Neurologist最新文献

{"title":"Diagnostic Yield of Neuroimaging in Patients With Nonindex Seizures in the Emergency Department.","authors":"Camilo Espinosa-Jovel, Sandra Riveros, Shayla Sánchez, Mariana Orozco, Ana M Baldovino, Valeria León","doi":"10.1097/NRL.0000000000000697","DOIUrl":"https://doi.org/10.1097/NRL.0000000000000697","url":null,"abstract":"<p><strong>Objectives: </strong>The diagnostic yield of neuroimaging in patients with nonindex seizures, defined as those with established epilepsy presenting to the emergency department with a recurrent seizure, remains uncertain. Although head computed tomography (CT) is frequently performed, its impact on clinical decision-making is often limited. This study aimed to assess the frequency of neuroimaging use, its diagnostic yield, and the clinical factors associated with acute findings leading to management changes.</p><p><strong>Methods: </strong>We conducted a retrospective observational study of adult patients with epilepsy presenting with nonindex seizures to a tertiary public hospital in Bogotá, Colombia, between February 2023 and February 2024. Sociodemographic, clinical, and neuroimaging data were extracted from electronic medical records. Descriptive and bivariate analyses were performed.</p><p><strong>Results: </strong>A total of 307 patients were included (median age: 39 y; 58.6% male). Head CT was performed in 79.8% (n=245), revealing structural abnormalities in 43.6% (n=107). Only 3.7% (n=9) showed acute pathologic findings requiring changes in management. Most abnormalities were chronic and did not influence clinical decisions. The only variable significantly associated with acute CT findings was seizure-related traumatic brain injury (33.3% vs. 0%, P<0.001; OR=26.6, 95% CI: 11.2-62.8).</p><p><strong>Conclusions: </strong>The diagnostic yield of head CT in patients with nonindex seizures is low despite its widespread use in emergency settings. Routine neuroimaging may be unnecessary without clinical red flags such as trauma, new focal deficits, or atypical presentations. Evidence-based tools are needed to guide neuroimaging use and optimize resource utilization.</p>","PeriodicalId":49758,"journal":{"name":"Neurologist","volume":" ","pages":""},"PeriodicalIF":1.2,"publicationDate":"2026-10-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149220829","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":"Geographic Accessibility to Acute Stroke Care in Egypt: A Population-Level GIS Analysis With Hub-and-Spoke Network Optimization.","authors":"Ossama Y Mansour, Tamer Hassan, Hany Z Eldeen, Amr Mahmoud, Ahmed Ossama, Ehab S Mohamed, Nada Nasr, Farouk Hassan, Ahmed Hassawy, Khalid Sobh, Ibrahim Elmenshawi, Mohamed Badran, Islam El-Malky, Gihan Gewaifel, Hussam Salah","doi":"10.1097/NRL.0000000000000695","DOIUrl":"https://doi.org/10.1097/NRL.0000000000000695","url":null,"abstract":"<p><strong>Objectives: </strong>Egypt faces a disproportionate acute stroke burden, but geographic accessibility to intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) has not been systematically quantified using modality-specific treatment windows. The objective of the current work is to measure population-level geographic accessibility to IVT and MT across Egypt's 27 governorates, characterize access inequality determinants, and model the clinical impact and cost-effectiveness of targeted hub-and-spoke network expansion.</p><p><strong>Methods: </strong>We verified 29 IVT-capable hospitals and 13 MT-ready centers through a 3-phase protocol. Onset-to-treatment time was computed for 120 settlements representing 89.3% of the national population (108.3 million). MT eligibility was based on noncontrast CT for ASPECTS scoring and CT angiography for large-vessel occlusion confirmation. Treatment windows were classified as optimal (<180 min), within-window (IVT 180 to 270 min; MT 180 to 360 min), or denied (IVT >270 min; MT >360 min). A maximum-coverage location problem model identified the optimal deployment for 3 new MT hubs and 4 IVT spokes. Cost-utility analysis expressed outcomes in quality-adjusted life years over 10 years using Egypt's GDP per capita of $3800.