Respiratory Medicine Case Reports最新文献

{"title":"Painful large traumatic intercostal pulmonary hernia","authors":"Emilie Castermans ,&nbsp;Apostolos C. Agrafiotis ,&nbsp;Marie Bruyneel","doi":"10.1016/j.rmcr.2026.102412","DOIUrl":"10.1016/j.rmcr.2026.102412","url":null,"abstract":"<div><div>We present a case of traumatic intercostal pulmonary hernia that occurred following a fall. The patient had been experiencing pain for months prior to diagnosis. A chest CT scan revealed a large lung herniation measuring 9 x 4.5 × 9 cm between ribs 8 and 9, as well as fractures to ribs 6 to 11 on the right.</div><div>Surgical reconstruction of the chest wall using a Ventralight® prosthesis was performed via thoracotomy. The clinical course was favorable, with a significant decrease in chest pain.</div></div>","PeriodicalId":51565,"journal":{"name":"Respiratory Medicine Case Reports","volume":"61 ","pages":"Article 102412"},"PeriodicalIF":0.7,"publicationDate":"2026-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147554101","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":"Reverse triggering in mechanically ventilated ICU patients: Benefit or harm? Insights from bedside electrical impedance tomography in a case series","authors":"Song Zhang ,&nbsp;Siyi Yuan ,&nbsp;Elias Baedorf Kassis ,&nbsp;Songlin Wu ,&nbsp;Yi Chi ,&nbsp;Huaiwu He ,&nbsp;Daniel Talmor ,&nbsp;Longxiang Su ,&nbsp;Yun Long","doi":"10.1016/j.rmcr.2026.102402","DOIUrl":"10.1016/j.rmcr.2026.102402","url":null,"abstract":"<div><h3>Background</h3><div>Reverse triggering (RT) has been associated with potentially injurious ventilatory patterns in some settings, yet may also coincide with improved dependent ventilation or recruitment-like redistribution in selected patients. However, the effect of RT on patients with different underlying lung conditions are varied and objective tools or indicators for evaluation the effect of RT are still lacking.</div></div><div><h3>Case presentation</h3><div>There were four cases in this report, which consisted of three males and one female. These patients entered intensive care unit (ICU) for severe sepsis or underwent the hits of major surgeries. Case 1 and 4 represented the heavier lung injury accompanied by RT, even if RT resulted in improved dorsal ventilation or better ventilatory homogeneity, the effect of this transient benefit needs to be considered in the context of systemic conditions and disease progression. Patient-ventilation synchronization in critical situations may alleviate mechanical lung injury. Case 2 and 3 were associated with RT which may represent a physiological, non-injurious pattern of patient-ventilator interaction. One possible explanation is that this pattern may resemble mechanisms such as a diaphragmatic brake or a sigh-like recruitment effect.</div></div><div><h3>Conclusions</h3><div>These cases suggest that RT may present with different physiological patterns across patients. RT without appreciable pendelluft and without deterioration in global mechanics/EIT indices may be observed with close monitoring, whereas RT accompanied by prominent pendelluft or potentially injurious mechanics may warrant active mitigation.</div></div>","PeriodicalId":51565,"journal":{"name":"Respiratory Medicine Case Reports","volume":"61 ","pages":"Article 102402"},"PeriodicalIF":0.7,"publicationDate":"2026-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147554102","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":"Management of refractory status asthmaticus with sevoflurane in the intensive care unit: Case reports","authors":"Orlando Rubén Pérez-Nieto ,&nbsp;Jorge Beauregard-Mora ,&nbsp;Jonathan Reyes-Montufar ,&nbsp;Carlos Mendiola-Villalobos ,&nbsp;Alejandra Vargas-Torres ,&nbsp;Diego Edgar Ledesma-López ,&nbsp;Raúl Arturo González-Toribio ,&nbsp;Alexis Stephano Henales-Ocampo ,&nbsp;Tania Olga Mondragón-Labelle ,&nbsp;Ernesto Deloya-Tomas","doi":"10.1016/j.rmcr.2026.102426","DOIUrl":"10.1016/j.rmcr.2026.102426","url":null,"abstract":"<div><div>Status asthmaticus represents a severe asthma exacerbation requiring prompt medical attention and often necessitating