Journal of Surgical Oncology最新文献

{"title":"Open Thoracotomy Approach for Hyperthermic Intrathoracic Chemotherapy: How I Do It.","authors":"Rachid Eduardo Noleto da Nobrega Oliveira, Juliana Giorgi, Laureano Molins López-Rodó, Vinicius de Lima Vazquez","doi":"10.1002/jso.70051","DOIUrl":"https://doi.org/10.1002/jso.70051","url":null,"abstract":"<p><p>Open thoracotomy remains a fundamental approach for hyperthermic intrathoracic chemotherapy (HITHOC), particularly in patients with extensive pleural disease or complex anatomical challenges. This article explores the step-by-step technique for performing HITHOC via open thoracotomy, highlighting patient selection criteria, procedural nuances, and postoperative management. While associated with greater invasiveness and prolonged recovery, open thoracotomy provides unmatched access and control, ensuring optimal cytoreduction and effective chemotherapy distribution.</p>","PeriodicalId":17111,"journal":{"name":"Journal of Surgical Oncology","volume":" ","pages":""},"PeriodicalIF":2.0,"publicationDate":"2025-07-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144675071","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"How I Do It: A Two-Stage Nephrectomy and Caval Thrombectomy for Renal Cell Carcinoma With Level IV Thrombus Complicated by Budd-Chiari Syndrome.","authors":"Georgi Atanasov, Samith M Alwis, Dixon Woon, Joseph Ischia, Sara Qi, Graham Starkey, Siven Seevanayagam, Marcos V Perini","doi":"10.1002/jso.70049","DOIUrl":"https://doi.org/10.1002/jso.70049","url":null,"abstract":"","PeriodicalId":17111,"journal":{"name":"Journal of Surgical Oncology","volume":" ","pages":""},"PeriodicalIF":2.0,"publicationDate":"2025-07-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144682769","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Preventing Secondary Lymphedema: A Systematic Review and Meta-Analysis on the Efficacy of Immediate Lymphovenous Anastomosis.","authors":"Chandler Hinson, Matthew Sink, Dominic Henn, Douglas Sammer, Andrew Y Zhang, Jessica I Billig, Edward Chang, Andrei Odobescu","doi":"10.1002/jso.70046","DOIUrl":"https://doi.org/10.1002/jso.70046","url":null,"abstract":"<p><strong>Background: </strong>Secondary lymphedema is a debilitating condition following oncologic lymphadenectomy. Despite advancements in rehabilitation and microsurgical interventions, there is no cure for lymphedema. Performing a lymphovenous anastomosis (LVA) at the time of a regional node dissection has been purported to reduce the risks of secondary lymphedema; however, there are conflicting studies and no clear consensus about the routine use of LVA for preventing lymphedema after lymphadenectomy. The present study aims to perform a comprehensive review and meta-analysis on immediate LVA for the prevention of secondary lymphedema.</p><p><strong>Methods: </strong>A systematic review and literature search were performed using PubMed, Embase, Web of Science, and Cochrane databases. Studies evaluating primary or immediate LVA in oncologic surgery were included. Studies with a control group were included in the meta-analysis.</p><p><strong>Results: </strong>Overall, 39 studies, including 3697 patients (1,722 LVA; 1975 control), met inclusion criteria. Seventeen of the studies were included in the meta-analysis. Pooled analysis across all studies revealed a secondary lymphedema incidence of 7.1% in the LVA cohort versus 35.0% in controls. Meta-analysis demonstrated a significant reduction in lymphedema risk with immediate LVA (RR: 0.31). Subgroup analysis confirmed strong protective effects in breast cancer patients (RR: 0.28) and a significant but lesser benefit in dermatologic malignancies (RR: 0.35).</p><p><strong>Conclusion: </strong>Based on the current literature, immediate LVA at time of lymphadenectomy significantly reduces the risk of secondary lymphedema in patients undergoing oncologic treatment. Given these findings, patients undergoing multimodal oncologic treatment including radiation and surgical lymphadenectomy should be considered candidates for immediate LVA.