Case Reports in Critical Care最新文献

{"title":"Life-Threatening Bupropion Poisoning Successfully Treated by Intravenous Lipid Emulsion.","authors":"Francesca Chiara Della Casa, Vincent Haufroid, Kevin Delongie, Thomas Coppens, Ester Ponzetto, Nicolas De Schryver","doi":"10.1155/crcc/3324437","DOIUrl":"10.1155/crcc/3324437","url":null,"abstract":"<p><p>Bupropion is a synthetic cathinone that acts as a norepinephrine and dopamine reuptake inhibitor and is an atypical antidepressant commonly prescribed for major depressive disorder and smoking cessation. Although generally well tolerated at therapeutic doses, bupropion overdose can lead to severe toxicity, primarily characterized by seizures and cardiac arrhythmias. Management of severe intoxications remains mainly supportive, with no specific antidote available. Intravenous lipid emulsion (ILE) therapy has emerged as a potential treatment for poisoning with highly lipophilic drugs. Initially found to reverse local anesthetic toxicity, ILE is hypothesized to work via multiple mechanisms, including a \"lipid shuttle\" effect and direct stabilization of highly excitable membranes in the brain and heart. However, its precise role in nonanesthetic drug intoxications remains incompletely understood. We report a case of a massive, intentional bupropion overdose (24,000 mg) in a patient with no coingestion of other toxic substances aside from alcohol. The patient developed refractory seizures and severe ventricular arrhythmias, which were successfully reversed after ILE administration. Serial blood measurements of bupropion and its metabolites were performed before and after ILE administration, supporting both lipid sequestration of the drug and direct cardioprotective effects. A preprint of this study is available online (Della Casa et al. 2026).</p>","PeriodicalId":52357,"journal":{"name":"Case Reports in Critical Care","volume":"2026 ","pages":"3324437"},"PeriodicalIF":0.0,"publicationDate":"2026-08-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13486964/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148801530","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":"Emerging Threat of <i>Wickerhamomyces anomalous</i> (Formerly <i>Candida pelliculosa</i>) in Neonates: A Case Series and Review of Current Evidence.","authors":"Dipika Shaw, Gargi Mudey, Supriya Meshram, Deependra Manish, Aditi Warghade, Dhruba Hari Chandi","doi":"10.1155/crcc/3715878","DOIUrl":"10.1155/crcc/3715878","url":null,"abstract":"<p><strong>Introduction: </strong>Neonatal sepsis is a systemic infection in newborn infants within the first month of life. It is a serious condition with a higher rate of mortality, thus it requires prompt recognition and treatment. Invasive candidiasis (IC) is a substantial source of morbidity and mortality in the neonatal intensive care unit (NICU) and the third most frequent cause of late-onset sepsis in very-low-birth-weight (VLBW) newborns. For the IC, the major etiological agent is <i>Candida albicans,</i> but other nonalbicans <i>Candida</i> (NAC) species can also invade the bloodstream and spread the infection. In a recent scenario, the outbreak of <i>Wickerhamomyces anomalous</i> (formerly <i>C. pelliculosa</i>) fungemia in a NICU presents a significant challenge in healthcare settings. This case report series presents six cases of <i>W. anomalous</i> sepsis in neonates admitted to our NICU.</p><p><strong>Case report: </strong>The study investigated the clinical and treatment profile of six cases of fungemia originating from the NICU. The objective was to assess the therapy outcome. An automated system (VITEK 2) was used for rapid biochemical identification of <i>Candida</i> species, which revealed <i>W. anomalous</i> growth. Furthermore, the susceptibility of these isolates to antifungal drugs was evaluated using VITEK 2 automated antifungal susceptibility testing (AFST) system. In this case report, we presented six cases of term neonates who were admitted due to respiratory distress. The neonate received numerous antibiotic courses as well as nutrients from a parenteral source due to severe enteral nutrition intolerance. Notably, the four patients did not undergo any invasive procedures; they received only mechanical ventilation support. Subsequently, one patient (Case 6) underwent surgery, and another (Case 5) remained on a ventilator. Neither of the patients who underwent invasive procedures survived. Further, all the <i>W. anomalous</i> isolated from NICU cases were susceptible to fluconazole, voriconazole, and amphotericin B.