Neurohospitalist最新文献

{"title":"Dramatic Reanimation and Spontaneous Re-Canalization of a Fourth Ventricular Hemorrhage: \"REVIVE\" Phenomenon.","authors":"Saif Salman, Andrea Janu, Rohan Sharma, Diane McLaughlin, Morgan Hardman, Rabih Tawk, W David Freeman","doi":"10.1177/19418744241289972","DOIUrl":"10.1177/19418744241289972","url":null,"abstract":"<p><strong>Background: </strong>Intraventricular hemorrhage is a calamitous type of stroke where bleeding into the ventricular system can be defined as: primary, if confined within the ventricles; or secondary, due to intracerebral hemorrhage extending from adjacent parenchyma. Intraventricular blood clot can lead to secondary insult and inflammatory responses that culminates in hydrocephalus as the most common cause of death.</p><p><strong>Purpose: </strong>THerein, we report a patient with a high modified Graeb scale and low Glasgow coma scale. She spontaneously recanalized her fourth ventricle, decompressed her reticular activating system with remarkable spontaneous bilateral eye opening, and a consequently experienced a halfway drop in her mGS.</p><p><strong>Results: </strong>This is the first reported case of a spontaneous recanalization of 4th ventricle obstruction secondary to IVH without intervention and subsequent dramatic neurological improvement. We believe that the apixaban primarily preserved the liquid state of hemorrhage and her presumed elevated ICP was sufficient to push out the liquified blood in the 4th ventricle into the upper spinal canal , recanalizing the 4th ventricle by continuously creating downward CSF pressure waves. Given the RAS location around the 4th ventricle, we hypothesize spontaneous decompression from the clot lysis triggered the RAS activation with sudden arousal manifested as spontaneous bilateral eyes opening. Hence, we refer to this as the reticular activating system reactivation after ventricular hemorrhage evacuation, or simply the \"REVIVE\" phenomenon.</p><p><strong>Conclusion: </strong>This dramatic improvement from coma to awake state is worthy of recognition for future neurotherapeutic interventions.</p>","PeriodicalId":46355,"journal":{"name":"Neurohospitalist","volume":" ","pages":"202-205"},"PeriodicalIF":0.7,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11559456/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142630238","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Episodic Coma in Lewy Body Disorders: An Observational Report.","authors":"Joseph H Friedman","doi":"10.1177/19418744241286579","DOIUrl":"10.1177/19418744241286579","url":null,"abstract":"<p><strong>Background: </strong>and Purpose: Episodes of unresponsiveness are one of several criteria used to diagnose dementia with Lewy bodies and are also seen in people with Parkinson's disease dementia. Patients examined during episodes of coma, whose evaluations found no other explanation than the neurological disorder, have not been described. This paper describes four cases, seen in the past two years. The objective is to bring this uncommon phenomenon to the attention of hospital based neurologists and to demonstrate that this may not be due to autonomic dysfunction.</p><p><strong>Methods: </strong>These are brief case descriptions by medical personnel observing affected patients supplemented by family reports of similar episodes described on the internet.</p><p><strong>Results: </strong>Four cases are described, all older men with either dementia with Lewy bodies or Parkinson's disease dementia, who had single, or multiple episodes of otherwise unexplained coma and were examined during a spell. IRB approval waived.</p><p><strong>Conclusions: </strong>Episodic coma may occur in demented patients with an alpha-synucleinopathy and is the likely explanation when evaluations have found no other cause. This information will reassure the family and patient that this is the likely explanation but that spells may recur.</p>","PeriodicalId":46355,"journal":{"name":"Neurohospitalist","volume":" ","pages":"100-104"},"PeriodicalIF":0.7,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11559462/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142636168","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Optimal Timeline and Hematoma Size Parameters for Middle Meningeal Artery Embolization in Acute-On-Chronic Subdural Hematomas.","authors":"Michael Fana, Giulia Santangelo, Abdalla Albanna, Ammar Jum'ah, Mohammed Rehman","doi":"10.1177/19418744241285275","DOIUrl":"10.1177/19418744241285275","url":null,"abstract":"<p><strong>Background and purpose: </strong>Chronic subdural hematomas (cSDH) are subdural collection of blood for which the current treatment option remains as surgical evacuation due to recurring focal inflammation and angiogenesis. An adjunctive therapeutic intervention is endovascular embolization of the middle meningeal artery (MMA) to cease the prolific cycle of angiogenesis. Few investigations have been made into the indications of this treatment modality regarding the intervention timeline and hematoma size for non-surgical candidates with acute-on-chronic subdural hematomas.</p><p><strong>Methods: </strong>We examined the clinical outcomes of 19 patients with 31 acute-on-chronic SDHs undergone MMA embolization and highlighted preliminary trends in radiological and morbidity outcomes.