Journal of Clinical and Aesthetic Dermatology最新文献

{"title":"Managing Advanced Basal Cell Carcinoma: A Guide for the Dermatology Clinician.","authors":"Joshua Burshtein, Todd Schlesinger","doi":"","DOIUrl":"","url":null,"abstract":"<p><strong>Objective: </strong>Basal cell carcinoma (BCC) is the most common form of skin cancer. Advanced BCCs include locally advanced BCCs (laBCCs), primary or recurrent tumors that are not amenable to surgery or radiation therapy, and metastatic BCCs (mBCCs). The management of advanced BCC has been revolutionized in recent years by the development of hedgehog inhibitors (HHIs) and immunotherapies (ie, PD-1 inhibitors). We aim to review the current literature on therapeutic options and outline treatment strategies to optimize care for patients with advanced BCC.</p><p><strong>Methods: </strong>A comprehensive literature search was completed using the keywords \"advanced basal cell carcinoma,\" \"treatment,\" \"hedgehog inhibitor,\" \"vismodegib,\" \"sonidegib,\" \"PD1-inhibitor,\" and \"cemiplimab.\" The authors reviewed all studies and included those which addressed the topic of the review.</p><p><strong>Results: </strong>Surgery or radiotherapy may not be an option for certain high-risk BCCs due to due to invasion into local tissue, location near anatomically sensitive areas, or metastasis. There is increasing evidence for the efficacy of HHIs, including vismodegib and sonidegib, as the first-line treatment for these advanced BCCs. Despite known efficacy, utility of HHIs can be limited by their adverse event profiles. If patients fail HHIs due to inefficacy or adverse effects, there is evidence for use of the PD-1 inhibitor cemiplimab.</p><p><strong>Limitations: </strong>This is a review article and is limited by the information available in the published literature. In addition, comparison between studies is limited as they utilized varying methodologies.</p><p><strong>Conclusion: </strong>Treatment of advanced BCCs can be complex and poses challenges for clinicians. HHIs are currently the first-line treatments for laBCC and mBCC, while cemiplimab can be used if patients do not respond to or are unable to tolerate HHIs, or for whom HHIs are not appropriate.</p>","PeriodicalId":53616,"journal":{"name":"Journal of Clinical and Aesthetic Dermatology","volume":"18 3","pages":"21-27"},"PeriodicalIF":0.0,"publicationDate":"2025-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11932100/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143712113","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 Single-center, Double-blinded, Randomized, Placebo-controlled Trial Evaluating the Safety and Efficacy of a Dietary Supplement Containing Rosemary Extract on Visible Facial Skin Quality.","authors":"Zoe Diana Draelos, Audrey Gueniche, Margarita Yatskayer, Diane B Nelson","doi":"","DOIUrl":"","url":null,"abstract":"<p><strong>Objective: </strong>Glycative stress promotes the accumulation of advanced glycation end products (AGEs), impairing extracellular matrix proteins and accelerating skin aging. Rosemary extract has been shown to deglycate AGE crosslink proteins. The safety of a dietary supplement containing rosemary extract (BioR) and its efficacy on skin quality parameters was evaluated over 12 weeks.</p><p><strong>Methods: </strong>The randomized, double-blinded, placebo-controlled trial included female participants, aged 40 to 65 years, with moderate-to-severe skin dullness and roughness/texture, and mild-to-moderate erythema, pore size, and uneven pigmentation based on a six-point grading scale. Subjects were randomized to either BioR (n=52) or placebo ([PLB] n=52). The dosing schedule was as follows: from Weeks 1 to 4, two capsules three times daily; from Weeks 5 to 8, two capsules twice daily; from Weeks 9 to 12, one capsule twice daily. Capsules were taken with food. Investigator assessments occurred at baseline and Weeks 4, 8, and 12. Global skin quality (total sum of scores) and adverse events (AEs) were recorded over 12 weeks.</p><p><strong>Results: </strong>Mean age, severity and baseline demographics of subjects were similar across groups. Significant mean improvements in BioR versus PLB were observed in skin dullness (<i>p</i>=0.04), roughness/texture (<i>p</i>=0.001), erythema (<i>p</i>=0.05) and pore size (<i>p</i>=0.04) at Week 12. No significant differences occurred in uneven pigmentation. Significant mean improvements in global skin quality were demonstrated in BioR versus PLB at Weeks 8 (<i>p</i><0.0001) and 12 (<i>p</i>=0.002). One subject (BioR) discontinued at Week 4 due to possibly related, moderate gastrointestinal upset.</p><p><strong>Conclusion: </strong>Following 12 weeks of use, a dietary supplement containing rosemary extract and its natural cofactors led to significant mean visible improvements compared to placebo in skin dullness, roughness/texture, erythema, and pore size, and was well tolerated.