</p>","PeriodicalId":17111,"journal":{"name":"Journal of Surgical Oncology","volume":" ","pages":""},"PeriodicalIF":2.0,"publicationDate":"2025-07-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144649763","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Barbed Suture for Pancreaticojejunal Anastomosis: An Ally Against Pancreatic Fistula.","authors":"Rosita Sortino, Sophie M Eschlboeck, Christoph Kuemmerli, Martin Bolli","doi":"10.1002/jso.70048","DOIUrl":"https://doi.org/10.1002/jso.70048","url":null,"abstract":"<p><p>Pancreaticoduodenectomy (PD) is the standard treatment for resectable pancreatic head disease. The pancreatic anastomosis constitutes the mainstay of this procedure and is one of the drivers of its morbidity. Despite the development of a variety of techniques for pancreaticojejunostomy or pancreaticogastrostomy, high rates of postoperative pancreatic fistula (POPF), hampering early and fast patient recovery, are still reported. Here, based on the analysis of a cohort of 16 patients operated over 2 years, we describe a pancreaticojejunal anastomosis technique taking advantage of unidirectional barbed sutures. Although six of these patients were classified as \"high risk,\" according to updated International Study Group of Pancreatic Fistula (ISGPS) recommendations, we only observed one grade B POPF requiring antibiotic treatment, prolonged fasting and parenteral nutrition during the postoperative course. While larger studies are necessary to clarify this issue, our data suggests that barbed sutures could help prevent POPF development following PD.</p>","PeriodicalId":17111,"journal":{"name":"Journal of Surgical Oncology","volume":" ","pages":""},"PeriodicalIF":2.0,"publicationDate":"2025-07-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144649762","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Travel Distance and Insurance Status: Association With Treatment Access and Survival Among Patients With Hepatocellular Carcinoma.","authors":"Miho Akabane, Abdullah Altaf, Jun Kawashima, Yuki Imaoka, Timothy M Pawlik","doi":"10.1002/jso.70047","DOIUrl":"https://doi.org/10.1002/jso.70047","url":null,"abstract":"<p><strong>Introduction: </strong>Travel distance to healthcare facilities can affect hepatocellular carcinoma (HCC) treatment access, but its association with treatment rates, delays, and overall survival (OS) remains unclear. We evaluated the association of travel distance and insurance status with treatment receipt, delays, and OS.</p><p><strong>Methods: </strong>Patients diagnosed with HCC (2000-2019) were identified from National Cancer Database. Travel distance was categorized as Near (0-10 km), Medium (10-30 km), and Far (> 30 km). Multivariable logistic regression and Cox proportional hazards models were performed.</p><p><strong>Results: </strong>Among 191,742 patients, 47.9% had Medicare, 29.7% Private insurance, 14.9% Medicaid, and 5.5% were uninsured. Treatment rates increased with distance (Near: 40.9%, Medium: 43.7%, Far: 48.4%; p < 0.001), as did treatment at academic centers (Near: 43.3%, Medium: 52.0%, Far: 67.0%; p < 0.001). Private insurance was more common among individuals traveling farther (p < 0.001). Medicaid and uninsured patients were less likely to receive surgical/local treatment than Private or Medicare patients (p < 0.001). Distance (Medium vs. Near: OR 1.155; Far vs. Near: OR 1.440) and insurance (Private vs. Uninsured: OR 2.457; Medicare: OR 2.262; Medicaid: OR1.549) were associated with treatment receipt. Longer distances were associated with higher odds of treatment delays (Medium vs. Near: OR 1.116; Far vs. Near: OR 1.267). Five year OS was lowest in Near (18.0%) and highest in Far (27.6%) distance cohorts. On multivariable analysis, facility type (Community: HR 1.819; Comprehensive: HR 1.409; Integrated: HR 1.151 vs. Academic) and insurance (Private: HR 0.657; Medicare: HR 0.683; Medicaid: HR 0.809 vs. Uninsured) remained associated with OS.</p><p><strong>Conclusions: </strong>Travel distance and insurance status influenced HCC treatment access. Traveling farther resulted in treatment at academic centers and better OS but increased delays. Private insurance improved access, yet disparities persist.