South Dakota medicine : the journal of the South Dakota State Medical Association最新文献

{"title":"2024 Scholars' Research Symposium Abstract: ACLS Instructor Course to Enhance Medical Students' Resuscitation Competency and Confidence.","authors":"Katherine Nielson","doi":"","DOIUrl":"","url":null,"abstract":"<p><strong>Introduction: </strong>Physicians are expected to be competent in the management of cardiovascular emergencies. Despite the demand, there is a lack of research regarding how to better provide training for medical students to address cardiovascular emergencies. The authors of this project hypothesize that medical students participating in the Advanced Cardiac Life Support Instructors (ACLS-I) program will improve their emergency management and clinical teaching competencies and confidence.</p><p><strong>Methods: </strong>At the beginning of Pillar 2 (MS2) and after completion of ACLS training and certification, 16 medical students were accepted into the ACLS-I course. During Pillar 2 (MS2- MS3) participants completed the ACLS Instructor training course, obtained ACLS Instructor certification status, and taught at least 2 ACLS classes under supervision of the experienced ACLS instructors. At the end of Pillar 2 (MS3), 5 student-instructors and 58 noninstructors took a multiple-choice question (MCQ) quiz enhanced with the level of assurance rubric. Obtained data were analyzed to investigate ACLS instructors' competency in ACLS/non-ACLS knowledge compared to their peers. Students' performances were also assessed for correlation between knowledge accuracy and confidence in selected answers on the quiz. Additionally, the project investigated if course participants were more confident to participate in ACLS codes as providers and teach ACLS to healthcare students or providers using the 5-point Likert scale.</p><p><strong>Results: </strong>There was significant evidence (p less than 0.05) to suggest that ACLS-I students had a greater or equal mean raw score, were more competent in ACLS-I factual questions, and felt more comfortable teaching medical professionals and healthcare students how to manage cardiopulmonary emergencies and ACLS codes. There was not sufficient evidence (p greater than 0.05) to suggest that ACLS-I students were more competent in ACLS-I conceptual questions, more confident in their answers (correct and incorrect), and more confident in performing as a provider or team-leader in ACLS codes and cardiopulmonary emergencies.</p><p><strong>Conclusions: </strong>Completing an ACLS instructor course and participating as an ACLS instructor throughout medical school increases a medical student's factual ACLS knowledge and confidence in teaching ACLS codes compared to their peers. It does not increase accuracy and confidence of conceptual knowledge of cardiovascular emergencies.</p>","PeriodicalId":39219,"journal":{"name":"South Dakota medicine : the journal of the South Dakota State Medical Association","volume":"77 9","pages":"405"},"PeriodicalIF":0.0,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143012965","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"2024 Scholars' Research Symposium Abstract: ARPID-I: Initial Findings in Medical Students' Professional Identity Development.","authors":"Madison McLaury","doi":"","DOIUrl":"","url":null,"abstract":"&lt;p&gt;&lt;strong&gt;Introduction: &lt;/strong&gt;Professional identity is one of the frequently used and least clearly defined terms in healthcare education. Its simplest definition includes feeling, thinking, and acting like a representative of a given professional group. Many other aspects of professional identity exist. Professional identity development (PID) adds another layer of complexity to the topic for educators attempting to assess the process and dynamically measure its individual components. The project's aim was to re-define the term professional identity and create a battery of instruments to assess its development in medical students.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methods: &lt;/strong&gt;The first module, Assessment Rubric of Professional Identity Development (ARPID) was developed, piloted, reviewed, and deployed. ARPID is a 20-item multi-domain survey that assesses the following medical student characteristics: knowledge, skills, attitudes, feelings, readiness to act like a professional, confidence in decisionmaking, ability to sort relevant and irrelevant issues, ability to shift from fact-based to concept-based and metacognitive reasoning, ability to address ethical issues, and operate in the areas of clinical uncertainty. Answers to each question covered the range from novice to experienced professional. The survey was distributed to an entire body of medical students at a mid-western medical school in the U.S. 74 student responses were collected (26% response rate). Statistical analysis of the collected data included mean and standard deviation of confidence levels in each medical school class. Additionally, Spearman's rho analysis was performed on two sequential questions to better assess correlation of student's self-assessment and actual knowledge.