William Delahoussaye, Zachary A Stern-Buchbinder, Daniel Yoo, Leslie M Slowikowski, India M Hill, Mohamad Masoumy, Gregory K Fulton
{"title":"Cleft Lip and Palate Repairs in a Patient With Epidermolysis Bullosa Simplex.","authors":"William Delahoussaye, Zachary A Stern-Buchbinder, Daniel Yoo, Leslie M Slowikowski, India M Hill, Mohamad Masoumy, Gregory K Fulton","doi":"10.1177/10556656251351775","DOIUrl":"https://doi.org/10.1177/10556656251351775","url":null,"abstract":"<p><p>Epidermolysis bullosa simplex (EBS) is a rare congenital disorder that presents with blistering of the skin from minimal shearing or pulling, making surgical care complex in terms of preventative measures and management. Literature is limited regarding cleft care in this unique patient population. We present a case report outlining a multidisciplinary cleft treatment plan with a focus on communication with the patient's family. Cleft lip and palate repair was performed using standard techniques and timing without complication, demonstrating that cleft lip and palate repairs can safely be performed in a patient with EBS.</p>","PeriodicalId":49220,"journal":{"name":"Cleft Palate-Craniofacial Journal","volume":" ","pages":"10556656251351775"},"PeriodicalIF":1.1,"publicationDate":"2025-06-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144486776","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":"Complex Craniofacial Challenges: A Case Series of Tessier Clefts 14, 10, 7, and 4.","authors":"Kabita Kalita, Rishi Kumar Gupta, Poresh Baruah, Jyotirmay Baishya","doi":"10.1177/10556656251351097","DOIUrl":"https://doi.org/10.1177/10556656251351097","url":null,"abstract":"<p><p>Craniofacial clefts are very rare congenital anomalies with an incidence of around 1.4 to 4.85 per 100,000 live-births. Our hospital managed four unique cases of Tessier's cleft between 2022 and 2024. They comprise a patient with Tessier No. 14 cleft and a fronto-nasal-ethmoidal meningoencephalocele, second patient with Tessier No. 10 and 4 clefts and coloboma over the upper eyelids, third patient with Tessier No. 7 cleft and macrostomia, and the fourth patient with Tessier No. 14 cleft and hypertelorism. Our series emphasizes the importance of individualized surgical planning, multidisciplinary approach, and parental requirements in the treatment of such craniofacial anomalies.</p>","PeriodicalId":49220,"journal":{"name":"Cleft Palate-Craniofacial Journal","volume":" ","pages":"10556656251351097"},"PeriodicalIF":1.1,"publicationDate":"2025-06-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144477494","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}
Sai Cherukuri, Jainaha Srikumar, Alexandre Meira Pazelli, Samir Mardini, Uldis Bite, Kathy Brumfield, Edward S Ahn, Ashley Grossbach, Waleed Gibreel
{"title":"Cranial Remolding Orthosis Therapy for Positional Deformational Head Shape Abnormalities: The Parental Perspective.","authors":"Sai Cherukuri, Jainaha Srikumar, Alexandre Meira Pazelli, Samir Mardini, Uldis Bite, Kathy Brumfield, Edward S Ahn, Ashley Grossbach, Waleed Gibreel","doi":"10.1177/10556656251343425","DOIUrl":"10.1177/10556656251343425","url":null,"abstract":"<p><p>ObjectiveWe aimed to understand the impact of Cranial Remolding Orthotic therapy (CRO) on the quality of life of both infants with positional deformational head shape abnormalities (PDHSAs), including plagiocephaly and brachycephaly, and their caregivers.DesignSurvey study.SettingA single, tertiary academic center.Patients, ParticipantsFamilies of infants with PDHSAs who underwent CRO between 2007 and 2022.InterventionsCRO.Main Outcome Measure(s)Subjective assessment of caregiver perspectives.ResultsWe obtained 242 responses (72% male) from 1013 patients contacted (response rate 23.9%). CRO was initiated at a median age of 6 months (IQR 5-7 months), with a median treatment duration of 4 months (IQR 3-5 months). Insurance covered costs fully for 9.8% of respondents and partially for 47.0%; 43.2% paid completely out-of-pocket. Most were \"very satisfied\" or \"satisfied\" with head shape (89.2%) and ear position (93.3%). CRO did not impact children's sleep (75.2%), \"never\" or \"rarely\" impacted children's play (90.5%), and never impacted most families' attendance of social events (91.3%). Hair loss was temporary in 29.9% and permanent in 0.8%. Most families did not find CRO burdensome (73.1%) and \"never\" or \"rarely\" felt fatigued (68.5%).ConclusionsThe study sheds light on the mental and social effects of CRO on patients and caregivers, as well as physical adverse effects associated with treatment. Overall, patients' families expressed satisfaction with results and felt that administering CRO had minimal negative impacts on themselves and their children.