The journal of extra-corporeal technology最新文献

{"title":"Evaluation of bivalirudin-based anticoagulation for extracorporeal membrane oxygenation, including patients with COVID-19.","authors":"Miranda Raguindin, Casey Bardsley, Chelsea Bast, David Sugrue, Hasan Kazmi, Ashley Milkovits","doi":"10.1051/ject/2025045","DOIUrl":"10.1051/ject/2025045","url":null,"abstract":"<p><strong>Background: </strong>Although unfractionated heparin (UFH) has traditionally been used for anticoagulation during extracorporeal membrane oxygenation (ECMO), bivalirudin may be preferred due to fewer complications. A prior medication use evaluation of ECMO patients who received bivalirudin resulted in dosing updates for our pharmacist-directed bivalirudin protocol. This study intended to evaluate the efficacy and safety of bivalirudin for anticoagulation during ECMO support post-protocol initiation.</p><p><strong>Methods: </strong>This was a retrospective, single-center, pre-post study. Adult patients requiring ECMO support for at least 24 h and who received bivalirudin between January 1, 2015 to July 31, 2018 (pre-group) and May 1, 2019 to June 30, 2021 (post-group) were included.</p><p><strong>Results: </strong>There were 38 patients in the pre- and 35 patients in the post-group. The primary outcome, median time to two consecutive activated partial thromboplastin times (aPTTs) within therapeutic range for the initial goal range, was 8.9 h in the pre- and 14.2 h in the post-group (p = 0.517). In a subgroup analysis of the post-group, the primary outcome was higher in patients with COVID-19 (26.5 vs. 8.6 h, p = 0.018). The median number of dose adjustments to achieve goal aPTT was higher in COVID-19 patients (4 vs. 2, p = 0.017).</p><p><strong>Conclusion: </strong>These results suggest that a standardized pharmacist-directed protocol for bivalirudin in ECMO achieves timely therapeutic anticoagulation levels. Patients with COVID-19 trended toward longer times to two consecutive therapeutic aPTTs. Further studies are needed to evaluate dosing strategies in patients with and without COVID-19.</p>","PeriodicalId":519952,"journal":{"name":"The journal of extra-corporeal technology","volume":"58 1","pages":"57-64"},"PeriodicalIF":0.0,"publicationDate":"2026-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12984034/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147446746","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 bedside staffing model with perfusionists for pediatric extracorporeal membrane oxygenation (ECMO) at a high-volume center★.","authors":"Christopher Nemeh, Caitlin Cain-Trivette, Nicholas Schmoke, Caleb Varner, Michael Brewer, Eunice Clark, Holly Ream, Diana Vargas Chaves, Tarif Choudhury, Steven Stylianos, William Middlesworth, Eva W Cheung","doi":"10.1051/ject/2025040","DOIUrl":"10.1051/ject/2025040","url":null,"abstract":"<p><strong>Background: </strong>Extracorporeal membrane oxygenation (ECMO) in pediatric patients requires monitoring by specialists to optimize outcomes. Practice variability exists among pediatric ECMO centers across the country. We present a bedside pediatric ECMO staffing model with perfusionists that combines personnel expertise and technology.</p><p><strong>Methods: </strong>At our institution, ECMO care is provided in three intensive care units across one floor. Our primary bedside ECMO provider consists of pediatric perfusionists who provide 24/7 coverage of ECMO patients via remote monitoring and hourly bedside rounding. Neonatal and pediatric ECMO patients are supported using the Cardiohelp System^TM, which uses Spectrum Medical Quantum Elite Workstation and Variable Input Patient Electronic Records (VIPER) software that remotely delivers ECMO circuit parameters and alarms digitally to a monitor in a workroom and mobile devices. ECMO education and skills are reinforced via dedicated didactic and simulation sessions by an ECMO program coordinator. We compared institutional complication rates to other centers tracked by ELSO.</p><p><strong>Results: </strong>From 2017 to 2023, 289 cannulations were performed, consisting of a total of 62,742 cumulative ECMO hours, of which 92% of that time there were simultaneous ECMO patients. This rounding model has institutional mortality and complication rates that are comparable to ELSO rates.