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results: &lt;/strong&gt;Survey questions analyzing mean confidence, knowledge, and competence levels exhibited a positive relationship between these factors and years in medical school. Additionally, several aspects of data exhibited a Dunning-Kruger like trend involving knowledge and mean confidence level as medical students progressed through training. Spearman's rho analysis assessing correlation between confidence and competence level in students displayed a positive correlation in the first- and fourth-year student cohorts, and no correlation in the second- and third-year cohorts. The first-year cohort displayed a rho value of 0.510 with a p-value of 0.009. The second-year cohort displayed a rho of 0.000 with a p-value of 1.000, the third-year cohort displayed a rho of 0.002 with a p-value of 0.995, and the fourth-year cohort displayed a rho value of 0.497 with a p-value of 0.042.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions: &lt;/strong&gt;ARPID is a component in the battery of instruments used to measure and monitor medical students' PID. Given the importance of determining and following medical students' PID to optimize medical curricula and support students, this tool will enhance the way educators approach healthcare educa","PeriodicalId":39219,"journal":{"name":"South Dakota medicine : the journal of the South Dakota State Medical Association","volume":"77 9","pages":"401"},"PeriodicalIF":0.0,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143013222","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"2024 Scholars' Research Symposium Abstract: Kindling Wellness: Creating a Student-Run Podcast Series on Medical Student Wellness.","authors":"Kristi Pond","doi":"","DOIUrl":"","url":null,"abstract":"&lt;p&gt;&lt;strong&gt;Introduction: &lt;/strong&gt;Research has consistently shown that the prevalence of burnout symptoms (such as emotional and physical exhaustion, cynicism, or lack of interest in schoolwork, the sense of incompetence, or the feeling that you cannot be effective) in medical students is greater than the prevalence in the general population. Students with preexisting anxiety, depression, mood disorder or other psychological distress are more vulnerable to burnout. It is estimated that at least half of U.S. medical students experience or are affected by burnout during their education. With the high rates of burnout symptoms in medical students, it is becoming increasingly important to implement strategies to build student resilience to burnout. Overall, one of the first steps to decrease rates of burnout and improve medical student wellbeing is for students and faculty to develop an awareness and understanding of burnout, by exploring issues that may contribute to it. The Kindling Wellness podcast was created to serve as a wellness resource for medical students and health professionals.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Project description: &lt;/strong&gt;The initial 5-episode series of the podcast Kindling Wellness was built on the metaphor of a fire as one's wellness and the necessary components needed to keep a fire burning (heat, oxygen, and fuel). The Podcast was developed in 3 phases. Phase 1: Content Development included planning topics for discussion, choosing guests to interview, and deciding what platform on which to publish content. Phase 2: Podcast Interviews involved researching discussion topics, writing interview questions, interviewing guest speakers, and editing the content. Phase 3: Deployment and Awareness included publishing the Podcast on application platform - Spotify for Podcasters. The podcast was advertised using flyers posted in the medical school building, emails distributed to current medical students, and promotional posts via social media pages dedicated to the podcast. The podcast utilization was evaluated using analytics captured from the podcast application platform.