</p><p><strong>Results: </strong>Primary outcomes identified a 57.6% success rate for MMA embolization of acute-on-chronic SDHs defined as significantly reduced hematoma size (i.e. >50%) without recurring bleeds, peri-procedural complications, post-procedural neurological deficits, and need for post-procedural surgical evacuation. Subgroup analysis demonstrated a success rate of 90.9% in patients undergone embolization after a minimum 3-week delay from initial CT head study compared to 33.3% with early intervention as well as a success rate of 75% in patients presenting with a large (i.e. >10 mm) SDH compared to 30% for small SDH.</p><p><strong>Conclusion: </strong>Our preliminary data in this retrospective cohort study demonstrates significantly improved outcomes of MMA embolization in patients presenting with large (>10 mm) acute-on-chronic SDHs and in patients undergone embolization after >3 weeks from initial CT head and symptomatic presentation.</p>","PeriodicalId":46355,"journal":{"name":"Neurohospitalist","volume":" ","pages":"91-99"},"PeriodicalIF":0.7,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11559466/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142630171","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Pitfalls in the Evaluation of Respiratory Failure in Myasthenia Gravis Patients: A Case Series.","authors":"Sanem Pinar Uysal, Yuebing Li","doi":"10.1177/19418744241280528","DOIUrl":"10.1177/19418744241280528","url":null,"abstract":"<p><strong>Objectives: </strong>To highlight the importance of recognizing different presentations of respiratory failure due to myasthenic and non-myasthenic etiologies in myasthenia gravis (MG) patients.</p><p><strong>Methods: </strong>We describe 3 patients with different presentations of respiratory failure in MG.</p><p><strong>Cases: </strong>Patient 1 is a 49-year-old female with longstanding MG who presented with lethargy and neck weakness without notable respiratory distress. She was found to be in hypercarbic respiratory failure, which improved with plasmapheresis treatment. Patient 2 is a 58-year-old female who presented with ptosis, dysphagia, and dyspnea requiring intubation. Her hypophonia and dyspnea persisted despite escalation in MG treatment, and further workup revealed glottal stenosis secondary to granulomatosis with polyangiitis. Patient 3 is an 85-year-old female with MG presenting with refractory hypoxia, which was secondary to a large patent foramen ovale resulting in right-to-left shunting.</p><p><strong>Discussion: </strong>All 3 cases emphasize the role of clinical reasoning and careful analysis based on thorough history taking, detailed neurologic exam and comprehensive laboratory findings to determine the etiologies for respiratory dysfunction in MG and provide appropriate treatment.</p><p><strong>Conclusion: </strong>A lack of overt signs of respiratory distress in MG does not rule out the presence of respiratory failure due to the sedating effect of hypercapnia. There is a need to consider alternative etiologies of hypoxia in MG patients if typical symptoms or signs of MG exacerbations are absent.</p>","PeriodicalId":46355,"journal":{"name":"Neurohospitalist","volume":" ","pages":"151-154"},"PeriodicalIF":0.7,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11561952/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142648957","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Cavitating Osmotic Demyelination Syndrome Following Correction of Chronic Hyponatremia in Sheehan's Syndrome: A Novel Case Report.","authors":"Alamgir Shaikh, Moisés León-Ruiz, Ritwik Ghosh, Manoj Soren, Bilwatosh Mukhopadhyay, Shyamal Kanti Pal, Julián Benito-León","doi":"10.1177/19418744241279491","DOIUrl":"10.1177/19418744241279491","url":null,"abstract":"<p><strong>Introduction: </strong>Rapid correction of hyponatremia can result in osmotic demyelination syndrome (ODS). Sheehan's syndrome, a rare pituitary disorder caused by severe postpartum hemorrhage, is a potential cause of chronic hyponatremia. This case report describes a rare progression of extrapontine myelinolysis to central pontine myelinolysis, ultimately leading to ODS, following the correction of chronic hyponatremia associated with Sheehan's syndrome. Notably, this event occurred a decade after the initial postpartum hemorrhage due to placenta previa.</p><p><strong>Case report: </strong>A 40-year-old woman from rural West Bengal, India, presented in a comatose state after five years of progressively worsening symptoms, including fatigue, gastrointestinal disturbances, cold intolerance, hair loss, and severe apathy, which had been misdiagnosed as psychogenic and treated with selective serotonin reuptake inhibitors. Two days before her admission to our hospital, she was diagnosed with a lower respiratory tract infection, dehydration, and severe hyponatremia (118 mEq/L) at a local private healthcare facility. Despite treatment with 3% sodium chloride and intravenous antibiotics, her condition deteriorated, prompting her transfer. At the time of hospitalization, the patient was diagnosed with chronic hyponatremia and hypopituitarism consistent with Sheehan's syndrome. This condition was attributed to a severe postpartum hemorrhage that occurred a decade prior, resulting from placenta previa. Initial MRI revealed extrapontine myelinolysis, and the correction of her \"compensated\" hyponatremia was identified as the cause of her neurological decline. Follow-up MRIs at 7 and 14 weeks confirmed the development of cavitating ODS.