</p><p><strong>Conclusion: </strong>Our case serves as a reminder to maintain a higher level of suspicion for fungal infections in preterm and term infants in the NICU. Antifungal prophylaxis may be considered for these patients if one or more risk factors are present. Additionally, it is important to note that NAC species can occasionally be the causative agent. Therefore, we should always bear in mind the possibility of these fungal pathogens as infectious agents in neonates with risk factors.</p>","PeriodicalId":52357,"journal":{"name":"Case Reports in Critical Care","volume":"2026 ","pages":"3715878"},"PeriodicalIF":0.0,"publicationDate":"2026-08-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13479350/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148801440","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":"Critical Care-Based Decision-Making and Timing of Pregnancy Termination in Hypertriglyceridemia-Induced Acute Pancreatitis Complicated by Diabetic Ketoacidosis and Intrauterine Fetal Demise: A Case Report.","authors":"Yingshan Hu, Yue Mao, Hongmei Gao","doi":"10.1155/crcc/4122751","DOIUrl":"10.1155/crcc/4122751","url":null,"abstract":"<p><strong>Background: </strong>Acute abdominal pain accompanied by severe metabolic acidosis during pregnancy is frequently attributed to pregnancy-related conditions. Hypertriglyceridemia-induced acute pancreatitis (HTG-AP) complicated by diabetic ketoacidosis (DKA) is rare in pregnancy and may be overlooked because of overlapping clinical and laboratory features.</p><p><strong>Case presentation: </strong>We report a critically ill pregnant woman in the late second trimester who presented with abdominal pain and vomiting. Initial evaluation revealed severe metabolic acidosis and marked hypertriglyceridemia, and the patient was ultimately diagnosed with HTG-AP complicated by DKA. During the disease course, with confirmed intrauterine fetal demise (IUFD), management goals transitioned to maternal-centered critical care. However, the patient also exhibited profound metabolic derangement, intra-abdominal hypertension, and systemic stress responses, rendering immediate pregnancy termination associated with a high perioperative risk. The patient was admitted to the intensive care unit (ICU) and received continuous renal replacement therapy (CRRT) to correct refractory metabolic acidosis, followed by therapeutic plasma exchange to rapidly reduce triglyceride burden. These interventions stabilized the internal milieu and served as a bridging strategy for definitive critical care decision-making. After multidisciplinary evaluation, cesarean delivery was performed once maternal metabolic status had sufficiently stabilized. The patient's condition gradually improved, and she was discharged in good recovery.</p><p><strong>Conclusions: </strong>This case highlights the diagnostic pitfalls of HTG-AP complicated by DKA during pregnancy and underscores the importance of individualized decision-making regarding the timing of pregnancy termination in the setting of IUFD. Multidisciplinary collaboration and the appropriate use of extracorporeal organ support may play a crucial role in optimizing maternal outcomes in such complex critical care scenarios.</p>","PeriodicalId":52357,"journal":{"name":"Case Reports in Critical Care","volume":"2026 ","pages":"4122751"},"PeriodicalIF":0.0,"publicationDate":"2026-08-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13479467/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148801532","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":"Safety of Early Mobilisation in Critically Ill Patients Under Unusual High-Risk Conditions: A Latin American Case Series.","authors":"Andrés Mauricio Enriquez Popayán, Ruvistay Gutierrez-Arias, Luis Alexander Peña-López, Henry Mauricio Parada-Gereda","doi":"10.1155/crcc/7899295","DOIUrl":"10.1155/crcc/7899295","url":null,"abstract":"<p><strong>Background: </strong>Early mobilisation (EM) in the intensive care unit (ICU) is associated with a reduced incidence of intensive care unit-acquired weakness, shorter