</p>","PeriodicalId":53616,"journal":{"name":"Journal of Clinical and Aesthetic Dermatology","volume":"18 3","pages":"28-33"},"PeriodicalIF":0.0,"publicationDate":"2025-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11932106/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143712091","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":"An Overview of Atopic Dermatitis Disease Burden, Pathogenesis, and the Current Treatment Landscape: Recommendations for Appropriate Utilization of Systemic Therapies.","authors":"George Martin, Lakshi Aldredge, Douglas DiRuggiero, Melodie Young, Eric Simpson","doi":"","DOIUrl":"","url":null,"abstract":"<p><strong>Objective: </strong>To review the disease impact, immunopathogenesis, and treatment landscape of atopic dermatitis (AD), including recommendations for appropriate utilization of systemic treatments.</p><p><strong>Methods: </strong>A PubMed search for relevant articles on AD and the treatment landscape was conducted using the key words \"atopic dermatitis,\" \"biologic,\" \"therapeutic inertia,\" \"Janus kinase (JAK) inhibitor,\" and \"systemic treatment.\"</p><p><strong>Results: </strong>AD is a common, chronic inflammatory skin disease that can have a profound negative impact on quality of life. With recent advancements and approvals of systemic treatments, it is now possible to offer targeted therapy to patients with moderate-to-severe AD. When topical treatments are no longer sufficient for managing AD, recently published AD management guidelines recommend that providers consider/offer advanced systemic treatments.</p><p><strong>Limitations: </strong>More data are needed on the use of systemic treatments in special populations, including head-to-head comparisons of available systemic treatments in these populations.</p><p><strong>Conclusion: </strong>An increased awareness of the immunopathogenesis, diagnosis, and treatment landscape of AD is needed amongst healthcare providers (HCPs). Special consideration of diagnosis and treatment options should be given to certain populations, including patients of different ages, those who may be pregnant or become pregnant, are biologic-experienced, and/or have comorbidities. Of note, HCPs should be aware of the clinical presentation in patients with skin of color. Therapeutic inertia can prevent HCPs from intensifying treatment when needed, and HCPs should know when it is appropriate to offer systemic treatments, including biologics and JAK inhibitors.</p>","PeriodicalId":53616,"journal":{"name":"Journal of Clinical and Aesthetic Dermatology","volume":"18 3","pages":"51-66"},"PeriodicalIF":0.0,"publicationDate":"2025-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11932105/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143712096","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":"Exploring the Link Between Atopic Dermatitis and Eosinophilic Esophagitis.","authors":"Joanna Jaros, Kripa Ahuja, Peter Lio","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>Eosinophilic esophagitis (EoE) and atopic dermatitis (AD) are two known and sometimes comorbid type 2 helper cell-mediated diseases. EoE shares clinical features, immunologic pathways, susceptibility loci, and risk with atopic conditions including food allergies (food allergies), asthma, allergic rhinitis (AR), and AD. These conditions share an impaired immunological response against a range of antigens or allergens, leading to CD4+ Th2 differentiation and overproduction of immunoglobulin E (IgE). The emerging coexistence of EoE and AD presents a compelling area of study. Both diseases manifest on stratified squamous epithelium along the skin-gut continuum and have overlapping treatment algorithms that include avoidance of triggers, topical steroids, and dupilumab. This narrative review highlights the clinical and immunologic nuances underlying these two conditions and sheds light on potential new research and therapeutic avenues.</p>","PeriodicalId":53616,"journal":{"name":"Journal of Clinical and Aesthetic Dermatology","volume":"18 3","pages":"15-20"},"PeriodicalIF":0.0,"publicationDate":"2025-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11932097/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143712111","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":"Achievement of Optimal Treatment Targets with Oral Janus Kinase Inhibition in Elderly Patients with Atopic Dermatitis: A Real-world, Multicenter, Retrospective Study.","authors":"Diego Ruiz Dasilva, Noelle Desir, Iain Noel Encarnacion, Naiem Issa, E James Song, Nicholas K Mollanazar","doi":"","DOIUrl":"","url":null,"abstract":"<p><strong>Objective: </strong>Oral Janus kinase inhibitors (JAKi) have demonstrated high levels of efficacy with acceptable safety in patients with atopic dermatitis (AD), yet there remains significant hesitancy among the dermatologic community to use JAKi in elderly populations due to the potential increased risk of serious adverse events in this population. We aimed to perform a retrospective review to describe real-world outcomes for the use of selective JAK-1 inhibitors in patients with AD aged 65 years or older.</p><p><strong>Methods: </strong>We conducted a multicenter retrospective review. AD cases were identified by ICD-10-CM codes L20.8/L20.89/L20.9. Patients aged 65 years or older years treated with a selective JAK-1 inhibitor were included. Body surface area (BSA), Investigator Global Assessment (IGA), and Peak Pruritus Numerical Rating Scale (NRS) were collected and evaluated independently.