</p><p><strong>Discussion: </strong>This case highlights several key points: First, even a relatively gradual correction of hyponatremia can precipitate ODS, especially in patients with chronic conditions like Sheehan's syndrome. Second, it underscores the importance of meticulous management of chronic hyponatremia to prevent severe neurological outcomes. Third, it illustrates the diagnostic challenges of differentiating Sheehan's syndrome from primary psychiatric disorders, particularly in low-resource settings where the syndrome remains prevalent. The case also emphasizes the need for awareness among healthcare providers about the potential for severe complications arising from even minor corrections in serum sodium levels in such patients.</p>","PeriodicalId":46355,"journal":{"name":"Neurohospitalist","volume":" ","pages":"188-194"},"PeriodicalIF":0.7,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11561923/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142648978","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Mamillopontine Distance Before and After Treatment in Spontaneous Intracranial Hypotension.","authors":"Evan Madill, Narayan Kissoon, Shamik Bhattacharyya","doi":"10.1177/19418744241273313","DOIUrl":"10.1177/19418744241273313","url":null,"abstract":"<p><p>We describe a case of spontaneous intracranial hypotension secondary to a CSF-venous fistula that was treated with transvenous embolization. We present the imaging findings from a brain MRI before and after embolization demonstrating changes in the patient's mamillopontine distance. Decreased mamillopontine distance is a marker of spontaneous intracranial hypotension and a minor criterion in the Bern Score.</p>","PeriodicalId":46355,"journal":{"name":"Neurohospitalist","volume":" ","pages":"221-222"},"PeriodicalIF":0.7,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11561963/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142649054","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Scrub Typhus Meningoencephalitis Presenting as Generalized Convulsive Status Epilepticus with Basal Ganglia and Extra-limbic Cortical Involvement, Complicated by Cortical Multifocal Myoclonus.","authors":"Uttam Biswas, Moisés León-Ruiz, Ritwik Ghosh, Ritun Sarkar, Raghul Bheeman, Arpan Mukhopadhyay, Julián Benito-León","doi":"10.1177/19418744241276903","DOIUrl":"10.1177/19418744241276903","url":null,"abstract":"<p><strong>Background: </strong>Scrub typhus is an acute febrile infectious disease highly prevalent in the Asia Pacific region, often referred to as the \"tsutsugamushi triangle.\" This mite-borne rickettsial zoonosis is caused by <i>Orientia tsutsugamushi</i>, an intracellular Gram-negative organism that primarily targets endothelial cells. The resulting vasculitis leads to multisystem involvement. In terms of neurological manifestations, meningoencephalitis is the most common presentation of scrub typhus. Other frequent neurological manifestations include cranial nerve paresis, transverse myelitis, and polyneuropathy. Status epilepticus, while reported, is a rare presenting feature of this infection. Although scrub typhus has been documented to present as limbic encephalitis, there have been no previous descriptions in the literature of neuroradiological patterns affecting the basal ganglia or extra-limbic cortices in this condition.</p><p><strong>Case report: </strong>We report a case of a 23-year-old previously healthy woman who presented with scrub typhus meningoencephalitis. The condition manifested as encephalitis with involvement of the basal ganglia and extra-limbic cortices. She presented with generalized convulsive status epilepticus, which was complicated by cortical multifocal myoclonus.</p><p><strong>Discussion: </strong>Scrub typhus can be a significant diagnostic challenge, potentially presenting with generalized convulsive status epilepticus and mimicking both clinical and radiological features of arboviral encephalitides, such as those caused by West Nile and Japanese encephalitis viruses. Furthermore, as demonstrated in this case, its radiological presentation can resemble that of autoimmune encephalitis. Given that scrub typhus is amenable to treatment with antibiotics, such as doxycycline and azithromycin, which do not increase seizure risk, it should be considered in the differential diagnosis for patients presenting with seizures or encephalitis, especially in endemic areas.