Revista clinica espanola最新文献

{"title":"Retraso diagnóstico y oportunidades perdidas en la detección precoz de la fibrilación auricular: estudio transversal","authors":"F. Richard Espiga ,&nbsp;M. Almendro Delia ,&nbsp;F. Caballero Martínez ,&nbsp;D. Monge Martín ,&nbsp;F. Neria Serrano ,&nbsp;R. Quirós López","doi":"10.1016/j.rce.2024.06.011","DOIUrl":"10.1016/j.rce.2024.06.011","url":null,"abstract":"<div><h3>Introduction</h3><div>We analysed the frequency of atrial fibrillation (AF) delayed diagnosis and the factors associated with it in newly diagnosed patients.</div></div><div><h3>Methods</h3><div>This was a descriptive, cross-sectional, multicentre study. Data were collected from newly diagnosed patients with AF through medical records review and interviews during cardiology, internal medicine, primary care and emergency department consultations in Spain.</div></div><div><h3>Results</h3><div>A total of 201 physicians participated in the study (64.2% cardiologists, 21.4% internists). 948 patients (58% men; mean age 72.8 years) were included. In 41.8% of patients, AF was classified as paroxysmal at diagnosis, 30.9% as persistent and 27.3% as permanent. The diagnosis was coincidental in 37%. It was considered that a delayed diagnosis occurred in 49.3% of patients. This delay was associated with the presence of permanent or persistent AF, older age or valvular disease. 74.8% of patients had some contact with the healthcare system in the preceding year. The diagnosis could have been established between 1-6 months earlier in 50.7% of cases and more than six months earlier in 20.1%. 54.4% of the patients had experienced AF compatible symptomatology previously. Of these, 32.6% had a consultation without a diagnosis.</div></div><div><h3>Conclusions</h3><div>In a significant proportion of AF cases, there is a diagnostic delay. Many people with compatible symptoms neither seek consultations nor contact the healthcare system facilities. Consequently, the opportunity for early diagnosis is lost.</div></div>","PeriodicalId":21223,"journal":{"name":"Revista clinica espanola","volume":"224 9","pages":"Pages 560-568"},"PeriodicalIF":2.3,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142573115","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"El receptor soluble para productos finales de glicación avanzada se correlacionó positivamente con la lesión renal con la enfermedad coronaria","authors":"L. Chen ,&nbsp;X.-J. Zeng ,&nbsp;X.-Y. Guo ,&nbsp;J. Liu ,&nbsp;F-H. Du ,&nbsp;C-X. Guo","doi":"10.1016/j.rce.2024.06.016","DOIUrl":"10.1016/j.rce.2024.06.016","url":null,"abstract":"<div><h3>Aims</h3><div>Coronary heart disease (CHD) patients with changed serum soluble receptor for advanced glycation end-products (sRAGE) will experience microalbuminuria and even kidney dysfunction. However, the role of sRAGE for microalbuminuria in CHD is still not established. This study aimed to evaluate the association between sRAGE and early kidney dysfunction in CHD patients.</div></div><div><h3>Materials and methods</h3><div>In this cross-sectional study, sRAGE and urinary albumin to creatinine ratio (uACR) were measured in hospitalized CHD patients who have undergone coronary arteriography to evaluate the distinction and correlation between sRAGE and uACR.</div></div><div><h3>Results</h3><div>There were 127 CHD patients (mean age: 63.06<!--> <!-->±<!--> <!-->10.93 years, 93 males) in the study, whose sRAGE were 1.83<!--> <!-->±<!--> <!-->0.64<!--> <!-->μg/L. The sRAGE level was higher in kidney injury group (uACR ≥<!--> <!-->30<!--> <!-->mg/g) compared with no kidney injury group (uACR &lt;<!--> <!-->30<!--> <!-->mg/g) [2.08<!--> <!-->±<!--> <!-->0.70 vs. 1.75<!--> <!-->±<!--> <!-->0.61<!--> <!-->μg/L, <em>P</em> <!-->&lt;<!--> <!-->.05]. Moreover, the positive correlation between serum sRAGE and uACR was significant in CHD patients (<em>r</em> <!