intensive care. These case reports describe two adult patients with refractory status asthmaticus who required advanced interventions, including invasive mechanical ventilation and sevoflurane administration due to persistent bronchospasm despite standard therapies. The first case involves a 66-year-old female with a history of asthma and type 2 diabetes who developed bronchospasm following elective cataract surgery, leading to respiratory failure and cardiac arrest. The second case concerns a 26-year-old female with poorly controlled allergic eosinophilic asthma, exacerbated by non-adherence to treatment and environmental exposures, resulting in near-fatal respiratory distress. In both instances, sevoflurane was employed for its bronchodilatory effects via calcium channel inhibition and modulation of inflammatory responses, leading to improved bronchospasm and successful weaning from mechanical ventilation. Ventilatory strategies emphasized low respiratory rates and extended I:E ratios to prevent air trapping and dynamic hyperinflation. Spontaneous breathing trials with zero PEEP facilitated extubation, followed by high-flow nasal cannula support in the first case. Both patients stabilized and were discharged from the ICU. These cases highlight the challenges in managing refractory asthma exacerbations, particularly in perioperative and non-adherent contexts, and underscore sevoflurane's potential as a rescue therapy when conventional treatments fail. They emphasize the importance of vigilant monitoring, timely escalation of care, and tailored ventilatory management to optimize outcomes in status asthmaticus.</div></div>","PeriodicalId":51565,"journal":{"name":"Respiratory Medicine Case Reports","volume":"61 ","pages":"Article 102426"},"PeriodicalIF":0.7,"publicationDate":"2026-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147859026","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":"Perioperative venous thromboembolism salvage via VA-ECMO-bridged surgical thrombectomy: A case report","authors":"Dongmei Hu ,&nbsp;Hong Zhao,&nbsp;Yingdian Yu","doi":"10.1016/j.rmcr.2025.102354","DOIUrl":"10.1016/j.rmcr.2025.102354","url":null,"abstract":"<div><div>Deep vein thrombosis (DVT) and subsequent pulmonary embolism (PE) represent critical postoperative complications, often characterized by an insidious onset and underappreciated risk. We present a case of a 47-year-old paraplegic male who developed sudden hypoxemia and hemodynamic collapse on postoperative day 10 following cervical vertebroplasty. Bedside echocardiography promptly confirmed high-risk PE with right ventricular strain. In cases where pharmacologic thrombolysis was ineffective, emergent veno-arterial extracorporeal membrane oxygenation (VA-ECMO) was instituted to provide circulatory support, thereby ensuring safe inter-hospital transfer. Subsequent imaging revealed right main pulmonary artery occlusion and bilateral iliac vein thrombosis. A multidisciplinary team executed a combined strategy of iliac vein filter placement and surgical thrombectomy, achieving complete clot removal. VA-ECMO support was successfully weaned within 48 hours, followed by full cardiopulmonary recovery. This case underscores several key principles in managing catastrophic PE: (1) the imperatives of maintaining a high index of suspicion for venous thromboembolism in immobilized postoperative patients with acute clinical deterioration; (2) the pivotal role of bedside ultrasound as a rapid diagnostic tool when pulmonary angiography is not immediately obtainable; (3) the utility of VA-ECMO as a vital rescue and bridge therapy in pharmacologically refractory, unstable PE; and (4) the critical importance of a coordinated, time-sensitive, multidisciplinary pathway from diagnosis to definitive surgical intervention for survival.