Pulmonary CirculationPub Date : 2025-04-07eCollection Date: 2025-04-01DOI: 10.1002/pul2.70066
Sepideh Hejazi, Maryam Masinaei, Maryam Emadzadeh, Shima Baniassad, Sara Amini, Soroush Attaran, Mohammad Javad Najafzadeh, Davood Attaran, Amir Baniasad
{"title":"Assessment of the Relationship Between the Six-Minute Walk Test (6MWT) With Serum Chloride Level and Mean Pulmonary Arterial Pressure in Patients With Pulmonary Arterial Hypertension.","authors":"Sepideh Hejazi, Maryam Masinaei, Maryam Emadzadeh, Shima Baniassad, Sara Amini, Soroush Attaran, Mohammad Javad Najafzadeh, Davood Attaran, Amir Baniasad","doi":"10.1002/pul2.70066","DOIUrl":"https://doi.org/10.1002/pul2.70066","url":null,"abstract":"<p><p>Pulmonary artery hypertension (PAH) is a fatal disease associated with high mortality, especially in countries with limited health resources in terms of lack of access to diagnostic and therapeutic evaluations. Therefore, it is necessary to discover inexpensive and available serum biomarkers for examining patients. This study investigates the relationship between PAH patients' six-minute walk (6MWT) distance, serum chloride levels, and mean pulmonary arterial pressure (mPAP). In this cross-sectional study, patients with PAH referring to the pulmonary hypertension clinic of our tertiary hospital were included. Then, the patient's demographic information and clinical findings were recorded, and the serum level of chloride and the 6MWT were examined in the patients. In the present study, 70 PAH patients were evaluated. All patients were female, and the mean age of the patients was 39.44 ± 8.33 years old. Hypochloremia was considered as serum chloride < 97 mmol/L in our study. The mPAP of patients with hypochloremia was significantly higher than non-hypochloremia patients (<i>p</i> < 0.001). The serum chloride levels had a significant positive correlation with the 6MWT distance (<i>r</i> = 0.634, <i>p</i> < 0.001). According to the linear regression analysis results, serum chloride level was a significant predictor of 6MWT distance even after adjustment for age and creatinine (<i>β</i> = 0.48; <i>p</i> = 0.002). Serum chloride level can be used as an inexpensive method for the evaluation of disease severity in PAH patients, especially in patients with higher time since the diagnosis of PAH.</p>","PeriodicalId":20927,"journal":{"name":"Pulmonary Circulation","volume":"15 2","pages":"e70066"},"PeriodicalIF":2.2,"publicationDate":"2025-04-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11973496/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143804204","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pulmonary CirculationPub Date : 2025-04-06eCollection Date: 2025-04-01DOI: 10.1002/pul2.70070
Taylor P Saley, Ryan D Coleman
{"title":"Shedding Light on the Dark Side of the Moon-Understanding Pediatric Right Ventricular Work in Pulmonary Hypertension.","authors":"Taylor P Saley, Ryan D Coleman","doi":"10.1002/pul2.70070","DOIUrl":"10.1002/pul2.70070","url":null,"abstract":"","PeriodicalId":20927,"journal":{"name":"Pulmonary Circulation","volume":"15 2","pages":"e70070"},"PeriodicalIF":2.2,"publicationDate":"2025-04-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11972546/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143796083","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pulmonary CirculationPub Date : 2025-04-02eCollection Date: 2025-04-01DOI: 10.1002/pul2.70068
Edward C Kirkpatrick, Stephanie Handler, Melodee Liegl, Amy Y Pan, G Ganesh Konduri, Todd M Gudausky, Adeleye J Afolayan