</p>","PeriodicalId":17111,"journal":{"name":"Journal of Surgical Oncology","volume":" ","pages":""},"PeriodicalIF":2.0,"publicationDate":"2025-07-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144649764","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Medicaid Reimbursement for Orthopedic Oncology Procedures Is Over 22% Lower Than Medicare and Highly Inconsistent Among States.","authors":"Adam P Henderson, M Lane Moore, Georgia R Sullivan, Katelyn T Koschmeder, Collin L Braithwaite, Eugenia A Lin, Krista A Goulding, Meagan E Tibbo","doi":"10.1002/jso.70042","DOIUrl":"https://doi.org/10.1002/jso.70042","url":null,"abstract":"<p><strong>Background and objectives: </strong>Medicaid reimbursement to physicians has been demonstrated to be lower than reimbursement from Medicare and private insurance. Studies on Medicaid reimbursement for orthopedic oncology procedures, however, are limited. This study compares Medicaid reimbursement rates to Medicare for 38 common musculoskeletal oncology procedures and assesses variability among states.</p><p><strong>Methods: </strong>We collected 38 current procedural terminology (CPT) codes for commonly performed orthopedic oncology procedures. Medicare rates were obtained from the 2023 Centers for Medicare and Medicaid physician (CMS) fee schedule. Medicaid rates were collected from electronic state website fee schedules. Reimbursement for the two insurance types were compared with state and national averages. Dollar differences were adjusted for work relative value units (RVU) to ascertain procedural variability. The Medicare Wage Index, representing differences in wages across states, was used to adjust medicaid rates to compare more accurately to medicare. Coefficient of variation values, calculated by dividing the standard deviation by the mean, were calculated to assess variation among procedures.</p><p><strong>Results: </strong>Medicaid reimbursed orthopedic oncologists 22.1% less than medicare on average, increasing to 33.0% when adjusting for wage differences. State Medicaid reimbursement ranged from 37% to 131% of Medicare, with 38 states reimbursing less than Medicare on average. The coefficient of variation for Medicaid procedures ranged from 0.24 to 0.46, indicating wide variability among states and procedures, while for Medicare, the coefficient of variation was low at 0.06 to 0.07.</p><p><strong>Conclusions: </strong>Medicaid reimbursement for common orthopedic oncology procedures is substantially lower and more variable than Medicare, despite the often urgent nature of these surgeries. Disparities in reimbursement may impact access to care for this population, highlighting the need for policy reform.</p>","PeriodicalId":17111,"journal":{"name":"Journal of Surgical Oncology","volume":" ","pages":""},"PeriodicalIF":2.0,"publicationDate":"2025-07-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144637405","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Outcomes of Organ-Preserving Local Excision Compared to Radical Resection in Stage I Early-Onset Rectal Cancer: A Propensity-Score SEER-Based Analysis.","authors":"Spencer Barnes, Sameh Hany Emile, Anjelli Wignakumar, Justin Dourado, Cameron Perrone, Matthew Bilotti, Steven D Wexner","doi":"10.1002/jso.70044","DOIUrl":"https://doi.org/10.1002/jso.70044","url":null,"abstract":"<p><strong>Background: </strong>Organ-preserving approaches to rectal cancer have shown promising results in reducing adverse events and improving quality of life without compromising oncologic outcomes. This study aimed to compare the outcomes of organ-preserving local excision (LE) and radical resection (RR) for patients with stage I early-onset rectal cancer.</p><p><strong>Methods: </strong>In this retrospective cohort study, patients aged 20-50 years with clinical stage I rectal cancer were identified in the Surveillance, Epidemiology, and End Results (SEER) database (2000-2020). Patients were divided according to the type of surgery into two groups: LE and RR. The groups were propensity-score matched for tumor grade, stage, size, and pretreatment CEA levels. Overall survival (OS) and cancer-specific survival (CSS) were the main outcomes. Kaplan-Meier statistics and Cox regression analyses were used to assess survival.