</p><p><strong>Results: </strong>IVT optimal access was 71.8% nationally (77.0 million), while MT optimal access was only 56.2% (60.9 million), with 20.4% denied MT under the 6-hour threshold. Nine of 13 MT-ready centers (69.2%) concentrated in Cairo/Giza (19.2% of the population). Hub-and-spoke deployment improved MT optimal access from 56.2% to 75.8% nationally. Probabilistic sensitivity analysis demonstrated 73.2% and 91.4% probabilities of cost-effectiveness at 3× and 4× GDP thresholds, respectively.</p><p><strong>Conclusions: </strong>Egypt's MT access crisis reflects infrastructure maldistribution rather than patient ineligibility. A hub-and-spoke model using NCCT+CTA-based MT selection within the 6-hour window is clinically sound, operationally feasible, and probabilistically cost-effective.</p>","PeriodicalId":49758,"journal":{"name":"Neurologist","volume":" ","pages":""},"PeriodicalIF":1.2,"publicationDate":"2026-10-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149220835","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":"Can Generative AI Score the NIHSS? Performance of Large Language Models on Standardized Clinical Cases.","authors":"Luiz G B Santos, Mike Y Hamasaki, Adroaldo Lunardelli, Renan G de Oliveira","doi":"10.1097/NRL.0000000000000696","DOIUrl":"https://doi.org/10.1097/NRL.0000000000000696","url":null,"abstract":"","PeriodicalId":49758,"journal":{"name":"Neurologist","volume":" ","pages":""},"PeriodicalIF":1.2,"publicationDate":"2026-10-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149197412","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 Neurology in Practice: The Shoulder (Part 1).","authors":"Stéphane Mathis, Emilie Géfard-Gontier, Valentin Strub, Capucine Blaise, Paula Peydro-Lavoie, Donald Taylor-Parkins, Guilhem Solé, Gwendal Le Masson","doi":"10.1097/NRL.0000000000000693","DOIUrl":"https://doi.org/10.1097/NRL.0000000000000693","url":null,"abstract":"<p><strong>Background: </strong>The shoulder's complex anatomy and biomechanics render it uniquely susceptible to neurological disorders, spanning radiculopathies, plexopathies, and myopathies. Despite its clinical relevance, the shoulder remains understudied in neurological practice, where its dysfunction often serves as an early marker of underlying pathology. A comprehensive understanding of its anatomic, neural, and vascular foundations is essential for accurate diagnosis and management.</p><p><strong>Revision summary: </strong>This review focuses on the shoulder's osteoligamentous architecture, motor and sensory innervation, vascular supply, and reflexes governing its function. Key topics include: anatomic foundations (glenohumeral and scapulothoracic articulations, ligamentous support, and muscular dynamics), neural control (brachial plexus organization, motor/sensory innervation patterns, and vascular-neural interactions in thoracic outlet syndrome), clinical examination (diagnostic maneuvers and provocative tests to localize nerve root or plexus lesions), and pathologic signatures (scapular dyskinesis, scapula alata, and reflex abnormalities as indicators of neurological dysfunction). Emphasis is placed on practical tools for bedside evaluation, including illustrated anatomic landmarks, reflex testing protocols, and differential diagnostic algorithms.</p><p><strong>Conclusion: </strong>By synthesizing anatomic precision with clinical applicability, this review equips neurologists to differentiate neurological, orthopedic, and vascular causes of shoulder dysfunction. The framework presented here-combining historical perspectives with evidence-based techniques-aims to refine diagnostic accuracy and inform targeted interventions. Part 2 will explore specific neurological pathologies (eg, central syndromes, myopathies, and postinjury complications) to complete this comprehensive resource for clinical practice.