</p><p><strong>Conclusion: </strong>We describe a bedside ECMO staffing model with perfusionists, in contrast to ECMO specialists seen at other institutions. The complication and mortality rates are comparable to ELSO rates, suggesting the safety of this model. Further exploration regarding resource utilization and costs is warranted.</p>","PeriodicalId":519952,"journal":{"name":"The journal of extra-corporeal technology","volume":"58 1","pages":"51-56"},"PeriodicalIF":0.0,"publicationDate":"2026-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12984027/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147446473","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":"Is continuous in-line blood gas monitoring reliable during cardiopulmonary bypass when PaO₂ and PaCO₂ are calculated rather than measured?","authors":"Min-Ho Lee, Tami Rosenthal","doi":"10.1051/ject/2025051","DOIUrl":"10.1051/ject/2025051","url":null,"abstract":"<p><strong>Background: </strong>The accuracy and precision of continuous in-line blood gas monitoring (CILBGM) are crucial for optimal blood gas management during cardiopulmonary bypass (CPB) and improved patient outcomes. CILBGM devices, such as the CDI 500/550 system, measure PaO₂ and PaCO_2, and B-Capta measures PaO₂ through direct contact with arterial blood. However, the Quantum perfusion system with Quantum Ventilation₂ (Quantum System) does not measure but calculates PaO₂ and PaCO₂ using several non-invasive sensors and proprietary formulas. We have observed that the calculated in-line PaO₂ and PaCO₂ values from Quantum System are frequently significantly higher than those obtained from iSTAT, a point-of-care blood analyzer, exceeding acceptable targets.</p><p><strong>Methods: </strong>We conducted a retrospective study involving 81 patients who underwent cardiac surgery using the Quantum System with its own CILBGM and the FX05 oxygenator. The aim was to identify the degree, timing, and possible patterns of error of the calculated in-line PaO₂ and PaCO₂.</p><p><strong>Results: </strong>Our study showed that the errors of calculated in-line PaO₂ exceed the acceptable target at the 1st blood gas series and during the rewarming and rewarmed periods, correlating with patient weight. The calculated in-line PaCO₂ exhibited an upward drift during the rewarming period, correlating with the temperature gradient rather than patient weight. Based on several correlations identified, we derived a formula to predict FiO₂ based on patient weight, which would achieve the target PaO₂ at the 1st blood gas series when using the FX05 oxygenator.</p><p><strong>Conclusion: </strong>We identified when and how the errors in calculating in-line PaO₂ and PaCO₂ occurred and developed several recommendations to minimize significant deviations from actual PaO₂ and PaCO₂ during CPB. Our results suggest that achieving acceptable PaO₂ and PaCO₂ calculations throughout CPB using a single universal formula for each, embedded in the Quantum System, is challenging due to the variety of oxygenators available, different patient sizes, and changing conditions during CPB.</p>","PeriodicalId":519952,"journal":{"name":"The journal of extra-corporeal technology","volume":"58 1","pages":"43-50"},"PeriodicalIF":0.0,"publicationDate":"2026-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12984026/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147446663","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":"Perfusion strategy and surgical repair of Type A interrupted aortic arch and Type 1 aortopulmonary window: a case report.","authors":"Paula Leigh, Ed Harman, S Adil Husain","doi":"10.1051/ject/2025052","DOIUrl":"10.1051/ject/2025052","url":null,"abstract":"<p><strong>Overview: </strong>Interrupted aortic arch in combination with an aortopulmonary window is an uncommon congenital cardiovascular defect. The anatomic separation between the aortic arch and descending aorta, combined with the communication between the ascending aorta and pulmonary trunk, leads us to a unique case where we can utilize the patient's anatomic defect towards an efficient perfusion strategy.