Palliative Medicine最新文献

{"title":"Interventions to address supportive care needs of people with pulmonary fibrosis and/or their caregivers: A scoping review.","authors":"Naa-Dromoh Quarshie, Matthew Wells, Giles Dixon, Sarah Mulholland, Sarah Rudd, Anne-Marie Russell, Shaney L Barratt","doi":"10.1177/02692163251326164","DOIUrl":"https://doi.org/10.1177/02692163251326164","url":null,"abstract":"<p><strong>Background: </strong>Pulmonary fibrosis is often accompanied by high levels of unmet supportive care needs that impact psycho-social well-being and overall quality of life for both the person with pulmonary fibrosis and their family. The provision of appropriate services to reduce unmet supportive care needs represents a key health care priority.</p><p><strong>Aim: </strong>To provide the first broad-level overview of the available evidence of the characteristics and impact of interventions developed to address unmet supportive care needs in people with pulmonary fibrosis and/or their caregivers.</p><p><strong>Design: </strong>Scoping review. The protocol was registered with Figshare.com (protocol number 25452100).</p><p><strong>Data sources: </strong>Systematic electronic searches were performed in Cochrane Central, EMBASE, Medline, PsysINFO and CINAHL from inception to March 2024 to identify all studies describing interventions to address supportive care needs of people with pulmonary fibrosis and/or their carers.</p><p><strong>Results: </strong>A total of 24 studies (1 abstract and 23 full text studies) met inclusion criteria. There was considerable heterogeneity in interventions described and outcome measures used. Multimodal interventions with a focus on symptom control, quality of life, peer support and psychosocial input appear to be crucial to integrated, effective and patient led supportive care. The generalisability of interventions is limited by small sample size, the use of inconsistent and/or non-validated evaluation measures and study attrition.</p><p><strong>Conclusions: </strong>Further research with greater involvement of key stakeholders is urgently required. Future directions should also assess barriers to supportive care and investigate other avenues such as telehealth or remote delivery to improve access and acceptability.</p>","PeriodicalId":19849,"journal":{"name":"Palliative Medicine","volume":" ","pages":"2692163251326164"},"PeriodicalIF":3.6,"publicationDate":"2025-03-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143743556","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":"A mixed methods exploration of the health and caregiving experiences of fathers of children with a life-limiting condition.","authors":"Victoria Fisher, Karl Atkin, Lorna K Fraser","doi":"10.1177/02692163251327877","DOIUrl":"https://doi.org/10.1177/02692163251327877","url":null,"abstract":"<p><strong>Background: </strong>Fathers of children with a life-limiting condition are underrepresented in the literature. We know little about their experiences of caregiving, the impact of this on their health and their support needs.</p><p><strong>Aim: </strong>To explore the health and caregiving experiences of fathers of children with a life-limiting condition, both quantitatively and qualitatively.</p><p><strong>Design: </strong>A convergent mixed methods design comprised of (1) a quantitative survey and (2) semi-structured qualitative interviews prioritising the qualitative data.</p><p><strong>Setting/participants: </strong>Thirty-two fathers of children with a life-limiting condition took part in the survey. They were recruited via social media, three UK children's hospices and one UK children's hospital. Twelve of these fathers went on to take part in a qualitative semi-structured interview.</p><p><strong>Results: </strong>Thematic analysis resulted in three themes: (1) Everyday precarity; (2) cumulative distress; past, present and future; (3) the scope and severity of the impact of caregiving on fathers; a lack of understanding from others. In the survey, fathers reported high levels of carer strain and distress, alongside high levels of family wellbeing and positive appraisals of caregiving.</p><p><strong>Conclusion: </strong>Fathers' extensive and overwhelming daily routines are inflexible and unstable, leading to multidimensional precarity and a sense of overwhelm. Current care provision does not address the unique and fluctuating support needs of fathers, which are linked to those of their child, and need to be understood in the context of both parenting and caregiving. A process capable of identifying and addressing fathers' support needs to be established.