hospital length of stay and improved functional outcomes. However, most of the available evidence derives from patient populations at low risk of safety-related adverse events. This limits the generalisability of its benefits to more complex clinical scenarios, such as the concurrent administration of blood products, continuous parenteral nutrition, antiarrhythmic infusions or multiple haemodynamic pharmacological support. Consequently, evidence regarding the safety of EM in these contexts remains scarce. This case series is aimed at describing the safety of EM under unusual and high-risk clinical conditions, an area that remains underexplored in the international literature.</p><p><strong>Case presentation: </strong>We describe six critically ill patients presenting with conditions traditionally considered high risk for EM. Two patients were receiving active transfusion of blood products: a 70-year-old woman under invasive mechanical ventilation and a 69-year-old man with upper gastrointestinal bleeding and moderate anaemia; both performed active exercises during red blood cell transfusion. Two additional patients were receiving continuous enteral nutrition: a 42-year-old man requiring invasive mechanical ventilation and a 76-year-old woman; both undertook active exercises during nutritional administration. The fifth case involved a 65-year-old woman with atrial flutter treated with an amiodarone infusion. The sixth case was a 65-year-old woman with cardiomyopathy and suspected sepsis, requiring triple haemodynamic pharmacological support with noradrenaline, vasopressin and dobutamine. Exercise prescription was individualised according to intensity, type and duration, based on the dosing determined by the attending physiotherapist. All interventions were conducted under continuous monitoring. No adverse events or complications related to EM or invasive devices were observed.</p><p><strong>Conclusions: </strong>EM can be safely implemented in critically ill patients, even under conditions traditionally considered high risk, provided that strict criteria for clinical stability and continuous monitoring are applied. These findings provide relevant preliminary evidence supporting the feasibility of active rehabilitation in the ICU and open new avenues for research aimed at defining specific safety criteria for EM in high-risk populations.</p>","PeriodicalId":52357,"journal":{"name":"Case Reports in Critical Care","volume":"2026 ","pages":"7899295"},"PeriodicalIF":0.0,"publicationDate":"2026-08-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13474320/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148764420","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":"Anaphylactic Shock Probably due to a Cross-Reaction Between Cefuroxime and Piperacillin-Presentation of a Fatal Case, Diagnostic Considerations, and Literature Review.","authors":"August Fiegl, Arndt Hartmann, Christian Führling, Niklas Carbon, Roland C E Francis, Andreas Wehrfritz","doi":"10.1155/crcc/6339253","DOIUrl":"10.1155/crcc/6339253","url":null,"abstract":"<p><p>Although beta-lactam antibiotics are widely used in intensive care, rare but potentially fatal anaphylactic reactions can occur due to cross-reactions between penicillins and cephalosporins. We report the case of a 68-year-old man who suffered perioperative cardiac arrest following the administration of cefuroxime. During the postoperative period, the patient received ampicillin/sulbactam without any signs of hypersensitivity. Following a switch to piperacillin/tazobactam prior to a procedure, the patient suddenly developed cardiovascular arrest and died. The autopsy revealed no macroscopic cause of death, but immunohistochemistry showed mast cell degranulation (\"starry sky pattern\") in the tissue, suggesting anaphylaxis. We present the clinical and histopathological findings of a case with severe allergic reactions to both cefuroxime and piperacillin/tazobactam, as a result of either cross-reaction or isolated sensitization to both antibiotics. This case report highlights the potential risks of cross-reactivity between beta-lactam antibiotics and the importance of autopsy in ambiguous cases. Clinicians should be aware of cross-reactivity or cosensitization to multiple beta-lactams in patients with a beta-lactam allergy and consider non-beta-lactam alternatives in high-risk cases.