</p>","PeriodicalId":46355,"journal":{"name":"Neurohospitalist","volume":" ","pages":"182-187"},"PeriodicalIF":0.7,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11561911/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142648964","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"A 38-year-Old Woman With Flaccid Tetraparesis after Presenting With Abdominal Pain.","authors":"Carolina Rodrigues Dal Bo, Julia Miranda Menezes, Barbara Gabriela Gomes Silva, Sarah Ingrid Farias Dos Santos, Marisa Petrucelli Doher, René de Araújo Gleizer","doi":"10.1177/19418744241281000","DOIUrl":"10.1177/19418744241281000","url":null,"abstract":"<p><p>A 38-year-old woman presented in the emergency department with acute abdominal pain. She underwent laparoscopic cholecystectomy. Postoperatively, she developed worsening abdominal pain, tachycardia, flaccid tetraparesis, urinary retention, constipation and SIADH. She also developed red-colored urine. Porphobilinogen was requested in an isolated urine sample, with the test result showing 256 mg/g of creatinine. This case didactically emphasizes the necessity of considering differential diagnosis in acute abdomen pain associated with neurological disorders.</p>","PeriodicalId":46355,"journal":{"name":"Neurohospitalist","volume":" ","pages":"172-175"},"PeriodicalIF":0.7,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11561945/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142648859","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Cortical (Spastic) Isolated Unilateral Foot Drop: The Foot Knob Area.","authors":"Jamir Pitton Rissardo, Ana Letícia Fornari Caprara","doi":"10.1177/19418744241279884","DOIUrl":"10.1177/19418744241279884","url":null,"abstract":"<p><p>Foot drop is a condition characterized by impairment of the ability to dorsiflex the foot at the ankle joint. We aim to review the literature and report a case of isolated unilateral foot drop of central causes. A 59-year-old male previously healthy presenting with a right foot drop was admitted. Severe weakness of ankle dorsiflexion with intact plantar flexion was observed. Deep tendon reflexes were normal, no clonus was appreciated, and a plantar response resulted in flexion of all toes. Neuroimaging showed a lesion in the high left frontal lobe, centered along the medial aspect of the precentral gyrus. Levetiracetam and dexamethasone were started, and after four days, the patient reported a slight improvement in his ability to dorsiflex his ankle. Abdominal imaging showed a large right renal mass with invasion of the renal pelvis fat, suggestive of renal cell carcinoma, and cytology diagnosed clear cell renal cell carcinoma. There are 25 articles containing 33 individuals with unilateral foot drop secondary to non-traumatic central causes in the literature. The mean and median age were 50.26 (SD = 20.57) and 55.5 years old (12 - 79 years). Most of the patients were males, which accounted for 55.88% (19/34). The side of the foot drop was right at 58.82% (20/34).</p>","PeriodicalId":46355,"journal":{"name":"Neurohospitalist","volume":" ","pages":"136-150"},"PeriodicalIF":0.7,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11561966/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142648983","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Long-Term Seizure Outcomes in Autoimmune Encephalitis.","authors":"Lucy Jia, Carla Y Kim, Maria Pleshkevich, Runze Cui, Yifei Sun, Julien Hébert, Claude Steriade, Kiran T Thakur","doi":"10.1177/19418744251331650","DOIUrl":"10.1177/19418744251331650","url":null,"abstract":"<p><strong>Introduction: </strong>Seizures are common in autoimmune encephalitis (AE), but identifying patients at risk of chronic epilepsy in the post-acute phase remains challenging. This study aims to identify risk factors of treatment-resistant postencephalitic epilepsy.</p><p><strong>Methods: </strong>This retrospective cohort study included patients with AE who experienced new-onset seizures within one year of symptom onset from two tertiary care centers in New York. EEG findings were analyzed separately based on whether the EEG recording was obtained in the acute (<3 months from symptom onset) or subacute phase. A multivariate logistic regression model was used to identify independent predictors of postencephalitic epilepsy.</p><p><strong>Results: </strong>Eighty-nine patients were included (median age: 33 years). Neural antibodies were present in 73% of patients (NMDAR: 35, LGI1: 19, GAD65: 9, Hu: 1, AGNA-1: 1). Over a median follow-up of 4.9 years, 29.2% developed treatment-resistant postencephalitic epilepsy. Independent predictors of postencephalitic epilepsy included focal slowing on acute EEG (OR 0.15, CI 0.02-0.90), interictal epileptiform discharges (IEDs) or periodic discharges (PDs) on subacute EEG (OR 20.01, CI 1.94-206.44), and cell surface antibodies (OR 0.21, CI 0.05-0.89). Immunotherapy within three months of onset was associated with decreased epilepsy development in patients with neural antibodies (OR 4.16, CI 1.11-16.30).</p><p><strong>Conclusions: </strong>Nearly one-third of patients with AE and acute seizures developed treatment-resistant postencephalitic epilepsy, with significant predictors including absence of focal slowing on acute EEG, presence of IEDs and PDs on subacute EEG, absence of cell surface antibodies, and absence of early immunotherapy treatment of patients with positive neural antibodies.</p>","PeriodicalId":46355,"journal":{"name":"Neurohospitalist","volume":" ","pages":"19418744251331650"},"PeriodicalIF":0.7,"publicationDate":"2025-04-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11962926/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143781474","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}