</p>","PeriodicalId":19849,"journal":{"name":"Palliative Medicine","volume":" ","pages":"2692163251327877"},"PeriodicalIF":3.6,"publicationDate":"2025-03-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143700962","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":"Providing life-sustaining treatments at home for those with Motor Neurone Disease: A qualitative study of bereaved family members' experiences of responsibility.","authors":"Eleanor Wilson, Jonathan Palmer, Georgios Kaltsakas, Jeong-Su Lee, Christina Faull","doi":"10.1177/02692163251327866","DOIUrl":"https://doi.org/10.1177/02692163251327866","url":null,"abstract":"<p><strong>Background: </strong>Motor neurone disease is an incurable neurodegenerative condition that progressively impairs motor function. It affects mobility, speech, swallowing and breathing, leading to significant dependence on others. Home mechanical ventilation can alleviate respiratory symptoms and improve survival.</p><p><strong>Aim: </strong>To examine the experiences of bereaved family members involved in the care of someone with motor neurone disease who had died with home mechanical ventilation in place, or following its withdrawal.</p><p><strong>Design: </strong>An interpretive constructivist approach was used to carry out qualitative interviews.</p><p><strong>Setting/participants: </strong>Bereaved family members from England and Wales whose relative had died with ventilation in place, or after withdrawal.</p><p><strong>Results: </strong>Thirty-six bereaved family members took part. Their experiences highlight the extensive responsibilities and emotional burdens of managing home mechanical ventilation. Family members reported feelings of heightened responsibility, distrust in the abilities of professional caregivers, significant impacts on their mental and physical well-being and the ways in which knowledgeable care providers could lift such responsibilities.</p><p><strong>Conclusions: </strong>As the use of technology to sustain life increases, we need to question how much we expect of family members in providing care for those with complex interventions, such as ventilation, at home. This research underscores the critical role family members' play in home care for people with motor neurone disease and calls for a greater understanding of the impacts of maintaining responsibility for life-sustaining treatments. There is a need for better support and training for both family and professional caregivers to alleviate some of the responsibility placed upon family members.</p>","PeriodicalId":19849,"journal":{"name":"Palliative Medicine","volume":" ","pages":"2692163251327866"},"PeriodicalIF":3.6,"publicationDate":"2025-03-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143676904","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":"Advance care planning and quality of life: A qualitative interview study in people with young-onset dementia and their family caregivers.","authors":"Jasper Maters, Marieke Perry, Ton de Wit, Raymond T C M Koopmans, Marjolein E de Vugt, Christian Bakker, Jenny T van der Steen","doi":"10.1177/02692163251324796","DOIUrl":"https://doi.org/10.1177/02692163251324796","url":null,"abstract":"<p><strong>Background: </strong>The importance of palliative care and advance care planning in dementia is increasingly recognized. However, little is known about the distinct needs and preferences of people with young-onset dementia.</p><p><strong>Aim: </strong>To explore how people with young-onset dementia and their family caregivers experience quality of life, and how these experiences shape their views on the future, palliative care needs, and advance care planning.</p><p><strong>Design: </strong>A qualitative interview study, using inductive thematic analysis.</p><p><strong>Setting/participants: </strong>Ten community-dwelling people with young-onset dementia and their family caregivers from the Netherlands.</p><p><strong>Results: </strong>Four themes were found: sense of self, connection to others, acceptance versus resistance in the face of adversity, and orientation toward the future versus focus on the present. The first two themes represent the main aspects of quality of life. The third theme covers acceptance versus resistance in coping with the disease, support, and the future. The expectations of a decrease in quality of life could adversely affect the attitude toward the future and thus reduce the willingness to engage in advance care planning, which relates to the final theme. Quality of life explicitly influenced treatment decisions for those who engaged in advance care planning.