</p>","PeriodicalId":49220,"journal":{"name":"Cleft Palate-Craniofacial Journal","volume":" ","pages":"10556656251343425"},"PeriodicalIF":1.1,"publicationDate":"2025-06-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144340549","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}
Robert Conville, Nor Nadia Zakaria, Martin Woods, Golfam Khoshkhounejad
{"title":"Does Tooth Removal at the Time of Secondary Alveolar Bone Grafting Influence the Outcome for Cleft Patients?","authors":"Robert Conville, Nor Nadia Zakaria, Martin Woods, Golfam Khoshkhounejad","doi":"10.1177/10556656251346720","DOIUrl":"https://doi.org/10.1177/10556656251346720","url":null,"abstract":"<p><p>ObjectiveTo investigate whether tooth removal at the time of secondary alveolar bone grafting (SABG) has any association with the surgical outcome and to assess the overall radiographic outcomes of SABG.DesignSingle-center retrospective cohort study.<i>Setting</i>Tertiary UK cleft service.MethodsAny patient diagnosed with a cleft lip and/or palate aged under 16 years who had a SABG over a 3-year period (January 2021-June 2023) were included in the study. Patients with a craniofacial syndrome or those who had a repeat SABG were excluded. Two trained independent assessors were calibrated to use the Kindelan scoring index. Intra and inter-rater reliability was assessed using kappa statistics at the dichotomous level for the calibrated assessors (success vs failure). Chi-square tests were used to assess any associations (<i>P</i> < .05).ResultsNinety patients and 105 SABG (mean age 10.12 years SD 1.45) were included in the study. The overall success rate of the SABGs included was 85.7%. There were no significant differences in outcomes between those who had tooth extraction at the time of bone grafting (<i>P</i> > .05). There were also no statistically significant association between cleft type and cleft side and graft success.ConclusionsTooth extraction during the time of SABG surgery did not significantly influence its success. The results demonstrated that the SABG success rate was in line with the UK national outcome data.</p>","PeriodicalId":49220,"journal":{"name":"Cleft Palate-Craniofacial Journal","volume":" ","pages":"10556656251346720"},"PeriodicalIF":1.1,"publicationDate":"2025-06-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144318446","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}
Nicola M Stock, Bruna Costa, Anna Zarola, Allyn Auslander, Hugh Brewster, Phyllida Swift, Leela Imam, Usama Hamdan, Gareth Davies, Sara Horne, Priti P Desai
{"title":"The Psychosocial Impact of Cleft Lip and/or Palate on Caregivers and Individuals in Low- and Middle-Income Countries: A Narrative Review.","authors":"Nicola M Stock, Bruna Costa, Anna Zarola, Allyn Auslander, Hugh Brewster, Phyllida Swift, Leela Imam, Usama Hamdan, Gareth Davies, Sara Horne, Priti P Desai","doi":"10.1177/10556656251343393","DOIUrl":"https://doi.org/10.1177/10556656251343393","url":null,"abstract":"<p><p>Low- and middle-income countries (LMICs) represent the highest incidence, morbidity, and Disability Adjusted Life Years for cleft lip and/or palate (CL/P) globally. Most cleft care models now include psychosocial support, yet the psychosocial impacts of CL/P in LMICs are understudied. This narrative review aimed to synthesize published literature to provide a foundation for future research and evidence-based psychosocial support. Seventy-one peer-reviewed articles published between September 2003 and July 2024 were included. Themes pertaining to caregivers included Social