-->=<!--> <!-->0.196, <em>P</em> <!-->&lt;<!--> <!-->.05). Binary logistic regression suggests sRAGE as a predictor for microalbuminuria in CHD patients [odd ratio<!--> <!-->=<!--> <!-->2.62 (1.12-6.15), <em>P</em> <!-->&lt;<!--> <!-->.05]. The area under the receiver operating characteristic curve (AUC) of sRAGE is higher than that of the traditional indicators of renal function such as creatinine and estimated glomerular filtration rate, indicating sRAGE might have a good performance in evaluating early kidney injury in CHD patients [AUC is 0.660 (0.543-0.778), <em>P</em> <!-->&lt;<!--> <!-->.01].</div></div><div><h3>Conclusions</h3><div>Serum sRAGE was positively correlated to uACR and might serve as a potential marker to predict early kidney injury in CHD patients.</div></div>","PeriodicalId":21223,"journal":{"name":"Revista clinica espanola","volume":"224 9","pages":"Pages 580-587"},"PeriodicalIF":2.3,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142573504","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Perspectiva clínica de las miopatías necrotizantes inmunomediadas anti-HMG-Co-A-reductasa: análisis de tres casos","authors":"J.P. de la Fuente Peñaloza ,&nbsp;L. Quintana Cabezas ,&nbsp;M.C. Yubini Lagos","doi":"10.1016/j.rce.2024.07.002","DOIUrl":"10.1016/j.rce.2024.07.002","url":null,"abstract":"","PeriodicalId":21223,"journal":{"name":"Revista clinica espanola","volume":"224 9","pages":"Pages 623-625"},"PeriodicalIF":2.3,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142573507","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Anemia de la inflamación y metabolismo del hierro en las enfermedades crónicas","authors":"S. Conde Díez ,&nbsp;R. de las Cuevas Allende ,&nbsp;E. Conde García","doi":"10.1016/j.rce.2024.06.013","DOIUrl":"10.1016/j.rce.2024.06.013","url":null,"abstract":"<div><div>Anemia of inflammation begins with the activation of the immune system and the subsequent release of cytokines that lead to an elevation of hepcidin, responsible for hypoferremia, and a suppression of erythropoiesis due to lack of iron. The anemia is usually mild/moderate, normocytic/normochromic and is the most prevalent, after iron deficiency anemia, and is the most common in patients with chronic diseases, in the elderly and in hospitalized patients. Anemia can influence the patient's quality of life and have a negative impact on survival. Treatment should be aimed at improving the underlying disease and correcting the anemia. Intravenous iron, erythropoietin and prolyl hydroxylase inhibitors are the current basis of treatment, but future therapy is directed against hepcidin, which is ultimately responsible for anemia.</div></div>","PeriodicalId":21223,"journal":{"name":"Revista clinica espanola","volume":"224 9","pages":"Pages 598-608"},"PeriodicalIF":2.3,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142573116","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Resumen ejecutivo de la reflexión estratégica de la Sociedad Española de Medicina Interna 2025-2029 para garantizar la asistencia integral a la persona enferma en un Sistema Nacional de Salud de alto valor","authors":"J. Carretero Gómez ,&nbsp;M.M. Chimeno Viñas ,&nbsp;J.M. Porcel Pérez ,&nbsp;M. Méndez Bailón ,&nbsp;P. Pérez Martínez ,&nbsp;M.T. Herranz Marín ,&nbsp;F.J. Elola Somoza ,&nbsp;en nombre de los miembros de los comités para el proceso de reflexión estratégica de la SEMI","doi":"10.1016/j.rce.2024.08.001","DOIUrl":"10.1016/j.rce.2024.08.001","url":null,"abstract":"<div><h3>Aims</h3><div>To design a strategic framework for the policy and activity of the Spanish Society of Internal Medicine (SEMI).</div></div><div><h3>Methods</h3><div>Expert consensus. Participation through expert committees and consultation of internists on the proposed strategic lines.