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Outcomes: &lt;/strong&gt;Podcast episodes were released over a 6-month span from November 2022 to June 2023. The 1st podcast was a discussion with Michelle Schimelpfenig, DO about an overview of the podcast series and of medical student wellness. The 2nd podcast discussed mental health and counseling with Rebecca Glover, LPC-MH. The 3rd podcast was entitled \"Creating margin and practicing gratitude\" with Craig Uthe, MD. The 4th podcast was \"Finding your Fire\" with Gary Timmerman, MD and Jenny Guido, MD, and the 5th podcast was entitled \"Fueling your wellness and leadership\" featuring Tim Ridgway, MD. Podcast analytics were recorded simultaneously as listeners played the podcast episodes. There were 98 all-time plays; the first episode was the most listened to at 60 plays. The age of listeners ranged from 18-59 years old with most listeners in the 23-27 age range (35%).","PeriodicalId":39219,"journal":{"name":"South Dakota medicine : the journal of the South Dakota State Medical Association","volume":"77 9","pages":"407"},"PeriodicalIF":0.0,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143013536","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"2024 Scholars' Research Symposium Abstract: Rapid Cycle Deliberate Practice (RCDP) to Master Airway Intubation.","authors":"Kirsten R Kim Sawtelle","doi":"","DOIUrl":"","url":null,"abstract":"<p><strong>Introduction: </strong>Simulation has become an integral part of health care education curricula that is used to teach a variety of topics, from emergency situations to physical diagnoses. Without further reinforcement, the skills learned through the simulation are subject to deterioration over time. Rapid Cycle Deliberate Practice (RCDP) is a teaching method that was developed to resist this deterioration and achieve mastery of skills. In RCDP, learners cycle through a series of high-intensity and fast-paced scenarios until performance mastery was achieved. The individualized feedback is optimized with a 2:1 learner: instructor ratio. The goal of RCDP is to ensure 100% competency and time-efficiency of learners' performances. This study examined two sub-types of RCDP-style teaching to determine retention after 6-months.</p><p><strong>Methods: </strong>A two-day airway management course was conducted using RCDP to teach endotracheal intubation to second-year medical students using Medical Students as Simulations Educators (MSASE) as instructors. On Day 1, learners participated in 40-minute training sessions using a 2:1 ratio of learners to educators to practice intravenous induction into anesthesia and endotracheal intubation. Half the groups used an immediate-feedback (IF) RCDP approach while the other half used a delayed-feedback (DF) RCDP approach. Day 2 was completed 1 week later using similar methods. Learners participated in a 1-day simulation course in 6 months to assess retention (Day 3).</p><p><strong>Results: </strong>On Day 1, the IF group achieved mastery in fewer trials compared to the DF group (p = 0.004). The DF group required an average of 1.14 (CI = 0.845 - 1.433) trials until mastery, while the IF group required 0.516 (CI = 0.226 - 0.806) trials. The IF and DF groups demonstrated 98% knowledge and skills proficiency on Day 3, which is a significant increase from Day 1 and Day 2 scores of 92% and 88%, respectively. There was no significant difference in retention between the IF and DF groups.</p><p><strong>Conclusions: </strong>RCDP is an effective teaching method to achieve mastery with performing endotracheal intubation to second-year medical students. There was no significant difference between immediate-feedback and delayed-feedback when retention of this clinical skill was reassessed at 6 months.</p>","PeriodicalId":39219,"journal":{"name":"South Dakota medicine : the journal of the South Dakota State Medical Association","volume":"77 9","pages":"408"},"PeriodicalIF":0.0,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143013478","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"When Anticoagulation Matters: A Case of Large Left Atrial Thrombus After Left Atrial Appendage Ligation.","authors":"Emmanuel Fohle, Natale Wasef, Filip Oleszak, Maria Stys","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>Atrial fibrillation (AF) is the most frequently encountered arrhythmia in the clinical practice and is associated with stroke. In clinical practice, CHAD2DS2-VASc score is used as a tool to decide whether anticoagulation is needed. In those patients with high bleeding risk or falls, surgical ligation of the left atrial appendage (LAA) or percutaneous closure devices are strategies used to mitigate these challenges. However, there is no guideline advising on what patient's specific factors should be considered in determining initiation or continuation of anticoagulation post LAA ligation. Herein, we report the case of a patient with surgical ligation who developed large atrial thrombus requiring emergent median sternotomy.