Experiences, Emotional Well-Being, Treatment Experiences, and overall Quality of Life. Themes regarding individuals with CL/P included Developmental Trajectory, Social Integration, Emotional Health, Satisfaction with Treatment, and Health-Related Quality of Life. Most articles focused on upper-middle-income countries. East Asia and Pacific was the most studied geographical region in LMICs, while Europe and Central Asia was the least studied. Only 28 of 135 LMICs (20.7%) were represented in the included psychosocial literature. Most studies (69%) utilized a quantitative design. Sample sizes ranged from 2 to 295, with 73% of studies recruiting from a single site. Few studies (28%) compared their data to reference or control groups. Just over half of studies used standardized, validated measures. Most studies were led by LMIC teams. This review calls for ongoing monitoring of psychological health in individuals with CL/P and their caregivers and coordinated investment into multifaceted psychosocial program in LMICs. Building practice-relevant research capacity in LMICs to develop the evidence-base is essential.</p>","PeriodicalId":49220,"journal":{"name":"Cleft Palate-Craniofacial Journal","volume":" ","pages":"10556656251343393"},"PeriodicalIF":1.1,"publicationDate":"2025-06-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144303346","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}
Anna Stenson Zerpe, Mia Ramklint, Daniel Nowinski, Caisa Öster
{"title":"Assessing Parents' Perceived Stress, Psychological Distress, and Health-Related Quality of Life Before and One Year After Their Child's Craniosynostosis Surgery.","authors":"Anna Stenson Zerpe, Mia Ramklint, Daniel Nowinski, Caisa Öster","doi":"10.1177/10556656251347704","DOIUrl":"https://doi.org/10.1177/10556656251347704","url":null,"abstract":"<p><p>ObjectiveAssessing parents' perceived stress, psychological distress, and health-related quality of life (HRQoL) before their child's craniosynostosis surgery and one year after.Setting/ParticipantsParents of children with nonsyndromic craniosynostosis, scheduled to undergo surgery at the Uppsala Craniofacial Centre, were invited to participate. Data were collected between May 2016 and February 2025. There were 157 eligible patients; 103 (66%) parents participated, and 29 (28%) provided data at both time points.<i>Main Outcome Measures:</i> Swedish parenting stress questionnaire (SPSQ), Hopkins Symptom Checklist (HSCL-25), EQ VAS.ResultsThe HSCL-25 total score and the subscale depression were rated higher before the surgery than one year after. There were no differences in the SPSQ total score, or EQ VAS scores before and after surgery, but parents rated their feelings of incompetence higher at follow-up. Participants did not report more parental stress on SPSQ subscales than the average population of parents, either before or after surgery. Before surgery, SPSQ subscales incompetence and role restriction were associated with symptoms of depression. After, the association between these subscales remained. Moreover, an association was found between the subscale incompetence and symptoms of anxiety.ConclusionsParents whose children underwent surgery for craniosynostosis did not seem to experience higher levels of parental stress than Swedish parents in general. There were no differences in perceived parental stress and HRQoL before and one year after surgery, while the psychological distress was higher before. A positive association between parental stress and symptoms of depression was seen both before and after surgery.</p>","PeriodicalId":49220,"journal":{"name":"Cleft Palate-Craniofacial Journal","volume":" ","pages":"10556656251347704"},"PeriodicalIF":1.1,"publicationDate":"2025-06-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144303415","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}
Savannah C Braud, Zachary D Zapatero, Yuliia Kovach, Mangalam Karuppiah, Milind Sangani, David W Low