</p><p><strong>Conclusions: </strong>The perception of young-onset dementia and its impact on quality of life varies among people with young-onset dementia and their family caregivers, but common values include a sense of self and connection to others. Advance care planning should be introduced as a way to protect these values and align them with palliative care goals.</p>","PeriodicalId":19849,"journal":{"name":"Palliative Medicine","volume":" ","pages":"2692163251324796"},"PeriodicalIF":3.6,"publicationDate":"2025-03-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143634392","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":"Off-label drug use in palliative medicine: Delphi study for the consensus of evidence-based treatment recommendations.","authors":"Stefanie Pügge, Aleksandra Dukic-Ott, Julian Baumgärtel, Saskia Jünger, Claudia Bausewein, Constanze Rémi","doi":"10.1177/02692163251323123","DOIUrl":"https://doi.org/10.1177/02692163251323123","url":null,"abstract":"<p><strong>Background: </strong>Off-label use of drugs is an integral part of everyday clinical practice in palliative medicine. However, it is associated with many uncertainties, that is, drug therapy safety or legal issues including cost coverage. Healthcare professionals often lack time and resources for comprehensive literature search and patient-specific risk-benefit analyses.</p><p><strong>Aim: </strong>The aim of this project is to develop, evaluate and rate agreement/disagreement on treatment recommendations for off-label use in adult palliative medicine.</p><p><strong>Design: </strong>Online Delphi study with two rounds each to rate agreement/disagreement with treatment recommendations for off-label use in adult palliative medicine. An international expert panel consisting of physicians, pharmacists and nurses working in palliative care evaluated previously developed recommendations based on the best available evidence.</p><p><strong>Setting: </strong>/participants:Professionals (physicians, pharmacists, nursing staff) working in inpatient and home palliative care involved in the medication process were recruited as experts to participate. Between 64 and 75 experts participated in the first two Delphi studies.</p><p><strong>Results: </strong>A total of 64/68 recommendations on 21 drugs and 14 applications were agreed upon. Topics related to routes of administration as well as indications for sialorrhea, bronchorrhea, xerostomia, pruritus, singultus, fistula, gastroparesis and hot flashes. Recommendations that reached consensus are available to health care professionals via a free of charge database.</p><p><strong>Conclusion: </strong>For many off-label use applications, it is likely that there will be no registration studies and therefore no drug approvals in the future. The consensus-based recommendations are intended to facilitate individual treatment planning for prescribers and to enable a more reflected handling of off-label use.</p>","PeriodicalId":19849,"journal":{"name":"Palliative Medicine","volume":" ","pages":"2692163251323123"},"PeriodicalIF":3.6,"publicationDate":"2025-03-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143634394","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":"'Constipation': One word, many meanings amongst persons with cancer: An observational study.","authors":"Andrew Davies, Norah Fagan, Jenny Power, Amy Taylor","doi":"10.1177/02692163251325711","DOIUrl":"https://doi.org/10.1177/02692163251325711","url":null,"abstract":"<p><strong>Background: </strong>Constipation is common in people with advanced cancer and is associated with significant morbidity and health economic burden, but it is often sub-optimally managed. Despite international consensus diagnostic criteria for functional and opioid-induced constipation (Rome IV diagnostic criteria), the term 'constipation' means different things to different people, impacting assessment, diagnosis and management.</p><p><strong>Aim: </strong>To investigate the association between persons with advanced cancer self-reporting of constipation, response to the Rome IV diagnostic criteria statements for opioid-induced constipation and differences according to personal demographics.</p><p><strong>Design: </strong>Multicentre prospective observational study.</p><p><strong>Setting/participants: </strong>Twenty-four community, hospice and hospital research sites in 10 European countries recruited 1200 adults with cancer taking opioids for cancer/cancer-treatment related pain.</p><p><strong>Results: </strong>In response to the simple question <i>'Are you constipated?'</i>, 549 (45.5%) participants replied 'yes', 588 (49%) replied 'no' and 59 (5%) were 'unsure', but 713 (59.5%) participants met the Rome IV diagnostic criteria. Only 439 (61.5%) participants that met these criteria answered the simple question positively, whilst 230 (39%) answered negatively, although there was a statistically significant association between responses to the simple question and the criteria (χ²(1, <i>N</i> = 1136) = 149.945, <i>p</i> = 0.00001). There were certain significant differences in self-reporting according to age and country of origin.