</p><p><strong>Description: </strong>The patient was a 19-day-old neonate who was initially discharged home after birth with no suspicion of congenital heart disease. The patient was later diagnosed with a type A aortic interruption with a large type 1 aortopulmonary window. Due to the unique combination of defects, surgery was accomplished utilizing single instead of dual aortic cannulation, and the repair was accomplished using a double patch technique.</p><p><strong>Comment: </strong>An individualized perfusion strategy was employed by taking advantage of the defect.</p>","PeriodicalId":519952,"journal":{"name":"The journal of extra-corporeal technology","volume":"58 1","pages":"85-89"},"PeriodicalIF":0.0,"publicationDate":"2026-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12984032/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147446715","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":"The effect of surgical field suction flow rate and venous reservoir levels on gaseous microemboli transmission⋆.","authors":"Thomas Rath, Marisa Sugden, Edward Evans, Kyle Dana, Mitchell Rentschler, Charlotte Bolch, Nathaniel H Darban","doi":"10.1051/ject/2025067","DOIUrl":"10.1051/ject/2025067","url":null,"abstract":"<p><strong>Background: </strong>Minimizing Gaseous microemboli (GME) introduced into the CPB circuit can help alleviate neurologic injury. This study focuses on understanding how suction flow rate and the reservoir level can influence the introduction of GME past the venous reservoir during CPB.</p><p><strong>Methods: </strong>An in vitro mock CPB loop filled with bovine blood was used to simulate adult CPB. A Gampt BCC-300 bubble detector measured bubble size, volume, and count at three locations: post-reservoir (venous), post-oxygenator/arterial filter (arterial), and the venous inlet to the reservoir (recirculation). Room air was added into the suction line at 200 mL/min and mixed with blood to simulate aerated suction return. Bubble transmission was measured for three minutes at three reservoir levels, 200 mL, 500 mL, and 1000 mL, and at four pump sucker flow rates: 25 RPM (0.32 L/min), 50 RPM (0.65 L/min), 75 RPM (0.99 L/min), and 100 RPM (1.32 L/min). GME count data were pooled from three commonly used, coated, disposable reservoirs/oxygenator combinations: Medtronic Affinity Fusion, Terumo CAPIOX FX25, and Sorin Inspire 8F.</p><p><strong>Results: </strong>A total of 284 measurements were conducted, and the data from all reservoir manufacturers were analyzed and averaged. A statistically significant interaction was noticed between roller pump suction rate and reservoir level (p-value < 0.0001) at the venous sensor. As the suction flow rate increased, the reservoir level decreased, or a combination of the two occurred, a significant increase in GME count was observed at the post-reservoir sensor. Analysis of the GME count from the post-oxygenator/filter sensor revealed a significant increase as the suction flow rate increased from 25 RPM to 100 RPM.</p><p><strong>Conclusion: </strong>A minimum effective suction flow rate and maximum practical reservoir level are recommended to prevent the transmission of GME through the cardiopulmonary bypass circuit and potentially to the patient. Care should be taken to continuously monitor these variables throughout the case and adjust them accordingly.</p>","PeriodicalId":519952,"journal":{"name":"The journal of extra-corporeal technology","volume":"58 1","pages":"19-31"},"PeriodicalIF":0.0,"publicationDate":"2026-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12984039/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147446710","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":"Redefining the role of perfusionists in ECMO: from technical operators to clinical stakeholders.","authors":"Salman Pervaiz Butt, Salman Abdulaziz, Nabeel Razzaq, Arun Kumar, Fazil Ashiq, Umer Darr, Gopal Bhatnagar","doi":"10.1051/ject/2025046","DOIUrl":"10.1051/ject/2025046","url":null,"abstract":"<p><p>Extracorporeal Membrane Oxygenation (ECMO) is increasingly used in refractory cardiac and respiratory failure, yet the role of perfusionists remains narrowly defined. While traditionally viewed as technical operators, perfusionists possess advanced expertise that are essential across the continuum of care. Their exclusion from key clinical and academic roles represents a structural gap possibly with implications for safety and outcomes. This letter advocates for redefining perfusionists as clinical stakeholders, formally integrated into decision-making, quality improvement, and research initiatives. Their engagement can enhance ECMO practice across a multitude of areas. Recognizing perfusionists as integral members of the multidisciplinary team is essential to advancing outcomes, and meeting the demands of increasingly complex extracorporeal therapies.