{"title":"From Hip to Tip: Harvesting Iliac Crest Cartilage for Delayed Cleft Rhinoplasty.","authors":"Savannah C Braud, Zachary D Zapatero, Yuliia Kovach, Mangalam Karuppiah, Milind Sangani, David W Low","doi":"10.1177/10556656251349339","DOIUrl":"https://doi.org/10.1177/10556656251349339","url":null,"abstract":"<p><p>ObjectiveThis study evaluates nasal symmetry outcomes in patients with unilateral cleft lip (UCL) who underwent delayed rhinoplasty during iliac bone grafting (IBG), allowing concurrent bone grafting and cartilage harvesting to reduce donor sites.DesignRetrospective cohort study.SettingTertiary care pediatric hospital.PatientsThose with UCL who underwent IBG and primary rhinoplasty during the same operation.InterventionsPrimary rhinoplasty at the time of IBG.Main outcome measuresCephalometric analyses of pre- and postoperative basilar view nasal images assessed nostril height, nostril width, nasal circumference, and angle of columellar deviation.ResultsThe final cohort included 52 patients with a mean age of 7.61 years (range 5.51-13.7) at the time of concurrent IBG and delayed rhinoplasty, with a mean follow-up of 4.6 years (range 1.02-15.1). Cephalometric measurements were evaluated by the ratio of the shorter or smaller side to the longer or larger side. Average preoperative nostril height was 0.70 (range 0.23-0.95) which increased postoperatively to 1.0 (range 0.60-8.35) (P = 0.047). Average preoperative circumference was 1.27 (range 0.67-2.01) which decreased to 1.12 (range 0.70-1.68) postoperatively (P = 0.011). The angle of columellar deviation averaged 8.0 degrees (range 1.57-18.7) preoperatively which decreased to 6.0 degrees (range 0.22-18.4) postoperatively (P = 0.010).ConclusionsDelaying primary rhinoplasty until the time of IBG yields satisfactory outcomes, with iliac crest cartilage providing favorable, longlasting results in patients with UCL. This approach reduces the need for an additional donor site and may reduce the need for subsequent definitive rhinoplasty.</p>","PeriodicalId":49220,"journal":{"name":"Cleft Palate-Craniofacial Journal","volume":" ","pages":"10556656251349339"},"PeriodicalIF":1.1,"publicationDate":"2025-06-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144303418","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}
Sophia Z Chryssofos, Arjun Mehendale, Kevin He, Tinna Kosoko-Thoroddsen, Gary B Skolnick, Lauren H Yaeger, Sybill D Naidoo, Kamlesh B Patel
{"title":"The Current State of Prospective Registries for Congenital Craniofacial Anomalies: A Review.","authors":"Sophia Z Chryssofos, Arjun Mehendale, Kevin He, Tinna Kosoko-Thoroddsen, Gary B Skolnick, Lauren H Yaeger, Sybill D Naidoo, Kamlesh B Patel","doi":"10.1177/10556656251349881","DOIUrl":"https://doi.org/10.1177/10556656251349881","url":null,"abstract":"<p><p>ObjectiveThis review aims to summarize existing prospective registries for congenital craniofacial anomalies across the globe.DesignWe conducted a comprehensive review of Embase and the Google Search Engine for articles which gathered data from prospective craniofacial registries and registry websites, respectively. Registry details were verified by registry coordinators where email addresses were available.SettingInstitutional or national cleft lip and/or palate (CLP) centers.Main OutcomesFor each registry, we collected coordinating and contributing centers, registry goals, years of operation, number of patients, datapoints collected, funding, and quality assurance mechanisms.ResultsNine registries were identified. Six focused on CLP, 1 on craniosynostosis, 1 on craniofacial microsomia, and 1 on a range of craniofacial abnormalities. Only European and U.S.-centered registries were identified. Every existing European CLP registry represents all government-supported cleft centers in its respective nation. The 3 U.S.-based registries are expansive, but do not capture a nationwide patient base.ConclusionsThis review characterizes the current global state of prospective registries for research on congenital craniofacial anomalies. The strength and organization of data collection varies greatly by registry and by country, though the present landscape exhibits potential for improvement of craniofacial research and patient outcomes. With this evidence, we advocate for a nationally coordinated registry to improve outcomes for children with craniofacial anomalies across the United States.