{"title":"Pediatric Pulmonary Hypertension is Associated With Increased Circulating Levels of BMP 7 and CHIP.","authors":"Edward C Kirkpatrick, Stephanie Handler, Melodee Liegl, Amy Y Pan, G Ganesh Konduri, Todd M Gudausky, Adeleye J Afolayan","doi":"10.1002/pul2.70068","DOIUrl":"10.1002/pul2.70068","url":null,"abstract":"<p><p>Pulmonary arterial endothelial and smooth muscle cell homeostasis is regulated through the bone morphogenetic protein (BMP) and transforming growth factor beta (TGF-β) receptor pathways. Pathway imbalance results in pulmonary hypertension (PH). Each pathway has ligands and modulators influencing this balance. How these pathways differ in pediatric PH patients is unknown. Ten PH and 20 control subjects (ages 2-17 years) were prospectively enrolled. Pulmonary artery serum BMP 2, 4, 6, 7, 9, 10, activin A, TGF-β1, carboxyl terminus of Hsc70-interating protein (CHIP), NT Pro BNP, and CRP were measured by ELISA. Analyses were made using the Fisher's exact test, the Mann-Whitney test, ROC analysis, and Pearson and Spearman correlations as appropriate. PH subjects were group 1 (four with simple shunts) or group 3 PH. Control subjects had shunts scheduled for catheter closure but no PH. Only BMP 7 and CHIP levels were statistically elevated in PH patients versus controls; (BMP 7 0.081(0.076-0.084) vs. 0.074(0.069-0.08) OD, <i>p</i> = 0.044), (CHIP 0.17(0.14-0.24) vs. 0.13(0.12-0.15) OD, <i>p</i> = 0.007) respectively. BMP 7 levels correlated with RV systolic pressure (0.431, <i>p</i> = 0.02) and pulmonary resistance (0.446, <i>p</i> = 0.013). CHIP correlated with mean pulmonary artery pressure (0.449, <i>p</i> = 0.013) and resistance ratios (Rp/Rs) (0.419, <i>p</i> = 0.02). BMP 7 OD of 0.077 had sensitivity/specificity of 80% and 70% for PH. CHIP OD of 0.136 had sensitivity/specificity of 90% and 65% for PH. BMP 7 and CHIP levels are heightened in pediatric PH patients which correlate with catheterization values. BMP 7 and CHIP could provide sensitive markers for PH to aid in diagnosis and disease monitoring.</p>","PeriodicalId":20927,"journal":{"name":"Pulmonary Circulation","volume":"15 2","pages":"e70068"},"PeriodicalIF":2.2,"publicationDate":"2025-04-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11964942/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143781135","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pulmonary CirculationPub Date : 2025-04-02eCollection Date: 2025-04-01DOI: 10.1002/pul2.70072
Michelle Cash, Barbara Giambra, Lara Stone, Melissa Magness, Kimberly Luebbe, Samantha Moore, Ryan Moore, Russel Hirsch, Kimberley Miles, Michael Kim, Paul J Critser
{"title":"Hank the Heart and Animation-Based Education for Pulmonary Hypertension.","authors":"Michelle Cash, Barbara Giambra, Lara Stone, Melissa Magness, Kimberly Luebbe, Samantha Moore, Ryan Moore, Russel Hirsch, Kimberley Miles, Michael Kim, Paul J Critser","doi":"10.1002/pul2.70072","DOIUrl":"10.1002/pul2.70072","url":null,"abstract":"<p><p>Pulmonary hypertension (PH) is a rare, complex disease affecting both children and adults. Efforts to provide health education are imperative as health literacy impacts patient and caregiver capacity to acquire, process, and understand health information and make informed health decisions. The current study sought to understand patient and family perception of \"Hank the Heart\", an animation used for enhancing health literacy, and preferred learning methods for future educational preferences. A qualitative study was conducted to assess the \"Hank the Heart\" animation using focus groups of family caregivers and patients. Focus group and interview transcripts underwent inductive thematic analysis. Patients and families have complicated health and educational needs that require a personalized approach, and they identified with the animated character as a representation of their reality. We identified three primary themes: (1) An animated video was found to be helpful but not sufficient to address all caregiver and patient educational needs, (2) Parents and children resonated strongly with elements of the video that represent their own experiences, and (3) Patient and family centered ongoing and tailored education is needed. The use of animation videos as a form of education was well received. Patient and family insights and suggestions were offered for improving future animation development.</p>","PeriodicalId":20927,"journal":{"name":"Pulmonary Circulation","volume":"15 2","pages":"e70072"},"PeriodicalIF":2.2,"publicationDate":"2025-04-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11964943/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143781130","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Carly E Byrd, Jennifer E Schramm, Jun Yang, Allan E Barnes, Megan Griffiths, Anjira S Ambade, Darin T Rosen, Ilton M Cubero Salazar, Catherine E Simpson, Ryan J Tedford, Steven Hsu, Dhananjay Vaidya, Todd M Kolb, Michael W Pauciulo, William C Nichols, David D Ivy, Eric D Austin, Paul M Hassoun, Rachel L Damico, Allen D Everett