</p>","PeriodicalId":52357,"journal":{"name":"Case Reports in Critical Care","volume":"2026 ","pages":"6339253"},"PeriodicalIF":0.0,"publicationDate":"2026-08-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13463430/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148727044","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":"Diagnostic and Management Pitfalls of SGLT2 Inhibitor-Associated Ketoacidosis in the ICU: Lessons Following Cardiac Surgery and GLP-1 Agonist Interaction.","authors":"Ana Paula García Pérez, Damián Gutiérrez-Zárate, Karina Rosas-Sánchez, Alejandro Molina Romo, Manuel Nicolás Poblano","doi":"10.1155/crcc/4896065","DOIUrl":"10.1155/crcc/4896065","url":null,"abstract":"<p><p>Sodium-glucose cotransporter 2 inhibitors (SGLT2i) are cornerstones in the treatment of Type 2 diabetes (T2D), but their use is associated with diabetic ketoacidosis (DKA), a potentially life-threatening complication in the critical care setting. We present two cases of male patients with T2D who developed SGLT2i-associated ketoacidosis under different stressors: the first following coronary artery bypass graft (CABG) surgery and the second after the addition of semaglutide to his therapeutic regimen. Both patients presented with high anion gap metabolic acidosis, ketonuria, and plasma glucose levels < 200 mg/dL. Management required intravenous insulin protocols and glucose supplementation to reverse ketosis. This report emphasizes the need for preoperative suspension protocols and close monitoring of changes in combination therapy to avoid diagnostic delays in the intensive care unit.</p>","PeriodicalId":52357,"journal":{"name":"Case Reports in Critical Care","volume":"2026 ","pages":"4896065"},"PeriodicalIF":0.0,"publicationDate":"2026-08-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13444720/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148686658","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":"Timely Diagnosis of Cobalamin C Disease via Rapid Genome Sequencing in a Neonate With Severe Prenatally Detected Biventricular Dysfunction.","authors":"Yutaka Furuta, Samantha N Walkin, Scott K Ward, Rory J Tinker, Rizwan Hamid, John A Phillips, Rachel E Harris, Thomas A Cassini","doi":"10.1155/crcc/2778022","DOIUrl":"10.1155/crcc/2778022","url":null,"abstract":"<p><p>Cobalamin C (Cbl-C) disease, the most common inborn error of cobalamin metabolism caused by biallelic pathogenic <i>MMACHC</i> variants, leads to multisystem involvement from methylmalonic acid and homocysteine accumulation. When diagnosed early, it is treatable. Rapid genome sequencing (GS) is becoming increasingly accessible and enables timely diagnosis and prompt treatment. We report a neonate who had severely decreased prenatal and postnatal biventricular function requiring inotropic support. Given the critically ill condition and unclear etiology, rapid GS was obtained and revealed homozygous pathogenic <i>MMACHC</i> variants, confirming a diagnosis of Cbl-C disease. This prompted the early initiation of treatment with high-dose hydroxocobalamin, betaine, levocarnitine, and folic acid. His cardiac function gradually improved, and he was discharged at 28 days of life. Critical care providers should suspect treatable inherited metabolic disorders in patients with unexplained presentations and recognize rapid GS as a powerful tool for early identification and treatment in critically ill patients.</p>","PeriodicalId":52357,"journal":{"name":"Case Reports in Critical Care","volume":"2026 ","pages":"2778022"},"PeriodicalIF":0.0,"publicationDate":"2026-08-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13429937/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148671497","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":"Hypertonic Saline as Maintenance Intravenous Fluid in Diabetic Ketoacidosis.","authors":"Mahalia Sanon, Stanley J Linder","doi":"10.1155/crcc/6209006","DOIUrl":"10.1155/crcc/6209006","url":null,"abstract":"<p><strong>Introduction: </strong>Diabetic ketoacidosis is associated with cerebral edema, which, although rare, is associated with an increased mortality rate.</p><p><strong>Case report: </strong>In this case report, we discuss the use of a hypertonic saline solution in a 42-year-old male with wild-type gliosarcoma who presented with hyperglycemia to avoid cerebral edema.