</p>","PeriodicalId":39219,"journal":{"name":"South Dakota medicine : the journal of the South Dakota State Medical Association","volume":"77 8","pages":"358-360"},"PeriodicalIF":0.0,"publicationDate":"2024-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142297690","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The Pharmaceutical Future of Remimazolam as Compared to Propofol and Midazolam: A Literature Review.","authors":"Hannah Meyer, Sean McCann, Joel Farmer","doi":"","DOIUrl":"","url":null,"abstract":"<p><strong>Introduction: </strong>Remimazolam is an ultra-short-acting benzodiazepine with a predictable and quick recovery that was FDA approved in 2020. As a relatively new medication, it is not as mainstream as other sedatives such as propofol or midazolam. This research aims to highlight the differences, benefits, and drawbacks of remimazolam in comparison to other short-term sedatives in order to bring greater awareness, and to consolidate the current knowledge of the effects of remimazolam.</p><p><strong>Methods: </strong>The PubMed database was used to search for current relevant research to review. The search terms used were: \"remimazolam\", \"midazolam\", \"propofol\", and procedural sedation. The search also used qualifiers using only publications in English and published within the last five years. This query yielded 26 articles which were reviewed for content and relevance.</p><p><strong>Results: </strong>Sixteen of the reviewed studies resulted in common themes suggesting remimazolam to be an effective alternative for procedural sedation with fewer adverse effects. Primarily, remimazolam is observed to have decreased procedural hypotension, bradycardia, and injection site pain. With no studies demonstrating an increased frequency of bradycardia, remimazolam is theorized to be superior to propofol in respect to sedation-associated bradycardia. One specific study notes a 14% decrease in frequency of bradycardia compared to propofol. Further benefits of remimazolam over propofol include the availability of an effective and reliable antidote, flumazenil.</p><p><strong>Conclusion: </strong>In being that remimazolam has primarily been used and studied in short-term sedation, we can only confidently conclude remimazolam's safety in these settings. There is little research being done in the way of ICU sedation or general anesthesia, but with the relatively similar, or decreased rates of adverse events with remimazolam, we suspect an increase in clinical research of remimazolam in these settings. With continued robust research, remimazolam could become more widely accepted as a safe alternative to current sedatives.</p>","PeriodicalId":39219,"journal":{"name":"South Dakota medicine : the journal of the South Dakota State Medical Association","volume":"77 suppl 8","pages":"s20-s21"},"PeriodicalIF":0.0,"publicationDate":"2024-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142297598","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Crossing Bridges Before You Come to Them: Anticipating the Uneven Path Toward Clinical Kindness.","authors":"Ann Cook, Jerome W Freeman","doi":"","DOIUrl":"","url":null,"abstract":"","PeriodicalId":39219,"journal":{"name":"South Dakota medicine : the journal of the South Dakota State Medical Association","volume":"77 8","pages":"338-339"},"PeriodicalIF":0.0,"publicationDate":"2024-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142297685","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The Posterior Triangle and Posterior Muscles of the Neck in 3-Dimensions: Creating a Digital Anatomic Model Using Peer-Reviewed Literature, Radiographic Imaging, and an Experienced Medical Illustrator.","authors":"Mason Blue, Gabriela A Calcano, Dan C Schmidtman, Gabriel A Hernandez-Herrera, Emilyn P Frohn, Caitlin J Vander Wert, Kathryn M Van Abel, Jonathan M Morris, Linda X Yin","doi":"","DOIUrl":"","url":null,"abstract":"<p><strong>Introduction: </strong>The posterior cervical triangle houses an important nodal basin in the spread of several cancers in the head and neck, particularly cutaneous malignancies of the scalp. A safe and effective Level V neck dissection necessitates thorough understanding of the neurovascular structures housed within the region. Conventional 2D anatomical representations offer insights into the named structures, but fall short in illustrating the spatial relationships crucial in surgery. Here, we aim to develop an anatomically-precise 3D virtual model of the posterior cervical triangle and its constituent structures.