{"title":"Cellular Communication Network Protein 2 in the Right Ventricle of Pulmonary Arterial Hypertension.","authors":"Carly E Byrd, Jennifer E Schramm, Jun Yang, Allan E Barnes, Megan Griffiths, Anjira S Ambade, Darin T Rosen, Ilton M Cubero Salazar, Catherine E Simpson, Ryan J Tedford, Steven Hsu, Dhananjay Vaidya, Todd M Kolb, Michael W Pauciulo, William C Nichols, David D Ivy, Eric D Austin, Paul M Hassoun, Rachel L Damico, Allen D Everett","doi":"10.1002/pul2.70067","DOIUrl":"10.1002/pul2.70067","url":null,"abstract":"<p><p>Cellular communication network 2 (CCN2) is a secreted matricellular protein associated with pulmonary arterial hypertension (PAH) but has not been studied relative to PAH severity, outcomes, or right ventricle (RV) structure and function in a large human cohort and preclinical animal model. This study assessed the associations between CCN2 and PAH severity, survival, hemodynamic measurements, and cardiovascular dysfunction. Serum CCN2 levels were compared in 2548 adults with PAH and 216 controls. CCN2 levels in PAH patients were compared to functional and hemodynamic measurements, and survival outcomes. RV-pulmonary artery coupling and RV morphology were also assessed in a small subset of patients via pressure-volume loops and cardiac magnetic resonance imaging. In a preclinical PAH model, plasma CCN2 levels were compared between ventricles with PAH progression. CCN2 mRNA levels in both ventricles in the preclinical model were measured to compare with morphologic histologic variables. CCN2 serum levels were significantly higher in PAH compared to controls (<i>p</i> < 0.0001). Higher CCN2 levels were associated with reduced RV contractility (<i>p</i> = 0.003). Higher CCN2 levels were associated with worse 6MWD (<i>p</i> = 0.035), and higher risk of mortality or transplant (<i>p</i> = 0.025). In the preclinical model, prepulmonary CCN2 plasma levels increased with the progression of disease. CCN2 mRNA levels in the RV were associated with decreased RV capillary density (<i>p</i> = 0.015) and increased RV fibrosis (<i>p</i> = 0.045). Though more investigation is needed, it appears that CCN2 plays a role in the development of PAH and potentially in RV maladaptation in PAH.</p>","PeriodicalId":20927,"journal":{"name":"Pulmonary Circulation","volume":"15 2","pages":"e70067"},"PeriodicalIF":2.2,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11961549/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143773142","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pulmonary CirculationPub Date : 2025-03-31eCollection Date: 2025-04-01DOI: 10.1002/pul2.70064
Arun Jose, Alex D Moseley, Manisha Das, Robert E O'Donnell, Jean M Elwing
{"title":"Heart Rate Variability as a Marker of Disease Severity in Pulmonary Arterial Hypertension: A Prospective Cohort Study.","authors":"Arun Jose, Alex D Moseley, Manisha Das, Robert E O'Donnell, Jean M Elwing","doi":"10.1002/pul2.70064","DOIUrl":"10.1002/pul2.70064","url":null,"abstract":"<p><p>Pulmonary arterial hypertension (PAH) is a disease that can eventually progress to right ventricular failure. Heart rate variability (HRV), including standard deviation of R-to-R intervals (SDNN), has been associated with increased mortality across different populations. The purpose of this study was to examine the association between HRV and disease severity in PAH. This was a prospective cohort study of adult incident PAH patients who underwent