</p><p><strong>Results: </strong>From a total of 5846 patients (LE = 1,654; RR = 4192), 545 LE and 1090 RR patients were included after matching. There were no significant differences between LE and RR in the 5-year restricted mean OS (57.6 vs 57.7 months, p = 0.769) or CSS (58.3 vs 58.2 months, p = 0.8). The type of surgical resection was not independently associated with OS (HR: 1.26, 95%CI: 0.77, 2.08, p = 0.357) or CSS (HR: 1.18, 95%CI: 0.62, 2.24, p = 0.611).</p><p><strong>Conclusion: </strong>Our results underscore the need for tailored treatment guidelines for younger patients with stage I rectal cancer, and advocates for less invasive treatments that preserve organ function without altering oncological outcomes in patients with stage I early-onset rectal cancer.</p>","PeriodicalId":17111,"journal":{"name":"Journal of Surgical Oncology","volume":" ","pages":""},"PeriodicalIF":2.0,"publicationDate":"2025-07-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144626639","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Clinical Use of Liquid Biopsy in Metastatic Breast Cancer-An ESSO-EYSAC International Survey.","authors":"Ina Suppan, Dara Lundon, Pankaj Kumar Garg, Carmella Caballero, Ellen Heitzer, Andreas Brandl","doi":"10.1002/jso.70045","DOIUrl":"https://doi.org/10.1002/jso.70045","url":null,"abstract":"<p><strong>Introduction: </strong>Although recommendations for using Liquid Biopsy (LB) approaches to guide therapeutic decisions in metastatic breast cancer (mBC) have been embedded in various guidelines, uptake in clinical practice is slow. Here, we aimed to assess the utilization and key issues for implementation of LB across Europe.</p><p><strong>Materials and methods: </strong>Using the Redcap platform, we developed an online questionnaire including nineteen questions investigating three principal areas: respondent demographics; awareness, knowledge, and access to LB approaches; as well as future perspectives of LB. The survey was distributed to networks of surgical oncologists, via email, social media, and the ESSO-EYSAC website from March 2023 to May 2023.</p><p><strong>Results: </strong>A total of 292 breast cancer experts from 39 different countries completed the survey. Only 58 participants (20%) reported implementation of guidelines regarding LB testing. Overall, 119 participants (40.7%) indicated current use of liquid biopsy. The top three indications for LB utilization were \"clinical studies\" (n = 107, 36.8%), the \"evaluation of therapeutic possibilities\" (n = 109, 37.5%) and \"prognostication\" (n = 59, 20.3%). The major reasons for not using LB testing in the treatment of mBC patients were high costs and lack of reimbursement (n = 133, 38.7%) followed by lack of access (n = 126, 36.6%) and lack of evidence of the clinical utility (n = 62, 18.0%).</p><p><strong>Conclusion: </strong>LB testing is slowly becoming more popular in clinical practice, but still faces major difficulties such as high costs, and lack of reimbursement. More evidence is needed to show that individualization of treatment by utilization of LB leads to better outcome in mBC patients.</p>","PeriodicalId":17111,"journal":{"name":"Journal of Surgical Oncology","volume":" ","pages":""},"PeriodicalIF":2.0,"publicationDate":"2025-07-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144626638","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The Role of KRAS Status Among Patients Undergoing Staged Versus Simultaneous Resection for Synchronous Colorectal Liver Metastases.","authors":"Andrea Baldo, Odysseas P Chatzipanagiotou, Jun Kawashima, Gaya Spolverato, Andrea Ruzzenente, George A Poultsides, Kazunari Sasaki, Itaru Endo, Minoru Kitago, Federico Aucejo, Irinel Popescu, Tom Hugh, Nazim Bhimani, Matthew Weiss, Sepideh Gholami, Jin He, Luca Aldrighetti, Timothy M Pawlik","doi":"10.1002/jso.70040","DOIUrl":"https://doi.org/10.1002/jso.70040","url":null,"abstract":"<p><strong>Background: </strong>This study aimed to evaluate the impact of surgical timing-simultaneous versus staged resection-on outcomes of patients with colorectal liver metastases (CRLM) in relation to KRAS mutation status, which is a key factor affecting prognosis.