</p><p><strong>Results: </strong>Thirty-eight AD cases in patients aged 65 years or older treated with a selective JAK-1 inhibitor were identified. Patients were aged 65 to 96 years, and treatment duration ranged from 4 to 28 months. Thirty-six out of 38 patients (94.7%) tolerated treatment well; one was switched to another JAKi due to mood lability and another paused therapy during hospitalization for septic pneumonia. Thirty-five out of 37 (94.6%) patients achieved an IGA of 0/1, 28/30 (93.3%) achieved an NRS of 0/1, and 30/30 (100%) had a peak pruritus response with improvement of ≥4 points on NRS. There were no clinically meaningful laboratory abnormalities throughout the treatment course. No laboratory abnormality resulted in treatment discontinuation.</p><p><strong>Limitations: </strong>Limitations of this retrospective review include selection bias and missing data.</p><p><strong>Conclusion: </strong>We demonstrate the ability to achieve optimal treatment targets and safety of selective JAKi-1 inhibitors in elderly patients with AD.</p>","PeriodicalId":53616,"journal":{"name":"Journal of Clinical and Aesthetic Dermatology","volume":"18 2","pages":"25-29"},"PeriodicalIF":0.0,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11896624/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143617841","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":"Investigating Efficacy of Atopic Dermatitis Systemic Therapeutics After Discontinuation Part I: Biologics.","authors":"Naiem T Issa, Rama Abdin, Kabir Al-Tariq, Dana Jaalouk, Michael Kaiser, James Del Rosso, Shawn Kwatra","doi":"","DOIUrl":"","url":null,"abstract":"<p><strong>Objective: </strong>The authors sought to review published literature on the efficacy of biologics as monotherapy for atopic dermatitis (AD) following discontinuation.</p><p><strong>Methods: </strong>A comprehensive search of PubMed/MEDLINE was conducted examining drug withdrawal in AD clinical trials where participants were treated with biologics. Trials were included if they exclusively involved participants with AD that reported the maintenance or achievement of Eczema Area and Severity Index (EASI)-75 and Investigator Global Assessment (IGA) scores of 0 or 1 after withdrawal of biologic therapy. Clinical trials involving multidrug regimens, including those investigating concomitant topical therapeutics, were excluded from our analysis.</p><p><strong>Results: </strong>Five clinical trial programs met our inclusion criteria, each investigating a different biologic: dupilumab, tralokinumab, lebrikizumab, amlitelimab, and rocatinlimab.</p><p><strong>Limitations: </strong>Limitations to this review include a small number of trials that met the inclusion criteria, variations in study design that hinder direct comparisons, and the absence of long-term follow up data.</p><p><strong>Conclusion: </strong>The variability in eligibility criteria, treatment durations, and withdrawal periods across trials presents a major challenge in assessing biologics for AD, complicating the comparison of their sustained responses in the absence of head-to-head studies. This heterogeneity, combined with factors such as disease duration and prior use of systemic medications before trial enrollment, hampers the identification of key pathways in AD pathogenesis and impedes efforts to better understand and characterize the disease.</p>","PeriodicalId":53616,"journal":{"name":"Journal of Clinical and Aesthetic Dermatology","volume":"18 2","pages":"33-37"},"PeriodicalIF":0.0,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11896617/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143617846","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":"Efficacy of Mild-to-Moderate Chronic Hand Eczema Treatment Using Petrolatum and Panthenol Ointment vs. 0.1% Triamcinolone Acetonide in 10% Urea Cream: A Split-hand, Evaluator-blinded, Randomized, Controlled Trial.","authors":"Suparuj Lueangarun, Nutthawut Techalert, Therdpong Tempark","doi":"","DOIUrl":"","url":null,"abstract":"<p><strong>Background: </strong>There are many side effects resulting from the long-term use of conventional therapy (eg, high potency topical corticosteroids) for treatment of chronic hand eczema (CHE).</p><p><strong>Objective: </strong>This study aimed to explore the efficacy of CHE treatment using the healing ointment (HO) of anti-inflammatory ingredients compared with 0.1% triamcinolone acetonide in 10% urea cream (TAU).</p><p><strong>Methods: </strong>A split-hand, evaluator-blinded, randomized, controlled study was conducted in 26 patients (88.5% female, mean age 50.04 ± 9.63 years) with mild-to-moderate CHE. All patients were randomly assigned to apply HO or TAU twice daily on each side of the hand for consecutive 28 days.</p><p><strong>Results: </strong>There was an improvement of HECSI, TEWL, SCH, hemoglobin index, DLQI, and VAS on the HO treated side at Day 28, with statistical significance. Also, a statistically significant difference of TEWL reduction was observed on the HO treated side when compared to the TAU treated side at the same visit. Moreover, the superior post-moisturizing efficacy at seven days was noted for TEWL and SCH on the HO treated side.</p><p><strong>Conclusion: </strong>The use of HO with anti-inflammatory ingredients could be alternatively efficacious for treatment of CHE to prevent complications from the long-term application of steroids.