thoracoscopic precise pneumonectomy is safe and feasible.</div></div>","PeriodicalId":16733,"journal":{"name":"Journal of pediatric surgery","volume":"60 1","pages":"Article 162063"},"PeriodicalIF":2.4,"publicationDate":"2024-11-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142682070","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Sustained Positive Practice Change After Targeted Education in the Management of Ovarian Torsion","authors":"Matthew M. Byrne ,&nbsp;Nicole A. Wilson ,&nbsp;Elizabeth Levatino ,&nbsp;David M. Powell ,&nbsp;Marjorie J. Arca","doi":"10.1016/j.jpedsurg.2024.162062","DOIUrl":"10.1016/j.jpedsurg.2024.162062","url":null,"abstract":"<div><h3>Background</h3><div>Failure to perform ovarian conservation surgery (OCS) for patients who present with adnexal torsion was recognized as a practice gap by the American Pediatric Surgical Association (APSA) in 2017. A targeted educational campaign was conducted to promote detorsion and ovarian conservation surgery as the standard of care for ovarian torsion. We evaluated the practice change that has occurred for pediatric and adolescent patients with ovarian torsion from 2012 to 2022.</div></div><div><h3>Methods</h3><div>Using the American College of Surgeons (ACS) National Safety and Quality Improvement Project-Pediatrics (NSQIP-P) Participant Use Files from 2012 to 2022, we compared surgical treatment types during the time periods that encompassed the targeted educational period.</div></div><div><h3>Results</h3><div>A total of 2249 patients (70 %) underwent OCS surgery and 980 (30 %) patients underwent salpingectomy and/or oophorectomy (SO). Patients who were treated with OCS were older (12.4 [SD 3.6] vs. 11.4 [SD 4.8] years, p &lt; 0.01). Patients were more likely to be treated with SO if they were Black (11 vs. 15 %, p &lt; 0.01) or obese (28 vs. 33 %, p &lt; 0.01). From 2012 to 2017, 42 % of patients underwent OCS, compared to 76 % in 2018–2022 (p &lt; 0.01). A mixed effect analysis comparing year-over-year rates of SO across pediatric surgeons and gynecologic surgeons showed a statistically significant difference in rates across specialty and time (p &lt; 0.01), with pediatric surgeons performing fewer SOs.</div></div><div><h3>Conclusion</h3><div>In the treatment of ovarian torsion in pediatric and adolescent patients, we demonstrated successful adoption and sustained implementation of practice improvement coincident with the introduction of a comprehensive educational initiative.</div></div><div><h3>Type of Study</h3><div>Retrospective cohort.</div></div><div><h3>Level of Evidence</h3><div>IV.</div></div>","PeriodicalId":16733,"journal":{"name":"Journal of pediatric surgery","volume":"60 1","pages":"Article 162062"},"PeriodicalIF":2.4,"publicationDate":"2024-11-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142682074","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"We Must Say Good-bye to Dr. Mikko Pakarinen, but Please Say Hello to Drs. Augusto Zani and Robert Baird as Our Newest Executive Editors.","authors":"George W Holcomb","doi":"10.1016/j.jpedsurg.2024.162061","DOIUrl":"https://doi.org/10.1016/j.jpedsurg.2024.162061","url":null,"abstract":"","PeriodicalId":16733,"journal":{"name":"Journal of pediatric surgery","volume":" ","pages":"162061"},"PeriodicalIF":2.4,"publicationDate":"2024-11-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142676127","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Children With CDH are at High Risk for Pectus Excavatum Deformity and Progressive Thoracic Asymmetry: Chest Wall Deformities in CDH Survivors.","authors":"Carolin Riemer, Luisa Gräfin Lambsdorff, Nina Hutflesz, Christoph Mohr, Meike Weis, Christel Weiss, Richard Martel, Michaela Klinke Petrowsky, Katrin Zahn, Thomas Schaible, Michael Boettcher, Julia Elrod","doi":"10.1016/j.jpedsurg.2024.162057","DOIUrl":"https://doi.org/10.1016/j.jpedsurg.2024.162057","url":null,"abstract":"<p><strong>Background: </strong>Congenital diaphragmatic hernia (CDH) survivors exhibit an increased risk for developing musculoskeletal anomalies. This prospective long-term cohort study investigates the characteristics, predictors and dynamic changes of different chest wall deformities in a large cohort of CDH patients.</p><p><strong>Methods: </strong>All children diagnosed with CDH and treated at the University Hospital Mannheim from 2010 to 2023 were included. Thoracic morphology was evaluated based on 740 CT or MRI scans and statistical analysis was performed using the Mann-Whitney-U-Test, Fisher's Exact Test and Spearman's correlation. P-values<0.05 were considered statistically significant.