</div></div>","PeriodicalId":51565,"journal":{"name":"Respiratory Medicine Case Reports","volume":"59 ","pages":"Article 102354"},"PeriodicalIF":0.7,"publicationDate":"2026-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145927191","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":"A case of severe Legionella pneumonia treated with omadacycline and nemonoxacin","authors":"Tingrui Zhao ,&nbsp;Yukai Chen ,&nbsp;He Sun","doi":"10.1016/j.rmcr.2026.102437","DOIUrl":"10.1016/j.rmcr.2026.102437","url":null,"abstract":"<div><div>Severe <em>Legionella pneumophila</em> pneumonia carries high mortality, and treatment is challenged by emerging resistance to conventional fluoroquinolones/macrolides and diagnostic delays. Novel agents such as omadacycline and nemonoxacin show theoretical promise, yet robust clinical evidence in legionellosis is lacking. We report a 59-year-old man with severe community-acquired pneumonia(sCAP) who initially received empiric ceftazidime-avibactam plus nemonoxacin. Respiratory failure did not improve, and the inflammatory markers did not decline. Subsequent bronchoalveolar lavage fluid metagenomic next-generation sequencing(BALF-mNGS) and urinary <em>Legionella</em> antigen confirmed <em>Legionella</em> pneumonia. We then switched to dual therapy with omadacycline and nemonoxacin. The combination led to rapid improvements in inflammatory markers, hypoxemia, and creatine kinase levels. This case provides a clinical rationale for using omadacycline plus nemonoxacin as salvage therapy in severe <em>Legionella</em> pneumonia when conventional regimens fail.</div></div>","PeriodicalId":51565,"journal":{"name":"Respiratory Medicine Case Reports","volume":"62 ","pages":"Article 102437"},"PeriodicalIF":0.7,"publicationDate":"2026-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148158910","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":"Unilateral diffuse alveolar haemorrhage as an atypical presentation of PR3-ANCA-associated vasculitis: A case report","authors":"Poonam Patil,&nbsp;Babaji Ghewade,&nbsp;Ulhas Jadhav,&nbsp;Sanket Ghute,&nbsp;Beeravolu Harshith Reddy,&nbsp;Amisha Harish Soni,&nbsp;Shristi Jain","doi":"10.1016/j.rmcr.2026.102455","DOIUrl":"10.1016/j.rmcr.2026.102455","url":null,"abstract":"<div><div>Diffuse alveolar haemorrhage (DAH) is a life-threatening pulmonary manifestation of small-vessel vasculitis, most commonly associated with anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis. Unilateral DAH has been infrequently reported and may pose diagnostic challenges, as its radiological presentation can mimic pneumonia, pulmonary oedema, or localized haemorrhage. This atypical presentation may delay recognition of the underlying vasculitis and appropriate immunosuppressive therapy.</div><div>We present a case of a woman in her thirties with previously diagnosed PR3-ANCA-associated vasculitis who presented with acute worsening of dyspnea (mMRC grade IV) and hemoptysis. Radiological assessments revealed extensive right-sided ground-glass opacities with areas of consolidation and minimal left lower lobe involvement. Bronchoscopy with sequential bronchoalveolar lavage (BAL) showed progressively haemorrhagic aliquots consistent with DAH. Laboratory investigations revealed anemia (Hb 7.1 mg/dL) and elevated serum creatinine (5.02 mg/dL). The patient developed type I respiratory failure requiring mechanical ventilation and hemodialysis. She was treated with pulse intravenous methylprednisolone followed by rituximab therapy, along with trimethoprim-sulfamethoxazole prophylaxis. The patient improved clinically, radiologically, and biochemically and was discharged on supplemental oxygen.</div></div>","PeriodicalId":51565,"journal":{"name":"Respiratory Medicine Case Reports","volume":"62 ","pages":"Article 102455"},"PeriodicalIF":0.7,"publicationDate":"2026-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13312000/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148354700","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":"Persistent hiccups following endobronchial ultrasound-guided transbronchial needle aspiration","authors":"Monika Saran,&nbsp;Mithlesh Kushwah,&nbsp;Girish Sindhwani,&nbsp;Prasan Kumar Panda","doi":"10.1016/j.rmcr.2026.102462","DOIUrl":"10.1016/j.rmcr.2026.102462","url":null,"abstract":"<div><div>Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive diagnostic procedure widely used in modern pulmonary