</p><p><strong>Methods: </strong>Patients who underwent curative-intent resection for synchronous CRLM (sCRLM) were identified from an international, multi-institutional database. The association between clinicopathologic factors, staged versus simultaneous approach and wild-type (wtKRAS) versus mutated (mtKRAS) KRAS with long-term outcomes was assessed.</p><p><strong>Results: </strong>Among 385 patients who underwent curative-intent resection for sCRLM, 205 (53.2%) individuals underwent a simultaneous primary tumor and CRLM resection; 180 (46.8%) individuals underwent a staged surgical approach. On multivariable analysis, the staged approach remained associated with improved OS compared with the simultaneous approach among patients who had mtKRAS CRLM (HR: 0.62, 95% CI: 0.39-0.99). Patients with mtKRAS and high TBS demonstrated an improved 5-year OS (67.0%, 95% CI: 54.2%-83.0% vs. 47.5%, 95% CI: 31.4%, 71.9%; p = 0.04) compared with a simultaneous procedure. There was no difference in OS among patients with either wtKRAS or mtKRAS and low TBS who underwent staged versus simultaneous resection (p > 0.05).</p><p><strong>Conclusion: </strong>Patients with sCRLM and an aggressive tumor biology as defined by KRAS status and TBS may benefit from a two-stage resection which may improve patient selection relative to achieving better long-term outcomes.</p>","PeriodicalId":17111,"journal":{"name":"Journal of Surgical Oncology","volume":" ","pages":""},"PeriodicalIF":2.0,"publicationDate":"2025-07-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144618647","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Local and National Trends in Emergency Presentation of Colon and Rectal Cancer.","authors":"Alyssa Habermann, Lukas Lee, Sarah Martey, Asad Siddiqui, Stacy Ranson, Stephen Sharp, Jaime Bohl, Nicole Wieghard","doi":"10.1002/jso.70041","DOIUrl":"https://doi.org/10.1002/jso.70041","url":null,"abstract":"<p><strong>Aim: </strong>Emergent diagnosis of colorectal cancer is associated with increased postoperative complications and poorer prognosis. We assessed the rate of emergent presentation of colorectal cancer at our institution, identified risk factors for emergent presentation, and compared our results to national data.</p><p><strong>Methods: </strong>Retrospective review was conducted of all patients treated for colon and rectal cancer at a single institution between 2012 and 2021. Pearson correlation identified trends over time in four major outcomes: setting of diagnosis, urgent/emergent surgery, obstruction, and/or perforation. Binomial logistic regression determined associations between outcomes and preoperative/demographic factors. NSQIP data of colectomy for colon cancer from 2012 to 2021 was analyzed for equivalent outcomes.</p><p><strong>Results: </strong>Seven hundred thirty-three patients with colon cancer and 429 with rectal cancer were included. Of patients with colon cancer, 48.2% were diagnosed in the inpatient setting, 31.8% underwent urgent/emergent surgery, 26.0% were obstructed, and 8.9% were perforated. Of patients with rectal cancer, 28.3% were diagnosed in the inpatient setting, 12.2% underwent urgent/emergent surgery, 18.0% were obstructed, and 6.0% were perforated. All outcomes increased over time. NSQIP reports 6.4% of colectomies for colon cancer were emergent, 4.0% of patients were obstructed, and 1.5% of patients were perforated, with no significant change over time. Medicaid insurance increased likelihood of emergent diagnosis and up to date colonoscopy was protective.</p><p><strong>Conclusion: </strong>The rate of emergent presentation and treatment of colon and rectal cancer at our institution is high compared to national data and is increasing over time. Risk factors identified suggest access to care is a barrier to timely diagnosis and treatment.</p>","PeriodicalId":17111,"journal":{"name":"Journal of Surgical Oncology","volume":" ","pages":""},"PeriodicalIF":2.0,"publicationDate":"2025-07-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144608657","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}