</p>","PeriodicalId":519952,"journal":{"name":"The journal of extra-corporeal technology","volume":"57 4","pages":"287-289"},"PeriodicalIF":0.0,"publicationDate":"2025-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12710219/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145770344","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":"Adaptation and distribution of cardioplegia practices in Thailand during the COVID-19 pandemic: insights from a nationwide survey.","authors":"Narongrit Kantathut, Parinya Leelayana, Piya Samankatiwat","doi":"10.1051/ject/2025030","DOIUrl":"10.1051/ject/2025030","url":null,"abstract":"<p><strong>Background: </strong>Cardioplegia is essential for myocardial protection during cardiac surgery. The COVID-19 pandemic disrupted supply chains, affecting the availability of commercial cardioplegia solutions in Thailand and prompting institutions to modify their strategies. This study evaluates the distribution, selection, and adaptation of cardioplegia practices among Thai cardiac surgical centers during the pandemic.</p><p><strong>Methods: </strong>A nationwide survey was conducted in cardiac surgical centers performing ≥100 cases per year. Data on cardioplegia availability, usage, and preferences across different surgeries were collected via direct or telephone interviews with surgeons or perfusionists. Descriptive statistical analyses were applied.</p><p><strong>Results: </strong>St. Thomas-based cardioplegia remained the most widely used (95%), with 77.1% of institutions preparing custom formulations due to supply shortages. Histidine-tryptophan-ketoglutarate (HTK) was the second most used (76%), particularly in aortic and complex congenital surgeries, followed by del Nido cardioplegia (27%), often in modified formulations. Most centers (74%) used two to three cardioplegia solutions. Blood cardioplegia was preferred for coronary artery bypass grafting (89.2%) and valve procedures (78.4%), whereas HTK dominated in aortic (54.1%) and complex congenital surgeries (71.4%).</p><p><strong>Conclusion: </strong>Despite the pandemic, St. Thomas-based cardioplegia remained dominant in Thailand, with increasing reliance on HTK and modified del Nido cardioplegia. The widespread use of custom-made cardioplegia highlights the impact of supply chain disruptions. Post-pandemic studies are essential to evaluate long-term adaptations and refine myocardial protection strategies.</p>","PeriodicalId":519952,"journal":{"name":"The journal of extra-corporeal technology","volume":"57 4","pages":"229-234"},"PeriodicalIF":0.0,"publicationDate":"2025-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12710218/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145770329","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":"Risk for sepsis during mechanical circulatory support★.","authors":"Kelsey Gore, Dean Linder, Juan José Martinez Duque, Junxi Wang, Joshua Baguley, Cortland Kolesnikowicz, Shaun Yockelson, Manila Singh, Adrian Alexis Ruiz, Bobby D Nossaman","doi":"10.1051/ject/2025041","DOIUrl":"10.1051/ject/2025041","url":null,"abstract":"<p><strong>Introduction: </strong>Patients receiving mechanical circulatory support (MCS) risk the development of sepsis. Examining risk factors for the development of sepsis and their relationships to MCS may allow for an improved understanding of these complications.</p><p><strong>Methods: </strong>Following IRB approval, patient characteristics, previously reported comorbidities, and the incidence of sepsis were studied in 199 patients who received 244 MCS therapies from January 2017 to October 2023. The clinical variables underwent ensemble machine learning modeling. Significant comorbidities predicting sepsis from the ensemble machine modeling underwent decision-tree analysis.