medicine. Major complications are rare and usually hemorrhagic or infectious, while neurological sequelae are exceptionally uncommon. We report a rare case of persistent hiccups following EBUS-TBNA in a middle-aged man evaluated for fever and necrotic mediastinal lymphadenopathy with a probable diagnosis of tuberculosis or invasive fungal diseases. Despite extensive investigations, including cross-sectional imaging and upper gastrointestinal endoscopy, no structural abnormalities such as mediastinitis or pleuritis were identified. The patient's hiccups were severe, interfered with sleep, and persistent despite oral intake of baclofen for 5 days; however, resolved within 2 days of combination therapy with baclofen and chlorpromazine. This case highlights that hiccups, although uncommon, may occur as a direct and debilitating iatrogenic complication of EBUS-TBNA, likely due to mechanical stimulation of mediastinal neural structures. Clinicians should be aware of this potential complication, particularly when hiccups occur immediately after the procedure.</div></div>","PeriodicalId":51565,"journal":{"name":"Respiratory Medicine Case Reports","volume":"63 ","pages":"Article 102462"},"PeriodicalIF":0.7,"publicationDate":"2026-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13380420/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148498414","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":"Reversible pre-capillary pulmonary hypertension due to long-standing arteriovenous fistula","authors":"Laura Saldivar,&nbsp;Emily Garber,&nbsp;Khaled Boubes,&nbsp;Elie Homsy","doi":"10.1016/j.rmcr.2026.102467","DOIUrl":"10.1016/j.rmcr.2026.102467","url":null,"abstract":"<div><div>Chronic kidney disease predisposes patients to the development of pulmonary hypertension (PH) via multiple potential mechanisms. AV fistulas have been found to be superior to AV grafts in terms of maintaining patency, however unlike grafts fistulas can expand significantly over time which predisposes patients to high output heart failure and subsequent PH. This report demonstrates a case of newly diagnosed pre-capillary PH in a young patient presenting with dyspnea. The patient had an AV fistula placed 18 years prior to presentation for CKD and ultimately underwent transplantation. Pulmonary angiography was negative for PE and echocardiography demonstrated an elevated RVSP of 67 mmHg that was confirmed via right heart catheterization. This case was unique in that the patient's pre-capillary PH was reversed after AV fistula ligation and the patient also experienced improvement in renal graft function (Cr 1.43 to 1.2 mg/dL). AV fistulas can have a significant effect on cardiac function and clinicians should survey patients with AV fistulas for PH via screening echocardiography. Fistulas with outputs greater than 1.5-2 L/min should be considered for revision or ligation to decrease the risk of development of PH.</div></div>","PeriodicalId":51565,"journal":{"name":"Respiratory Medicine Case Reports","volume":"63 ","pages":"Article 102467"},"PeriodicalIF":0.7,"publicationDate":"2026-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13380133/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148498436","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":"Diesel Siphoner's Lung: Acute exogenous lipoid pneumonia following accidental aspiration of diesel fuel—two case reports and a literature review","authors":"Nian Dong,&nbsp;Miaotong Lin,&nbsp;Qiongyan Wu,&nbsp;Zhenghui Wu,&nbsp;Zhonglin Bai,&nbsp;Aifang Sun,&nbsp;Longwang Chen,&nbsp;Zhongqiu Lu","doi":"10.1016/j.rmcr.2026.102478","DOIUrl":"10.1016/j.rmcr.2026.102478","url":null,"abstract":"<div><h3>Background</h3><div>Diesel Siphoner's Lung is a severe, life-threatening subtype of acute exogenous lipoid pneumonia (ELP) caused by accidental diesel fuel aspiration. While diagnosis is typically straightforward with a clear exposure history, clinical management is challenging due to rapidly progressive respiratory failure. Given the relative rarity of such accidents and the lack of standardized management guidelines, optimizing therapeutic strategies remains a significant clinical challenge.