cardiac magnetic resonance imaging (CMR) at baseline and following 6 months. Study subjects recorded HRV using wearable chest actigraphy devices for at least 1 h every 2 weeks. The primary end point was correlation between HRV and right ventricular ejection fraction (RVEF) on CMR. Multivariable mixed effects regression models were used. A total of 20 subjects completed the study, predominantly female and White race, with severe PAH at the time of enrollment that improved significantly following 6 months of treatment. Linear relationships were observed between HRV (SDNN) and measures of PAH severity on CMR, including RVEF (SDNN coefficient 0.18, <i>p</i> = 0.006) and right ventricular-pulmonary arterial coupling ratio (SDNN coefficient 0.008, <i>p</i> = 0.003). Comparable relationships were observed between heart rate captured using HRV device and these CMR measures (RVEF coefficient -0.37, <i>p</i> = 0.007; coupling ratio coefficient -0.013, <i>p</i> = 0.016). We conclude that noninvasively captured HRV (SDNN) and heart rate strongly correlate with PAH disease severity (right ventricular structure and function) on CMR, and may complement existing methods of risk assessment in PAH, particularly in high-risk incident PAH.</p>","PeriodicalId":20927,"journal":{"name":"Pulmonary Circulation","volume":"15 2","pages":"e70064"},"PeriodicalIF":2.2,"publicationDate":"2025-03-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11955741/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143764444","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pulmonary CirculationPub Date : 2025-03-26eCollection Date: 2025-01-01DOI: 10.1002/pul2.70049
Inge von Alvensleben, Brian B Graham, Gustavo A Balanza, Carlos Brockmann, Ericka C Pérez, Ximena Y Vicente, Carla Arteaga, Claudia Scherer, Franz P Freudenthal, Rubin M Tuder, Alexandra Heath
{"title":"High Altitude May Protect Against the Early Development of Irreversible Pulmonary Hypertension in Patients With Congenital Heart Disease.","authors":"Inge von Alvensleben, Brian B Graham, Gustavo A Balanza, Carlos Brockmann, Ericka C Pérez, Ximena Y Vicente, Carla Arteaga, Claudia Scherer, Franz P Freudenthal, Rubin M Tuder, Alexandra Heath","doi":"10.1002/pul2.70049","DOIUrl":"10.1002/pul2.70049","url":null,"abstract":"<p><p>Congenital heart disease (CHD) occurs at increased prevalence at high altitude, but there may be a paradoxical later onset of the development of Eisenmenger syndrome. We hypothesized that congenital heart disease patients at high altitude are protected from an early onset of irreversible pulmonary hypertension. We present a ospective observational case series study, supported by a PVRI grant, of patients in La Paz, Bolivia, located at 3600 m, who underwent surgery for CHD. 10 consecutive patients aged 5 to 29 years (mean 12) with left-to-right shunts and pulmonary hypertension underwent diagnostic catheterization to assess pulmonary pressure pre-operatively and six to 9 months postoperatively, and had a lung biopsy performed at the time of the surgery. Control lung tissue was obtained from patients living at the same altitude who underwent pulmonary hydatid cyst resection. 10 CHD patients and 4 control patients were analyzed. Pre-operatively, the patients had a significant response to hyperoxia with a fall in mean pulmonary pressure (mPAP) from 59.6 mmHg (SD 7.74) to 46.3 mmHg (SD 11.1); (<i>p</i> < 0.05). Postoperatively, the patients had an excellent response to surgery, with a mPAP of 26.4 mmHg (SD 6.42) (<i>p</i> < 0.05 vs. preoperative pressures). Analysis of the lung histology did not show evidence of pulmonary vascular remodeling in the CHD patients compared to the control patients. During the follow-up in up to 11 years, pulmonary pressure assessed by echocardiography remained normal. In conclusion, chronic hypobaric hypoxemia at high altitude may delay the development of pulmonary vascular disease in CHD patients.</p>","PeriodicalId":20927,"journal":{"name":"Pulmonary Circulation","volume":"15 1","pages":"e70049"},"PeriodicalIF":2.2,"publicationDate":"2025-03-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11938293/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143721248","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pulmonary CirculationPub Date : 2025-03-20eCollection Date: 2025-01-01DOI: 10.1002/pul2.70065