</p>","PeriodicalId":49758,"journal":{"name":"Neurologist","volume":" ","pages":""},"PeriodicalIF":1.2,"publicationDate":"2026-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149138971","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 Neurology in Practice: The Shoulder (Part 2).","authors":"Stéphane Mathis, Emilie Géfard-Gontier, Valentin Strub, Capucine Blaise, Paula Peydro-Lavoie, Guilhem Solé, Gwendal Le Masson","doi":"10.1097/NRL.0000000000000692","DOIUrl":"https://doi.org/10.1097/NRL.0000000000000692","url":null,"abstract":"<p><strong>Background: </strong>The shoulder's intricate neuroanatomy and biomechanics render it uniquely vulnerable to a broad spectrum of neurological disorders, from central lesions to peripheral nerve injuries. While Part 1 of this series established the anatomic and neurological foundations of shoulder function, Part 2 focuses on the pathologic landscape of neurological shoulder affections. These conditions-ranging from rare central syndromes to common peripheral neuropathies-often present diagnostic challenges due to overlapping clinical features with orthopedic and rheumatological disorders. A systematic understanding of their distinct manifestations is essential for accurate diagnosis and targeted management.</p><p><strong>Revision summary: </strong>This review synthesizes historical insights with contemporary clinical evidence to explore neurological pathologies involving the shoulder. Key topics include central nervous system syndromes, peripheral nerve pathologies, neuromuscular junction and muscle disorders, postneurological injury complications, and therapeutic strategies (emerging research directions and multidisciplinary approaches to optimize patient outcomes, including rehabilitation protocols and surgical interventions). The review integrates practical tools for clinical evaluation, such as illustrated anatomic landmarks, reflex testing protocols, and differential diagnostic algorithms, while bridging historical observations with modern diagnostic techniques.</p><p><strong>Conclusion: </strong>By synthesizing anatomic precision with clinical applicability, this paper equips neurologists to recognize and manage neurological shoulder pathologies. The framework presented-combining historical depth with evidence-based techniques-aims to refine diagnostic accuracy, inform targeted interventions, and improve patient outcomes. Together with Part 1, this series provides a comprehensive resource for understanding the shoulder's role in neurological practice, from foundational anatomy to advanced pathologic management.</p>","PeriodicalId":49758,"journal":{"name":"Neurologist","volume":" ","pages":""},"PeriodicalIF":1.2,"publicationDate":"2026-09-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149138968","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":"Neuroepigenetics of the Environmental Exposome: Molecular and Clinical Implications in Neurodegeneration.","authors":"Elizabeth Avendaño-Arango, Isabella Salom-Palacio, Edgard Eliud Castillo-Támara, Belkis Palacio-Villalba","doi":"10.1097/NRL.0000000000000694","DOIUrl":"https://doi.org/10.1097/NRL.0000000000000694","url":null,"abstract":"<p><strong>Background: </strong>Neuroepigenetics studies the molecular mechanisms that regulate gene expression in the nervous system without altering the DNA sequence. The environmental exposome has emerged as a key factor influencing neuronal plasticity and brain homeostasis, contributing to vulnerability to neurodegeneration.</p><p><strong>Review summary: </strong>This narrative review analyzes the role of neuroepigenetic reprogramming as a central mechanism linking chronic environmental exposures with neurodegenerative diseases. Evidence indicates that alterations in DNA methylation, histone remodeling, and microRNA regulation contribute to mitochondrial dysfunction, oxidative stress, and chronic neuroinflammation. These mechanisms are critically involved in the pathogenesis of Alzheimer disease, Parkinson disease, and amyotrophic lateral sclerosis.</p><p><strong>Conclusions: </strong>Neuroepigenetics represents a central mechanistic axis in neurodegeneration by integrating environmental exposures with intrinsic biological processes. This framework offers new opportunities for the development of early biomarkers and targeted preventive and therapeutic strategies.</p>","PeriodicalId":49758,"journal":{"name":"Neurologist","volume":" ","pages":""},"PeriodicalIF":1.2,"publicationDate":"2026-09-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"149075907","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":"Vogt-Koyanagi-Harada (VKH) Syndrome Mimicking Bilateral Optic Neuritis.","authors":"Aashka Shah, Siddhartha Rao, Rajesh K Singh, Jasmine Parihar, Animesh Das, Arunmozhimaran Elavarasi, Deepti Vibha, Ajay Garg, Pradeep Venkatesh, Manjari Tripathi","doi":"10.1097/NRL.0000000000000690","DOIUrl":"https://doi.org/10.1097/NRL.0000000000000690","url":null,"abstract":"<p><strong>Introduction: </strong>Vogt-Koyanagi-Harada (VKH) syndrome is an idiopathic immune-related disorder that affects multiple organ systems, particularly targeting melanocytes in the uvea, ear, and meninges. It can sometimes present as subacute vision loss and or headache without other systemic features mimicking optic neuritis or Idiopathic intracranial hypertension, leading to an initial misdiagnosis.