</div></div><div><h3>Case presentation</h3><div>We report two cases of acute ELP resulting from diesel siphoning—a distinct clinical entity termed 'Diesel Siphoner's Lung'—demonstrating highly divergent clinical trajectories. Case 1, a previously healthy 48-year-old male, presented with acute lung injury (ALI) 8 hours post-aspiration. Prompt interventions, including endotracheal intubation, serial segmental bronchoalveolar lavage (sBAL) and systemic corticosteroid therapy, were adopted. Following progressive clinical improvement, the patient was extubated on the 8th day and subsequently discharged on the 25th day with substantial radiological resolution. Conversely, Case 2—a 45-year-old male with a history of diabetes and hypertension—was admitted with established acute respiratory distress syndrome (ARDS) 2 days post-aspiration. His clinical course was severely complicated by multidrug-resistant nosocomial infections and a left-sided hydropneumothorax, refractory to similar clinical management with endotracheal intubation, serial sBAL, and systemic corticosteroid therapy. Despite the initiation of extracorporeal membrane oxygenation (ECMO) rescue therapy on the 11th day, the patient ultimately succumbed to multiple organ failure on the 19th day.</div></div><div><h3>Conclusion</h3><div>The divergent outcomes of our two reported cases, coupled with findings from the relevant literature, highlight the critical necessity of an multimodal intervention strategy. We advocate for the prompt implementation of sBAL to mechanically remove aspirated lipids and halt ongoing chemical cytotoxicity, combined with early systemic corticosteroid therapy to attenuate the fulminant inflammatory cascade. Furthermore, in severe cases presenting with refractory hypoxemia and irreversible pulmonary damage, ECMO should be recognized as a viable and crucial bridge to subsequent lung transplantation.</div></div>","PeriodicalId":51565,"journal":{"name":"Respiratory Medicine Case Reports","volume":"63 ","pages":"Article 102478"},"PeriodicalIF":0.7,"publicationDate":"2026-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148777182","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":"Pulmonary histoplasmosis mimicking recurrent lung adenocarcinoma: A case report","authors":"Mauro Geller,&nbsp;Marcos Knobel,&nbsp;Marcelo Kalichsztein,&nbsp;Felipe Carbonieri,&nbsp;Regina C. Schechtman,&nbsp;David S. Lewi,&nbsp;Spyros G.E. Mezitis","doi":"10.1016/j.rmcr.2026.102484","DOIUrl":"10.1016/j.rmcr.2026.102484","url":null,"abstract":"<div><div>Pulmonary histoplasmosis, caused by the dimorphic fungus <em>Histoplasma capsulatum</em>, can present as solitary pulmonary nodules with granulomatous inflammation that radiologically and metabolically mimic malignant lesions, posing a significant diagnostic challenge in patients with a history of lung cancer. We report a case of a 69-year-old asymptomatic male with a prior left upper lobe adenocarcinoma resected in 2019, who presented with a new growing, hypermetabolic nodule in the left lower lobe during routine oncologic surveillance in December 2025. Sequential computed tomography (CT) demonstrated interval growth, and positron emission tomography (PET-CT) revealed intense fluorodeoxyglucose (FDG) uptake (SUVmax 7.2), strongly suggesting recurrence. Video-assisted thoracoscopic segmentectomy was performed; histopathological examination revealed chronic necrotizing granulomatous inflammation, with Grocott methenamine silver staining confirming small yeast forms consistent with <em>Histoplasma</em> spp. No malignancy was identified. This case underscores the diagnostic pitfall of fungal infections mimicking cancer recurrence in endemic regions and the indispensable role of histopathological confirmation prior to initiating systemic oncologic therapy.</div></div>","PeriodicalId":51565,"journal":{"name":"Respiratory Medicine Case Reports","volume":"63 ","pages":"Article 102484"},"PeriodicalIF":0.7,"publicationDate":"2026-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148777190","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}