Kimia Heydari, Carrie Johnson, I Diane Cooper, Kadija Hersi, Carl Tanba, Junfeng Sun, Michael A Solomon, Jason M Elinoff
{"title":"Flow Cytometric Determination of Circulating Progenitor Cells in Patients With Pulmonary Arterial Hypertension: A Systematic Review.","authors":"Kimia Heydari, Carrie Johnson, I Diane Cooper, Kadija Hersi, Carl Tanba, Junfeng Sun, Michael A Solomon, Jason M Elinoff","doi":"10.1002/pul2.70065","DOIUrl":"10.1002/pul2.70065","url":null,"abstract":"<p><p>Pulmonary arterial hypertension (PAH) is characterized by progressive narrowing and obliteration of distal, pre-capillary pulmonary vessels. Yet, noninvasive biomarkers that reflect this disease-defining process are lacking. A systematic review of PAH studies that measured circulating progenitor cells (CPCs) or circulating endothelial cells (CECs) in PAH by flow cytometry was performed to understand how future studies, leveraging state-of-the-art single-cell analyses, can advance the field. The study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews. Of the 2422 studies identified, 20 met inclusion criteria. Nineteen studies measured CPCs by flow cytometry, only one study examined CECs. A total of 647 PAH patients were included across all 19 CPC studies. Marker schemes chosen to define CPCs, and the methods of flow cytometry used, varied significantly across studies. Meta-analysis of a subgroup of CPC studies (<i>n</i> = 8) similarly identified a significant amount of heterogeneity even amongst studies using the same marker scheme. In conclusion, a systematic review of CPC studies in PAH patients reveals the limitations of the current literature. Future studies should include contemporary risk assessments, disease duration, reporting of comorbid conditions, and serial sampling over time. Furthermore, methods that incorporate best practices for detecting rare cell populations by flow cytometry are essential and should be reported in sufficient detail in future publications. With the emergence of single-cell technologies, future studies of circulating progenitor and endothelial cells in PAH remain relevant and may incorporate several insights from the current review to build upon the existing literature.</p>","PeriodicalId":20927,"journal":{"name":"Pulmonary Circulation","volume":"15 1","pages":"e70065"},"PeriodicalIF":2.2,"publicationDate":"2025-03-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11925724/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143691758","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pulmonary CirculationPub Date : 2025-03-11eCollection Date: 2025-01-01DOI: 10.1002/pul2.70021
Juan V Rodriguez, Haihua Zhang, Nathan Mesfin, Elizabeth S Klings, Justin K Lui
{"title":"Contribution of QRS Prolongation to Transplant-Free Survival in Sarcoidosis-Related Pulmonary Hypertension.","authors":"Juan V Rodriguez, Haihua Zhang, Nathan Mesfin, Elizabeth S Klings, Justin K Lui","doi":"10.1002/pul2.70021","DOIUrl":"10.1002/pul2.70021","url":null,"abstract":"<p><p>To study the contribution of QRS prolongation to transplant-free survival, we conducted an observational study of 68 patients with sarcoidosis-related pulmonary hypertension. Every 10-ms increase in QRS interval was associated with an adjusted HR of 1.23 (95% CI: 1.06, 1.44) for the composite outcome of lung transplantation and all-cause mortality.</p>","PeriodicalId":20927,"journal":{"name":"Pulmonary Circulation","volume":"15 1","pages":"e70021"},"PeriodicalIF":2.2,"publicationDate":"2025-03-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11894461/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143606043","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}