</p><p><strong>Case report: </strong>A 36-year-old male presented with an acute onset and progressive diminution of vision in both eyes for 5 days. Fundus examination revealed papillitis. Brain MRI and CSF examination were normal. Serum NMO and MOG were negative. Considering bilateral optic neuritis, he was started on intravenous methylprednisolone therapy, following which his vision showed initial improvement, followed by deterioration after 3 days. The MRI was reviewed again and showed a subtle FLAIR hyperintensity just lateral to the optic nerve entry in the posterior pole, suggestive of choroidal thickening. Optical coherence tomography showed bilateral large Neurosensory retinal detachment and intraretinal fluid. Fundus fluorescein angiography showed multifocal pinpoint hyperfluorescent spots due to leakage from the retinal pigment epithelium and dye pooling in the subretinal space, suggestive of VKH syndrome. Visual acuity improved after 3 cycles of plasma exchange to 6/6 in the right eye and 6/12 in the left eye.</p><p><strong>Conclusion: </strong>VKH should be considered in the differential diagnosis of any patient presenting with a history and examination suggestive of bilateral seronegative optic neuritis, even in the absence of characteristic extraocular manifestations of the disease.</p>","PeriodicalId":49758,"journal":{"name":"Neurologist","volume":" ","pages":""},"PeriodicalIF":1.2,"publicationDate":"2026-09-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148978614","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":"Recurrent Cardiac Cephalalgia: A Case Report and Pooled Narrative Review.","authors":"Ben J Braunecker, A Laine Green","doi":"10.1097/NRL.0000000000000686","DOIUrl":"https://doi.org/10.1097/NRL.0000000000000686","url":null,"abstract":"<p><strong>Introduction: </strong>Cardiac cephalalgia is a headache disorder associated with myocardial ischemia that presents as a moderate to severe exertional headache with potentially migrainous features that remains difficult to identify due to highly variable presentations and unclear pathophysiology.</p><p><strong>Case report: </strong>We present a diagnostically challenging case of cardiac cephalalgia in an elderly male with multiple cardiovascular risk factors and a remote history of percutaneous coronary intervention (PCI) for coronary artery disease (CAD), exemplified by a multiyear history of progressive exertional headaches without stereotypical cardiac symptoms, normal brain imaging, an unremarkable neurological exam, and the presence of a confounding SIADH. In an exceedingly rare event in the reported literature, this patient returned in the same year after treatment with a recurrence of symptoms.</p><p><strong>Conclusions: </strong>Given the heterogeneity in presentation of cardiac cephalalgia, accurate and efficient diagnosis remains challenging, especially in cases with isolated cephalalgia, but case reports such as this highlight the need for vigilance in history taking, examination, and work-up to identify a potentially lethal cardiovascular emergency underlying this type of headache. While the presentation varies widely, cardiac cephalalgia most commonly presents in older males as a severe, exertional, pressure-like headache in the frontal region, associated with angina but without autonomic features.