</p>","PeriodicalId":52357,"journal":{"name":"Case Reports in Critical Care","volume":"2026 ","pages":"6209006"},"PeriodicalIF":0.0,"publicationDate":"2026-07-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13424816/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148655071","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":"Use of Double Dose Intravenous Immunoglobulin Therapy in the Treatment of Streptococcal Toxic Shock Syndrome.","authors":"Yuning Xue, Alex Yartsev","doi":"10.1155/crcc/9649482","DOIUrl":"10.1155/crcc/9649482","url":null,"abstract":"<p><p>Streptococcal toxic shock syndrome (STSS) is a life-threatening condition with increasing incidence and high mortality worldwide. It is characterised by hypotension and multiorgan failure, resultant of invasive group A Streptococcus (GAS) infections. Intravenous immunoglobulin (IVIG) has been proposed as an adjunctive therapy that reduces mortality in patients with STSS, and is thought to exert its effects by neutralising streptococcal superantigens and exotoxins to modulate the host immune response. Currently, there is a paucity of knowledge about the efficacy of repeated dosing if patients remain unstable after the first dose of IVIG. In this report, we describe the case of a woman in her 60s with STSS and meningoencephalitis, who demonstrated an improvement in haemodynamic status after the first dose of IVIG, but subsequently had rebound of hypotension and high vasopressor requirements, which resolved after a second dose of IVIG. This case highlights the potential need for repeated dosing of IVIG in STSS, in situations where an initial improvement in haemodynamic status is followed by deterioration.</p>","PeriodicalId":52357,"journal":{"name":"Case Reports in Critical Care","volume":"2026 ","pages":"9649482"},"PeriodicalIF":0.0,"publicationDate":"2026-07-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13415746/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148622025","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":"BRASH Syndrome Unmasked: Digoxin Toxicity in the Setting of Cardiogenic Shock and Multiorgan Dysfunction.","authors":"Spencer Boehm, Jordan Bruni","doi":"10.1155/crcc/8778210","DOIUrl":"10.1155/crcc/8778210","url":null,"abstract":"<p><p>Digoxin, a cardiac glycoside historically used for rate control in atrial arrhythmias and symptom relief in chronic heart failure, possesses a narrow therapeutic index and is highly susceptible to pharmacokinetic and pharmacodynamic disruption in critically ill patients. Its use in acute decompensated heart failure and cardiogenic shock is therefore controversial. We present the case of a 75-year-old woman with chronic heart failure with reduced ejection fraction who developed progressive bradycardia and cardiogenic shock after treatment with digoxin and amiodarone for 2:1 atrial flutter. Her hospital course was complicated by acute kidney injury, severe hyperkalemia, ischemic hepatitis, and persistent bradycardia following electrical cardioversion. Serum digoxin levels were supratherapeutic early in the intensive care unit course and subsequently normalized, though bradyarrhythmias persisted. The patient's presentation and clinical trajectory were consistent with BRASH (bradycardia, renal failure, AV-nodal blockade, shock, and hyperkalemia) syndrome , with amiodarone-digoxin interaction and systemic hypoperfusion likely amplifying myocardial digoxin sensitivity. She improved with supportive therapy, correction of metabolic derangements, withdrawal of AV-nodal-blocking agents, and cardioversion, without administration of digoxin-specific antibody fragments. This case highlights the importance of early recognition of BRASH physiology, cautious use of AV-nodal blockers in low-output states, and prioritization of underlying physiologic correction over reliance on serum drug levels alone in critically ill patients.</p>","PeriodicalId":52357,"journal":{"name":"Case Reports in Critical Care","volume":"2026 ","pages":"8778210"},"PeriodicalIF":0.0,"publicationDate":"2026-07-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13370796/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148457642","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}