</p><p><strong>Conclusions: </strong>There is disparity between patients' self-reporting of constipation and the Rome IV diagnostic criteria. People with advanced cancer, especially those receiving opioid analgesics, need to be regularly assessed for constipation, but the use of a single question (<i>'Are you constipated?'</i>) is inadequate.Registry: European Study of Opioid Induced Constipation (E-StOIC), NCT05149833, https://clinicaltrials.gov/study/NCT05149833, 08/12/2021.</p>","PeriodicalId":19849,"journal":{"name":"Palliative Medicine","volume":" ","pages":"2692163251325711"},"PeriodicalIF":3.6,"publicationDate":"2025-03-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143606140","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":"Asian family members' participation in advance care planning: An integrative review.","authors":"Jing-Da Pan, Ka Yan Ho, Gui-Fen Guan, Min-Min Chang, Cui-Rong Tan, Xin-Yan Qiu, Hong-Li Liu, Ke-Lan Lin, Wen-Ting Xu, Shan Pan, Qi Liu, Ting Mao, Katherine Ka Wai Lam, Dong-Lan Ling","doi":"10.1177/02692163251317856","DOIUrl":"10.1177/02692163251317856","url":null,"abstract":"<p><strong>Background: </strong>Family members play a pivotal role in advance care planning for patients with life-limiting illnesses, particularly in Asia, where cultural values stress family-centeredness and paternalism.</p><p><strong>Aim: </strong>To synthesize the evidence pertaining to the extent of Asian family members' involvement in advance care planning.</p><p><strong>Design: </strong>An integrative review was conducted.</p><p><strong>Data sources: </strong>Data sources included MEDLINE, EMBASE, CINAHL, Web of Science, PubMed, Wan Fang, China National Knowledge Infrastructure databases, Google Scholar, and Open Gray.</p><p><strong>Results: </strong>21 studies were included. The willingness of Asian family members to participate in advance care planning is high, while their actual engagement remains low. Based on the barriers, facilitators, and Asian family members' roles influencing participation identified in our study, a six-dimensional conceptual model was developed: Asian family members' roles, problem-solving skills, communication, affective responsiveness, affective participation, and controlling behavior in advance care planning. Barriers to effective participation were identified: inadequate advance care planning legislation, insufficient public education, and influences from Confucianism or traditional beliefs. Additionally, filial piety was shown to have a paradoxical effect on Asian family members' participation in advance care planning in Asian countries.</p><p><strong>Conclusions: </strong>This study proposes a culturally sensitive model to illustrate family members' participation in advance care planning in Asia. This lays a foundation to develop culturally specific interventions to enhance family participation in advance care planning in the future. We recommend that Asian governments should enact legislations, enhance public education, and incorporate cultural characteristics into relevant policy frameworks to foster greater family involvement in advance care planning.</p>","PeriodicalId":19849,"journal":{"name":"Palliative Medicine","volume":" ","pages":"373-390"},"PeriodicalIF":3.6,"publicationDate":"2025-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143493056","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":"Measuring the quality of patient-provider relationships in serious illness: A scoping review.","authors":"Karen Wassef, Kristine Ma, Brigitte N Durieux, Tyler L Brown, Joanna Paladino, Sally Thorne, Justin J Sanders","doi":"10.1177/02692163251315304","DOIUrl":"10.1177/02692163251315304","url":null,"abstract":"<p><strong>Background: </strong>People affected by serious illness face several threats to their well-being: physical symptoms, psychological distress, disrupted social relations, and spiritual/existential crises. Relationships with clinicians provide a form of structured support that promotes shared decision-making and adaptive stress coping. Measuring relationship quality may improve quality assessment and patient care outcomes. However, researchers and those promoting quality improvement lack clear guidance on measuring this.</p><p><strong>Aim: </strong>To identify and assess items from valid measures of patient-provider relationship quality in serious illness settings for guiding quality assessment.