</p><p><strong>Results: </strong>Out of 1216 children with CDH, 548 received cross-sectional imaging examinations of the chest within the follow-up program. Mean Haller Index was 2.62 ± 0.55 and pectus excavatum deformity was present in 34.09 % of CDH patients. Thoracic asymmetry in favor of the right hemithorax was present in 45.90 % and showed a pronounced age-related progression. The severity of chest wall deformities showed a significant correlation with prenatal diagnosis, liver herniation, lower lung to head ratio and fetal relative lung volume, use of ECMO and inhaled nitric oxide, diaphragmatic patch closure and laparotomy.</p><p><strong>Conclusion: </strong>Children with CDH show an increased incidence of chest wall deformities, including pectus deformity and asymmetry with the potential for significant age-related progression. Measurement of thoracic morphology using standardized parameters based on MRI or CT scans should be implemented as an essential component of standardized follow-up programs. Rigorous randomized, controlled intervention trials are required to evaluate whether certain therapies can alter the trajectory of these chest wall deformities.</p>","PeriodicalId":16733,"journal":{"name":"Journal of pediatric surgery","volume":"60 1","pages":"162057"},"PeriodicalIF":2.4,"publicationDate":"2024-11-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142769922","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Intercostal Nerve Cryoablation in Minimally Invasive Repair of Pectus Excavatum: National Trends, Outcomes, and Predictors of Utilization","authors":"Alyssa Green,&nbsp;Gabriel Ramos-Gonzalez,&nbsp;JoAnn DeRosa,&nbsp;Nicole M. Chandler,&nbsp;Christopher W. Snyder","doi":"10.1016/j.jpedsurg.2024.162060","DOIUrl":"10.1016/j.jpedsurg.2024.162060","url":null,"abstract":"<div><h3>Purpose</h3><div>Intercostal nerve cryoablation during minimally invasive repair of pectus excavatum (MIRPE) is an effective pain control technique. Some insurers may not reimburse for cryoablation in this context, contending that it’s an experimental procedure. This study aimed to describe national trends in cryoablation use and evaluate outcomes and predictors of its use.</div></div><div><h3>Methods</h3><div>The Pediatric Health Information System database was queried for pectus excavatum patients aged 9–21 who underwent MIRPE between 2016 and 2023. Concurrent cryoablation use was identified using billing/supply codes. Temporal trends in cryoablation utilization were described and quantified using linear regression. Demographics, resource utilization, and outcomes were compared for patients based on cryoablation utilization using chi-square and Kruskal–Wallis tests. Predictors of cryoablation use were evaluated with logistic regression.</div></div><div><h3>Results</h3><div>This analysis included 2068 patients (mean age 15 ± 1.8 years; 86 % male). Cryoablation utilization increased from 33 % to 61 % from 2016 to 2023, with a strong positive trend (R² = 0.73). Cryoablation patients had fewer surgical complications (8 % vs 12 %, p = 0.004), shorter LOS (2.0 ± 1.3 vs. 2.8 ± 1.6 days, p &lt; 0.001), fewer total mean opiate days billed (1.4 ± 1.1 vs. 1.6 ± 1.4 days, p &lt; 0.0001) and higher total costs ($24,045 ± $9696 vs. $20,751 ± $9,237, p &lt; 0.001). High-volume centers (odds ratio (OR) 1.9, 95 % confidence interval (CI) 1.2–3.0) and commercial HMO insurance (OR 2.7, 95 % CI 1.9–3.8) were predictors of cryoablation use.</div></div><div><h3>Conclusion</h3><div>Cryoablation during MIRPE has increased nationally since 2016; now being performed in nearly two-thirds of all cases. Cryoablation should be considered a standard adjunct to MIRPE rather than an experimental technique.</div></div><div><h3>Level of evidence</h3><div>2.</div></div>","PeriodicalId":16733,"journal":{"name":"Journal of pediatric surgery","volume":"60 3","pages":"Article 162060"},"PeriodicalIF":2.4,"publicationDate":"2024-11-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142651765","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Prevent Injury by Providing Evidence.","authors":"Minna M Wieck","doi":"10.1016/j.jpedsurg.2024.162059","DOIUrl":"10.1016/j.jpedsurg.2024.162059","url":null,"abstract":"","PeriodicalId":16733,"journal":{"name":"Journal of pediatric surgery","volume":" ","pages":"162059"},"PeriodicalIF":2.4,"publicationDate":"2024-11-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142622852","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}