</p><p><strong>Results: </strong>In this study, the incidence of sepsis was 20% (95% CI: 16-26%). Following machine learning modeling, patients with a history of congestive heart failure or a history of previous cardiac surgery were associated with an increased risk for developing sepsis. The c-index statistic for this model was 0.76, with a misclassification rate of 19%. Decision-tree analysis observed that patients without chronic cardiovascular disease but with a history of prior cardiac surgery have a 60.3% (95% CI: 60.1-65.2%) incidence of sepsis during MCS therapy. Patients with a history of chronic cardiovascular disease and with a history of congestive heart failure have an 18.1% (95% CI: 17.2-18.7%) incidence of developing sepsis.</p><p><strong>Conclusion: </strong>The incidence of sepsis is high in this patient population. The novel associations of patients who have histories of congestive heart failure or previous cardiac surgery requiring MCS suggest an increased systemic inflammatory state exists that escalates the risk for developing sepsis. Further investigation into these background inflammatory conditions in patients requiring MCS is warranted.</p>","PeriodicalId":519952,"journal":{"name":"The journal of extra-corporeal technology","volume":"57 4","pages":"225-228"},"PeriodicalIF":0.0,"publicationDate":"2025-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12710251/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145770340","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 hemorrhage after pulmonary endarterectomy in a patient with chronic thromboembolic pulmonary hypertension: a case report.","authors":"Gleb Moroz, Alexander Edemskiy, Igor Kornilov, Ramzil Nasyrtdinov, Alexander Chernyavskiy","doi":"10.1051/ject/2025017","DOIUrl":"10.1051/ject/2025017","url":null,"abstract":"<p><p>Massive pulmonary hemorrhage is the severe complication of pulmonary endarterectomy, associated with high mortality rates. ECMO may be a life-saving option for patients with pulmonary hemorrhage. In this case, we have described the successful sequential application of both VA and VV ECMO modalities. VA ECMO was employed initially to reduce blood flow to the right heart and pulmonary artery. Once hemodynamic stability was achieved, VV-ECMO was utilized to support severe respiratory failure. A six-month follow-up demonstrated good clinical outcome, with no evidence of pulmonary artery rethrombosis.</p>","PeriodicalId":519952,"journal":{"name":"The journal of extra-corporeal technology","volume":"57 4","pages":"279-283"},"PeriodicalIF":0.0,"publicationDate":"2025-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12710245/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145770379","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":"Leveraging the perfusionist-surgeon dyad to improve the culture of safety.","authors":"Kenneth G Shann, Thoralf M Sundt","doi":"10.1051/ject/2025022","DOIUrl":"10.1051/ject/2025022","url":null,"abstract":"<p><p>The cardiac surgical operating room is a complex, high risk environment dependent on efficient teamwork and communication between multiple role groups to deliver safe and effective care. As awareness of the critical importance of culture on team performance broadens, there has been increasing focus in cardiac surgery on developing a culture of safety to minimize, trap and recover from errors in order to optimize patient outcome. Fundamental to this effort are concepts such as Just Culture, collective responsibility and perhaps most fundamentally the establishment of psychological safety where individuals have a \"sense of being able to show and employ oneself without fear of negative consequences to self-image, status or career\". Team members who are engaged and feel empowered to raise concerns can help to recognize issues, improve intraoperative decision making and contribute to resilience of the team. Over the past decade we have made a concerted effort in our institution to establish such a culture, and have found principles of organizational psychology helpful in this endeavor.</p>","PeriodicalId":519952,"journal":{"name":"The journal of extra-corporeal technology","volume":"57 4","pages":"274-278"},"PeriodicalIF":0.0,"publicationDate":"2025-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12710221/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145770383","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}