</p><p><strong>Design: </strong>Scoping review.</p><p><strong>Data sources: </strong>We identified peer-reviewed, English-language articles published from 1990 to 2023 in CINAHL, Embase, and PubMed. Eligible articles described the validation of measures assessing healthcare experiences of patient populations characterized by serious illness. We used Clarke et al.'s theory of relationship quality to assess relationship-focused items.</p><p><strong>Results: </strong>From 3868 screened articles, we identified 101 publications describing 47 valid measures used in serious illness settings. Measures assessed patients and other caregivers. We determined that 597 of 2238 items (26.7%) related to relationships. Most measures (<i>n</i> = 46) included items related to engaging the patient as a whole person. Measures evaluated how providers promote information exchange (<i>n</i> = 35), foster therapeutic alliance (<i>n</i> = 35), recognize and respond to emotion (<i>n</i> = 27), and include patients in care-related decisions (<i>n</i> = 23). Few instruments (<i>n</i> = 9) assessed patient self-management and navigation.</p><p><strong>Conclusions: </strong>Measures include items that assess patient-provider relationship quality in serious illness settings. Researchers may consider these for evaluating and improving relationship quality, a patient-centered care and research outcome.</p>","PeriodicalId":19849,"journal":{"name":"Palliative Medicine","volume":" ","pages":"332-345"},"PeriodicalIF":3.6,"publicationDate":"2025-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11877987/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143365566","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":"The spiritual care intervention \"In dialogue with your life story\": Results of a longitudinal study on palliative clients' spiritual wellbeing.","authors":"Anke I Liefbroer, Annemarie Foppen, Iris R Wierstra, Ineke Nagel","doi":"10.1177/02692163251319143","DOIUrl":"10.1177/02692163251319143","url":null,"abstract":"<p><strong>Background: </strong>Spiritual care is important for palliative care, but the evidence base for spiritual care provision is low.</p><p><strong>Aim: </strong>To investigate the course over time of clients' spiritual wellbeing who participated in the spiritual care intervention \"In dialogue with your life story.\"</p><p><strong>Design: </strong>The intervention consisted of six individual sessions between client and chaplain of various faiths. A longitudinal study was conducted pre- and post-intervention, and a follow-up approximately 10 weeks after post-intervention. Spiritual wellbeing was measured using the EORTC QLQ-SWB32 and NEIS, and symptoms of anxiety and depression as secondary outcome measure using the HADS. Latent growth modeling was used to investigate changes in outcome measures over time.</p><p><strong>Setting/participants: </strong>Adult clients receiving home-based, palliative care were eligible to participate in this study.</p><p><strong>Results: </strong>A total of 75 clients and 33 chaplains participated. On the four EORTC QLQ-SWQ32-subscales, a significant increase was found over time on \"relationship with self,\" \"relationship with others,\" and '\"existential wellbeing\" (linear trends). \"Relationship with someone or something greater\" significantly increased over time but decreased 10 weeks post-intervention (quadratic trend). On the two NEIS-subscales, ego-integrity significantly increased over time (linear trend), while despair significantly decreased (quadratic trend). On the two HADS-subscales, symptoms of anxiety significantly decreased over time (linear trend). No significant change was found for depressive symptoms.</p><p><strong>Conclusions: </strong>We provided first empirical evidence for an increase in clients' spiritual wellbeing after enrollment in the spiritual care intervention \"In dialogue with your life story.\" Future research using control conditions is needed to investigate its causal effect.</p>","PeriodicalId":19849,"journal":{"name":"Palliative Medicine","volume":" ","pages":"413-424"},"PeriodicalIF":3.6,"publicationDate":"2025-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11877982/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143449895","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":"Thanks to Reviewers.","authors":"","doi":"10.1177/02692163251315041","DOIUrl":"https://doi.org/10.1177/02692163251315041","url":null,"abstract":"","PeriodicalId":19849,"journal":{"name":"Palliative Medicine","volume":"39 3","pages":"437-440"},"PeriodicalIF":3.6,"publicationDate":"2025-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143542996","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}