</p>","PeriodicalId":49220,"journal":{"name":"Cleft Palate-Craniofacial Journal","volume":" ","pages":"10556656251349881"},"PeriodicalIF":1.1,"publicationDate":"2025-06-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144303345","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":"Clinical Presentation of Congenital Oral Mucosal Synechiae in A Newborn in Association with Cleft Palate.","authors":"Chanchal Kumari, Ruchi Singhal, Ritu Namdev, Ankita Sharma, Ankita Dahiya","doi":"10.1177/10556656251349335","DOIUrl":"https://doi.org/10.1177/10556656251349335","url":null,"abstract":"<p><p>This case report presents a rare occurrence of congenital oral mucosal synechiae in a 5-day-old neonate with a cleft palate, leading to feeding difficulties. The infant exhibited a soft fibrous band restricting oral mobility, which was successfully excised using electrocautery. Immediate postsurgical improvements included restored mouth opening and the ability to breastfeed. Histopathological analysis confirmed connective tissue composition. This case highlights the importance of recognizing mucosal synechiae in neonates and its associated cleft and other craniofacial anomalies, contributing to the limited literature on this rare presentation and guiding future clinical management strategies, offering valuable insights for clinicians handling similar presentations.</p>","PeriodicalId":49220,"journal":{"name":"Cleft Palate-Craniofacial Journal","volume":" ","pages":"10556656251349335"},"PeriodicalIF":1.1,"publicationDate":"2025-06-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144303416","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}
Dominic J Romeo, Leigh Friedman, Manisha Banala, Carlos E Barrero, Benjamin B Massenburg, Jinggang J Ng, Meagan Wu, Leanne Magee, Jordan W Swanson, Jesse A Taylor, Scott P Bartlett
{"title":"Quality of Life in Craniofacial Microsomia: Resilience Through Young Adulthood.","authors":"Dominic J Romeo, Leigh Friedman, Manisha Banala, Carlos E Barrero, Benjamin B Massenburg, Jinggang J Ng, Meagan Wu, Leanne Magee, Jordan W Swanson, Jesse A Taylor, Scott P Bartlett","doi":"10.1177/10556656251347171","DOIUrl":"https://doi.org/10.1177/10556656251347171","url":null,"abstract":"<p><p>ObjectiveWhile studies have analyzed the quality of life (QOL) in children with craniofacial microsomia (CFM), little is known about QOL in adults with CFM. This study compares QOL in adults with CFM to a comparative group using a validated questionnaire.DesignCross-sectional.SettingTertiary care center.Patients, ParticipantsAdults aged 18 years or older with CFM were contacted and administered the World Health Organization (WHO) QOL Biomedical Research and Educating Foundation questionnaire.Main Outcome Measure(s)Quality of life in adults with CFM.ResultsOne hundred and fourteen patients met inclusion criteria, 40 (35.1%) were successfully contacted, and 28 (24.6%) completed the questionnaire in 8.6 ± 2.6 min. Respondents were 23.3 ± 4.6 years old (minimum 18.4, maximum 32.8 years) with 16 (57.1%) females and 12 (42.9%) males. This cohort of adults with CFM scored lower in the physical domain (13.8 ± 1.7 vs 15.5 ± 3.2, <i>P</i> < .01), similar in the psychological (14.7 ± 1.9 vs 13.8 ± 3.2, <i>P</i> > .05), and higher in both the social (16.0 ± 3.2 vs 13.2 ± 3.2, <i>P</i> < .01) and environmental (16.8 ± 1.6 vs 11.7 ± 2.7, <i>P</i> < .01) domains than the WHO norm sample. There was no association between overall phenotypic severity or craniofacial surgical burden and QOL (<i>P</i> > .05).ConclusionsAdults treated for CFM perceive their physical health QOL to be lower than the WHO norms but report higher QOL in the social and environmental domains. Adult patients with CFM may demonstrate resilience and can live high-quality lives. These results underscore that their lives are not defined by CFM.</p>","PeriodicalId":49220,"journal":{"name":"Cleft Palate-Craniofacial Journal","volume":" ","pages":"10556656251347171"},"PeriodicalIF":1.1,"publicationDate":"2025-06-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144303343","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}