</div></div><div><h3>Results</h3><div>The SEMI's motto was changed to “comprehensive care for patients.” Seven strategic lines were defined: Contribute to the transformation of the health system; participate in university teaching; guarantee comprehensive healthcare for patients; provide internal medicine residents and internists with the skills to practice in 21st century healthcare; promote research and the generation of scientific evidence in internal medicine; incorporate technological innovation and digital tools; position the SEMI as a model institution for healthcare policy.</div></div><div><h3>Conclusions</h3><div>SEMI seeks to be a key player in the transformation of the Spanish healthcare system.</div></div>","PeriodicalId":21223,"journal":{"name":"Revista clinica espanola","volume":"224 9","pages":"Pages 609-622"},"PeriodicalIF":2.3,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142573506","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Resultados de la implementación del proyecto DP-TRANSFERS en Cataluña: un método traslacional para mejorar el cribado y la prevención de la diabetes en atención primaria","authors":"J.J. Cabré ,&nbsp;F. Barrio ,&nbsp;J. Vizcaíno ,&nbsp;A. Martínez ,&nbsp;T. Mur ,&nbsp;R. Sagarra ,&nbsp;S. Dalmau","doi":"10.1016/j.rce.2024.06.017","DOIUrl":"10.1016/j.rce.2024.06.017","url":null,"abstract":"<div><h3>Introduction</h3><div>DP-TRANSFERS is a translational lifestyle intervention project, which follows a previous protocol described in the DE-PLAN-CAT study.</div></div><div><h3>Objective</h3><div>Analyze the feasibility of reproducing the intensive intervention and estimating the effect of translation in real conditions of clinical practice in primary care.</div></div><div><h3>Methodology</h3><div>Implementation of the face-to-face group intervention adjusted to 2 years. After screening, the intervention consisted of a basic module and a continuity module. Stratifying by clusters (health centers), a representative sample (centers, professionals and participants) was evaluated (FINDRISC<!--> <!-->&gt;11 and/or prediabetes) from 2016 to 2020. The effect of the intervention on the incidence of diabetes was analyzed.</div></div><div><h3>Results</h3><div>The intervention, feasible in 95 of 123 centers, involved 343 of 647 professionals. Of 2,381 subjects screened, 1,713 participated in the basic module, with 1,186 participants completing the first year and 776 completing the second. 121 participants (7.06%) were diagnosed with diabetes: 77 (4.49%) during the first year; 44 (2.57%) during the second.</div><div>The bivariate analysis showed that those subjects in whom diabetes affected differed in: previous glycemic status, A1c, HDL-cholesterol, FINDRISC score and adherence to the Mediterranean diet, and in the differences between the beginning and end of the study of: body weight, BMI and abdominal circumference.</div></div><div><h3>Conclusions</h3><div>The intensive intervention substantially reduced (23.6%) the incidence of diabetes compared to that previously estimated in standardized intervention. The following acted as protective factors: a better glycemic status, lower baseline risk, elevated HDL-cholesterol, or achieving a reduction in weight or abdominal circumference during the study.</div></div>","PeriodicalId":21223,"journal":{"name":"Revista clinica espanola","volume":"224 9","pages":"Pages 569-579"},"PeriodicalIF":2.3,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142573117","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"La amiloidosis cardiaca empeora el pronóstico en los pacientes con insuficiencia cardiaca: hallazgos del estudio PREVAMIC","authors":"R. Ruiz Hueso ,&nbsp;P. Salamanca Bautista ,&nbsp;M.A. Quesada Simón ,&nbsp;S. Yun ,&nbsp;A. Conde Martel ,&nbsp;J.L. Morales Rull ,&nbsp;I. Fiteni Mera ,&nbsp;D. Abad Pérez ,&nbsp;I. Páez Rubio ,&nbsp;Ó. Aramburu Bodas ,&nbsp;en representación del grupo de trabajo PREVAMIC","doi":"10.1016/j.rce.2024.06.006","DOIUrl":"10.1016/j.rce.2024.06.006","url":null,"abstract":"<div><h3>Background and objectives</h3><div>Cardiac amyloidosis (CA) is a common pathology in elderly patients that usually presents as heart failure (HF). However, it is not clear whether CA associated with HF has a worse prognosis compared with HF due to other etiologies.