</p>","PeriodicalId":49758,"journal":{"name":"Neurologist","volume":" ","pages":""},"PeriodicalIF":1.2,"publicationDate":"2026-09-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148978540","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":"Artificial Intelligence in the Prehospital Stage of Stroke: Can Virtual Assistants Optimize Triage?","authors":"Lucas Alessandro, Santiago Crema, Nicolás Bianciotti, Josefina Lombán, Carolina Irma Perez Arana, Franco G Bordón Orsingher, Agostina L Kañevsky, Virginia Pujol-Lereis, Diego Fernandez Slezak, Mauricio F Farez","doi":"10.1097/NRL.0000000000000682","DOIUrl":"10.1097/NRL.0000000000000682","url":null,"abstract":"<p><strong>Objectives: </strong>Many patients fail to access emergency services in time for acute stroke treatment. Artificial intelligence (AI) may help optimize prehospital triage. This study describes the development, refinement, and clinical validation of an AI-based virtual assistant (VA) for early stroke detection and appropriate emergency referral.</p><p><strong>Methods: </strong>A prospective cohort study was conducted between August 2024 and July 2025 in a tertiary care center in Buenos Aires, Argentina. The VA was applied to adult inpatients with acute stroke in a neurovascular unit. Before this, the tool had been optimized using a literature review and simulations with 1151 de-identified medical records. Clinical, demographic, and performance variables were recorded. The main outcomes were syndromic diagnostic alignment, identification of the most probable diagnosis, appropriate emergency referral, and user satisfaction.</p><p><strong>Results: </strong>A total of 78 participants were included (median age: 73 y; 56.4% male). The mean time from symptom onset to VA use was 2 days. Final diagnoses were ischemic stroke (80.8%), transient ischemic attack (11.5%), subarachnoid hemorrhage (5.1%), and intracerebral hemorrhage (2.6%). Syndromic diagnosis matched the clinical standard in 89.7% of cases; top-1 match in 71.8%, and top-3 in 91%. Emergency referral was adequate in 93.6% of cases. The median use involved 10 questions and 4 minutes. Over 90% rated the experience 4 or 5 out of 5.</p><p><strong>Conclusions: </strong>In this controlled validation involving patients with confirmed cerebrovascular disease, the AI-based VA demonstrated high agreement with clinical syndromic classification, appropriate urgency recommendations, and high user acceptance. Further evaluation in broader prehospital populations is warranted.</p>","PeriodicalId":49758,"journal":{"name":"Neurologist","volume":" ","pages":"211-218"},"PeriodicalIF":1.2,"publicationDate":"2026-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148377671","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":"Looking Beyond the Midline: An Uncommon Etiology of Internuclear Ophthalmoplegia of Abduction Due to Cerebral Venous Thrombosis.","authors":"Dipti Baskar, Aravinda G Maheswarappa","doi":"10.1097/NRL.0000000000000683","DOIUrl":"10.1097/NRL.0000000000000683","url":null,"abstract":"<p><strong>Introduction: </strong>Internuclear ophthalmoplegia (INO) is a horizontal gaze disorder caused by medial longitudinal fasciculus lesions. INO of abduction is an exceptionally rare variant characterized by abduction limitation with preserved convergence and contralateral adduction nystagmus, with unclear pathophysiology, and only a limited number of cases have been reported.</p><p><strong>Case report: </strong>A 27-year-old man presented with headache, vomiting, seizures, and altered sensorium. Examination revealed bilateral disc edema and abduction restriction of the right eye, with contralateral adduction nystagmus, consistent with INO of abduction. Brain MRI showed no brainstem lesions, while MR venography demonstrated cerebral venous thrombosis of the superior sagittal, left transverse, and sigmoid sinuses. Vitamin B12 deficiency with hyperhomocysteinemia was detected. Treatment with anticoagulation and acetazolamide resulted in complete resolution of the ocular motility deficits.</p><p><strong>Conclusion: </strong>This case highlights a reversible form of INO of abduction associated with raised intracranial pressure in the absence of structural brainstem lesions, likely due to pressure-mediated disruption of inhibitory gaze pathways. INO of abduction is an ultrarare but clinically important sign. Its recognition in patients with intracranial hypertension and normal brainstem imaging may aid in localization and facilitate timely, reversible treatment.</p>","PeriodicalId":49758,"journal":{"name":"Neurologist","volume":" ","pages":"223-225"},"PeriodicalIF":1.2,"publicationDate":"2026-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148334062","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}