</p><p><strong>Methods: </strong>Musculature and neurovasculature were segmented from the computerized tomography (CT) angiogram of a healthy 29-year-old female. Literature review of cadaveric studies was performed to identify the most common variants, relevant surgical relationships, and usual dimensions of structures contained in the model. Structures unable to be visualized on imaging were created de novo using data obtained in the literature review. A medical illustrator then used this data to develop a 3D anatomical model using ZBrush.</p><p><strong>Results: </strong>The musculature (sternocleidomastoid, trapezius, omohyoid, scalenes, erector spinae, and transversospinalis muscles) and neurovasculature (spinal accessory nerve, phrenic nerve, vertebral artery, subclavian artery, and brachial plexus) were characterized through literature review. Musculature and vasculature were segmented from CT angiography while neural structures were created de novo. Both radiographic and anatomic data were used to inform the creation of a 3D model, which will be uploaded to an online database for open access viewing.</p><p><strong>Conclusions: </strong>A dynamic understanding of the spatial relationships existing among structures housed within the posterior triangle of the neck is imperative when operating in the region. The development of an accurate 3D anatomical model of such structures based upon predominant variants found in the literature will supplement the education of practicing and aspiring head and neck surgeons.</p>","PeriodicalId":39219,"journal":{"name":"South Dakota medicine : the journal of the South Dakota State Medical Association","volume":"77 suppl 8","pages":"s17-s18"},"PeriodicalIF":0.0,"publicationDate":"2024-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142297599","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Obesity: A Profoundly Under Recognized Chronic Disease; And Its Impacts on Cardiovascular Disease.","authors":"Muhammad Asif","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>Obesity is a treatable chronic disease of high prevalence in the U.S. It has various direct and indirect adverse health effects in terms of morbidity and mortality. It not only increases cardiovascular mortality but is also associated with an increased risk of multiple cancers. However, unlike other chronic diseases, obesity diagnosis often misses patients' and providers' attention and historically has been undertreated. This article is written to highlight the impact of obesity on health with special reference to cardiovascular disease, stimulate the quest among the masses and primary care providers for the diagnosis and treatment of obesity, its complications, and benefits obtained from its treatment.</p>","PeriodicalId":39219,"journal":{"name":"South Dakota medicine : the journal of the South Dakota State Medical Association","volume":"77 8","pages":"378-379"},"PeriodicalIF":0.0,"publicationDate":"2024-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142297687","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The Evolution of Renal Denervation for the Treatment of Hypertension: Insights from Trials and Prospects for Clinical Practice.","authors":"Hammad Shabir Chaudhry, Dawood Shehzad, Mustafa Shehzad, Logan Johnke, Muhammad Asif, Dawlat Khan, Wahab Jahangir Khan","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>Hypertension affects 1.3 billion adults globally, with severe health implications if left untreated. Despite efforts, research suggests only a fraction achieve adequate control. Renal denervation (RDN) therapy has emerged as a potential solution, particularly for treatment-resistant cases. RDN targets the dysregulated sympathetic nervous system activity frequently encountered in resistant hypertension. Recent FDA approval of advanced RDN catheter systems in 2023 signifies a pivotal advancement in hypertension management. As an adjunctive to pharmacotherapy, RDN holds promise as a therapeutic modality in achieving optimal blood pressure control and attenuating hypertension-related morbidity and mortality. Further research elucidating the nuances of patient selection, procedural standardization, and long-term outcomes is warranted to optimize the clinical utility of RDN in the management of hypertension. This manuscript compiles evidence for the use of RDN and reviews the long-term safety data from recent trials.</p>","PeriodicalId":39219,"journal":{"name":"South Dakota medicine : the journal of the South Dakota State Medical Association","volume":"77 8","pages":"365-371"},"PeriodicalIF":0.0,"publicationDate":"2024-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142297689","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}