</div></div><div><h3>Material and methods</h3><div>Prospective, observational cohort study that recruited patients ≥65 years of age with HF in 30 Spanish centers. The cohort was divided according to whether the patients had AC or not. Patients were followed for 1 year.</div></div><div><h3>Results</h3><div>A total of 484 patients were included in the analysis. The population was elderly (median 86 years) and 49% were women CA was present in 23.8% of the included patients. In the CA group, there was a lower prevalence of diabetes mellitus and valvular disease. At one year of follow-up, mortality was significantly more frequent in patients with CA compared to those without (33.0 vs.14.9%, p<!--> <!-->&lt;<!--> <!-->0.001). However, there were no differences between both groups in visits to the emergency room or readmissions. In the multivariate analysis, the variables that were shown to predict all-cause mortality at one year of follow-up were chronic kidney disease (HR 1.75 (1.01-3.05) p<!--> <span>=</span> <!-->0.045), NT-proBNP levels (HR 2.51 (1.46-4.30) p<!--> <!-->&lt;<!--> <!-->0.001), confusion (HR 2.05 (1.01-4.17), p<!--> <span>=</span> <!-->0.048), and the presence of CA (HR 1.77 (1.11-2.84), p<!--> <span>=</span> <!-->0.017).</div></div><div><h3>Conclusion</h3><div>The presence of CA in elderly patients with HF is related to a worse prognosis at one year of follow-up. Early diagnosis of the pathology and multidisciplinary management can help improve patient outcomes.</div></div>","PeriodicalId":21223,"journal":{"name":"Revista clinica espanola","volume":"224 8","pages":"Pages 494-502"},"PeriodicalIF":2.3,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142417146","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Pneumocystis jirovecii en la enfermedad humana, ¿sólo neumonía?","authors":"E.J. Calderón ,&nbsp;V. Friaza","doi":"10.1016/j.rce.2024.07.001","DOIUrl":"10.1016/j.rce.2024.07.001","url":null,"abstract":"","PeriodicalId":21223,"journal":{"name":"Revista clinica espanola","volume":"224 8","pages":"Pages 546-548"},"PeriodicalIF":2.3,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142417247","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"El registro RICA-2: diseño y características basales de los primeros 1.000 pacientes","authors":"J.C. Trullàs ,&nbsp;M.C. Moreno-García ,&nbsp;V. Mittelbrunn-Alquézar ,&nbsp;A. Conde-Martel ,&nbsp;L. Soler-Rangel ,&nbsp;M. Montero-Pérez-Barquero ,&nbsp;J. Casado ,&nbsp;M. Sánchez-Marteles ,&nbsp;J.C. Arévalo-Lorido ,&nbsp;J. Pérez-Silvestre ,&nbsp;en representación de los investigadores del registro RICA-2","doi":"10.1016/j.rce.2024.06.010","DOIUrl":"10.1016/j.rce.2024.06.010","url":null,"abstract":"<div><h3>Background and objective</h3><div>Heart failure (HF) is a syndrome of epidemic proportions and one of the main reasons for hospital admission. Patient registries provide real-world clinical practice information which is complementary to clinical trials. RICA-2 is a registry of the Spanish Society of Internal Medicine. Its main goal is to know the clinical and epidemiological characteristics and prognostic factors of patients with HF treated in Internal Medicine Departments. The objective of this study is to present the design of the RICA-2, the baseline characteristics of the first 1000 patients included and their comparison with those of the historical cohort of the RICA registry.