</p>","PeriodicalId":53616,"journal":{"name":"Journal of Clinical and Aesthetic Dermatology","volume":"18 2","pages":"38-43"},"PeriodicalIF":0.0,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11896615/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143617842","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":"Environmental Impact and Sustainability Associated with the Practice of Dermatology.","authors":"Robert J Vanaria, Vishnu Bhupalam, Angelica Marrero-Perez, Aysham Chaudry, Nardin Awad, Mark Nestor","doi":"","DOIUrl":"","url":null,"abstract":"<p><strong>Objective: </strong>The environmental impact of the practice of medicine, including dermatology, can be significant, driven by a growing and aging population that increasingly demands medical resources. This review explores the environmental effects of the practice of dermatology and identifies actionable solutions to reduce negative environmental impacts.</p><p><strong>Methods: </strong>A PubMed search was conducted using the terms (\"environmental impact\" OR \"sustainability\") AND \"dermatology.\" Results were screened to include English-only articles between 2018 to 2024 and excluded duplicates. Further exploration of dermatology's environmental effects was enhanced through citation tracking and additional PubMed searches.</p><p><strong>Results: </strong>A total of 25 articles were included based on relevance and search terms and an additional 21 were added. Results were categorized into six categories for data representation. Patient travel was the largest contributor to negatively impact the environment, followed by waste management practices, journal publication and written patient material, and traveling to medical conferences. The environmental impact of pharmaceuticals, including topicals, is also notable. Potential sustainable alternatives include teledermatology, more appropriate waste production and segregation, and electronic versus printed formats and more virtual conferences. Additionally, dermatologic disease evolves in response to a changing environment, with new data indicating epidemiological shifts due to climate change. More sustainable practices within dermatology also have the potential to cut total overhead expenses.</p><p><strong>Conclusion: </strong>Clinical and surgical subspecialties, specifically dermatology, can contribute significantly to environmental pollution, leading to environmental and financial impacts, but implementing simple, documented methods can reduce their ecological footprint and provide potential financial benefits.</p>","PeriodicalId":53616,"journal":{"name":"Journal of Clinical and Aesthetic Dermatology","volume":"18 2","pages":"50-55"},"PeriodicalIF":0.0,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11896619/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143617843","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":"Successful Treatment of Recalcitrant Melasma with Picolaser and Isobionicamide-Cysteamine Combination.","authors":"Corey L Hartman, Michaela Crawford, Cheri Frey, Rawn Bosley, Riccardo Sfriso, Laure Dirlewanger, Behrooz Kasraee","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>Melasma is a highly recurrent disorder that is challenging to treat and significantly affects the quality of life of patients. Cysteamine is an endogenous antioxidant produced during the coenzyme A metabolism cycle and is naturally present in all mammalian cells. The depigmenting efficacy of topical cysteamine has been shown in several double-blind, randomized, placebo-controlled clinical trials. Isobionicamide is a derivative of vitamin B3 and a new depigmenting agent that inhibits melanosomal transfer and was found to potentiate cysteamine's inhibitory effect on tyrosinase. Picosecond lasers have been shown to be effective in treating melasma in dark-skinned individuals. Herein, we report the case of a 50-year-old patient (phototype V) with recalcitrant melasma who significantly responded to picosecond laser associated with the topical application of isobionicamide-cysteamine.</p>","PeriodicalId":53616,"journal":{"name":"Journal of Clinical and Aesthetic Dermatology","volume":"18 2","pages":"30-32"},"PeriodicalIF":0.0,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11896620/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143617849","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":"He Who Wills the End Wills the Means: An Overview of Trusts for Physicians.","authors":"Clay Cockerell, Justine Galambus","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>Even though physicians often have the access and ability to generate significant wealth, many report poor financial literacy and education. They may not fully understand the options available to them for passing on their wealth to their next of kin. Options include wills, trusts, or, if one dies without a will, simply following the states intestate succession laws. There are multiple types of trusts that each confer different benefits and drawbacks. Physicians in all stages of their career should be aware of these options and strongly consider working with an estate planning attorney and financial planner.</p>","PeriodicalId":53616,"journal":{"name":"Journal of Clinical and Aesthetic Dermatology","volume":"18 2","pages":"23-24"},"PeriodicalIF":0.0,"publicationDate":"2025-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11896618/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143617845","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}