</div></div><div><h3>Methods</h3><div>Observational, multicentre and prospective study of patients with HF with the following inclusion criteria: age equal to or greater than 18 years old, diagnosis of HF according to the European Guidelines, indistinct inclusion in decompensation or stable phase, of patients with <em>de novo</em> HF or chronic HF, regardless of left ventricular ejection fraction, aetiology and comorbidities.</div></div><div><h3>Results</h3><div>RICA-2 patients have advanced age (83 years old) and 51% are women. The comorbidity burden is higher than in the RICA registry (5 points in the Charlson comorbidity index), with predominating chronic decompensated HF (74%), hypertensive aetiology (39%) and preserved ejection fraction (52%). Most patients are pre-frail or vulnerable and are at risk of malnutrition.</div></div><div><h3>Conclusion</h3><div>The RICA-2 represents a contemporary cohort of patients that will provide us with clinical, epidemiological and prognostic information on patients with acute and chronic HF treated in Internal Medicine.</div></div>","PeriodicalId":21223,"journal":{"name":"Revista clinica espanola","volume":"224 8","pages":"Pages 522-533"},"PeriodicalIF":2.3,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142417249","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Factores de riesgo de mortalidad en pacientes con enfermedad del coronavirus 2019 con hipoxemia silente","authors":"B. Ximenes Braz ,&nbsp;G. Cavalcante Meneses ,&nbsp;G.B. da Silva Junior ,&nbsp;A.M. Costa Martins ,&nbsp;A.F. de S. Mourão Feitosa ,&nbsp;G.C. Lima Chagas ,&nbsp;E. De Francesco Daher","doi":"10.1016/j.rce.2024.06.004","DOIUrl":"10.1016/j.rce.2024.06.004","url":null,"abstract":"<div><h3>Objective</h3><div>To describe the predictors of mortality in hospitalized patients with severe acute respiratory syndrome (SARS) due to COVID-19 presenting with silent hypoxemia.</div></div><div><h3>Material and methods</h3><div>Retrospective cohort study of hospitalized patients with SARS due to COVID-19 and silent hypoxemia at admission, in Brazil, from January to June 2021. The primary outcome of interest was in-hospital death. Multivariable logistic regression analysis was performed.</div></div><div><h3>Results</h3><div>Of 46,102 patients, the mean age was 59<!--> <!-->±<!--> <!-->16<!--> <!-->years, and 41.6% were female. During hospitalization, 13,149 patients died. Compared to survivors, non-survivors were older (mean age, 66 vs. 56 years; <em>P</em> <!-->&lt;<!--> <!-->0.001), less frequently female (43.6% vs. 40.9%; <em>P</em> <!-->&lt;<!--> <!-->0.001), and more likely to have comorbidities (74.3% vs. 56.8%; <em>P</em> <!-->&lt;<!--> <!-->0.001). Non-survivors had higher needs for invasive mechanical ventilation (42.4% vs 6.6%; <em>P</em> <!-->&lt;<!--> <!-->0.001) and intensive care unit admission (56.9% vs 20%; <em>P</em> <!-->&lt;<!--> <!-->0.001) compared to survivors. In the multivariable regression analysis, advanced age (OR: 1.04; 95%CI: 1.037-1.04), presence of comorbidities (OR: 1.54; 95%CI: 1.47-1.62), cough (OR: 0.74; 95%CI: 0.71-0.79), respiratory distress (OR: 1.32; 95%CI: 1.26-1.38), and need for non-invasive respiratory support (OR: 0.37; 95%CI: 0.35-0.40) remained independently associated with death.</div></div><div><h3>Conclusions</h3><div>Advanced age, presence of comorbidities, and respiratory distress were independent risk factors for mortality, while cough and requirement for non-invasive respiratory support were independent protective factors against mortality in hospitalized patients with SARS due to COVID-19 with silent hypoxemia at presentation.</div></div>","PeriodicalId":21223,"journal":{"name":"Revista clinica espanola","volume":"224 8","pages":"Pages 485-493"},"PeriodicalIF":2.3,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142417145","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}