Annals of surgery open : perspectives of surgical history, education, and clinical approaches最新文献

{"title":"Keeping Open Surgery Alive: A Competency-Based Approach to Elevating Resident Skills.","authors":"Pamela B Andreatta, Brenton Franklin, Nicholas Koeberle, Mark Bowyer, Matthew Bradley","doi":"10.1097/AS9.0000000000000604","DOIUrl":"10.1097/AS9.0000000000000604","url":null,"abstract":"<p><strong>Objective: </strong>The study purpose was to determine if: (1) surgical residents would incrementally acquire open-procedural abilities for complex abdominal and vascular exposures through quarterly cadaver-based instruction, (2) chief residents would achieve parity with attending general surgeons when performing open surgical procedures for trauma.</p><p><strong>Background: </strong>Surgical education requires a solution for balancing the need to develop open-procedural skills for trauma and emergency surgery with the dwindling opportunity to perform these critical procedures during training.</p><p><strong>Methods: </strong>We implemented a 4-module open-procedures sequence on a quarterly basis for all levels [post-graduate years (PGY) 1-PGY5] of residents (N = 60) using human cadavers. Knowledge and procedural competencies were assessed for all residents over 3 years. We compared the procedural performance of PGY5s to attending general surgeons for 33 trauma procedures, with both groups assessed by independent faculty with no knowledge of their training. Comparative analyses were performed using <i>t</i> tests (<i>P</i> < 0.05) and effect sizes (Cohen's <i>d</i>).</p><p><strong>Results: </strong>Course outcomes demonstrate sustained acquisition of knowledge (<i>P</i> < 0.01) and procedural performance (<i>P</i> < 0.05) across all levels of residents. There were no significant differences between the performance of PGY5 residents and attending general surgeons when performing the 33 trauma procedures.</p><p><strong>Conclusions: </strong>The outcomes of this course demonstrate that developing the ability to perform open procedures during residency may require creative approaches that are nonetheless effective in preparing surgeons for future practice. The course modules are implemented in sequence with one module per quarter; however, alternate implementation schedules could accommodate most residency programs.</p>","PeriodicalId":72231,"journal":{"name":"Annals of surgery open : perspectives of surgical history, education, and clinical approaches","volume":"6 3","pages":"e604"},"PeriodicalIF":0.0,"publicationDate":"2025-09-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12453337/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145132954","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":"Missed Abdominal Wall Hernias.","authors":"Amanda L Nash, Theodore N Pappas, Jacob A Greenberg","doi":"10.1097/AS9.0000000000000615","DOIUrl":"10.1097/AS9.0000000000000615","url":null,"abstract":"","PeriodicalId":72231,"journal":{"name":"Annals of surgery open : perspectives of surgical history, education, and clinical approaches","volume":"6 3","pages":"e615"},"PeriodicalIF":0.0,"publicationDate":"2025-09-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12453323/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145132527","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 Association Between Online Surgeon Ratings and Patients' Postoperative Outcomes in the United States.","authors":"Raj Satkunasivam, Carlos Riveros, Michael Geng, Refik Saskin, Ruixin Li, Renil S Titus, Natalie Coburn, Avery Nathens, Benjamin N Breyer, Dharam Kaushik, Angela Jerath, Allan S Detsky, Yusuke Tsugawa, Christopher J D Wallis","doi":"10.1097/AS9.0000000000000612","DOIUrl":"10.1097/AS9.0000000000000612","url":null,"abstract":"<p><strong>Objective: </strong>To determine whether ratings are associated with postoperative outcomes.</p><p><strong>Background: </strong>Online ratings by patients or inclusion on lists of exceptional physicians are publicly available.</p><p><strong>Methods: </strong>In this retrospective study, Medicare fee-for-service beneficiaries 65 to 99 years old undergoing one of 14 major (elective/emergent) surgeries in the United States between 2016 and 2019 were analyzed. Data were analyzed from September 2023 to March 2024. Using computational methods to extract surgeon ratings from the three highest-volume publicly available patient-initiated and peer-nominated rating platforms. The exposure of interest was ratings (0-4, 4-4.49, ≥ 4.5) on patient-initiated platforms and \"Top Doctor\" status on the peer-nominated platform. The primary outcome was 30-day mortality. Secondary outcomes included 30-day complications, readmission, failure to rescue, and hospital length of stay. Using linear probability models, we controlled for patient, surgeon, and hospital factors to examine associations between ratings and outcomes.</p><p><strong>Results: </strong>We identified 2,690,315 patients operated on by 57,008 surgeons. Patient-initiated ratings were not consistently associated with 30-day mortality but were significantly associated with lower mortality among those treated by surgeons rated 4 to 4.49 on Platform B [adjusted risk difference (ARD), -0.06 % (95% confidence interval (CI) = -0.11 to -0.01)]. Patients treated by \"Top Doctor\" surgeons through peer-nomination had lower 30-day mortality ARD, -0.14 % (95% CI = -0.19 to -0.09). Surgeons with higher patient-initiated ratings had lower rates of 30-day complications and readmissions, while \"Top Doctors\" experienced lower rates of failure to rescue.</p><p><strong>Conclusions: </strong>Patient-initiated and peer-nominated ratings were associated with complications and readmission; mortality and failure to rescue, respectively, suggesting they capture different aspects of surgical care.</p>","PeriodicalId":72231,"journal":{"name":"Annals of surgery open : perspectives of surgical history, education, and clinical approaches","volume":"6 3","pages":"e612"},"PeriodicalIF":0.0,"publicationDate":"2025-09-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12453347/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145132692","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 Multicenter Collaborative Survey of Peritoneal Lavage Cytology in Gastric Cancer Surgery: Interinstitutional Methodological Differences and Positive Rate.","authors":"Keiichi Fujiya, Masanori Tokunaga, Kiyoshi Tone, Koki Nakanishi, Ryo Tanaka, Sho Sato, Junya Kitadani, Yoshihiko Kakiuchi, Izuma Nakayama, Shinji Hato, Souya Nunobe, Kazumasa Fujitani, Yukinori Kurokawa, Narikazu Boku, Takaki Yoshikawa","doi":"10.1097/AS9.0000000000000607","DOIUrl":"10.1097/AS9.0000000000000607","url":null,"abstract":"<p><strong>Objective: </strong>This study aimed to clarify the current status of cytological methodologies in high-volume gastric cancer centers and explore the relationship between methodology and positive rates.</p><p><strong>Background: </strong>International standards for peritoneal lavage cytological methods for collection, handling, and cytopreparation in gastric cancer have not been established yet.</p><p><strong>Methods: </strong>A questionnaire survey on cytological methodology was conducted in 61 institutions within the Japan Clinical Oncology Group in 2024. Aggregated data from patients with clinical T3 to T4 gastric cancer with cytology from 2017 to 2022 were collected to calculate positivity rates in each institution for the comparison of methodologies between institutions with high- and low-positivity rates.</p><p><strong>Results: </strong>Thirty-three institutions (64%) collected samples from 2 sites, primarily from the Douglas pouch and left subphrenic area. Fifty-eight institutions (95%) used ≤100 mL of normal saline for injection, and 51 (87%) performed intraoperative rapid cytology. Twenty-five institutions (41%) used additives in samples. Scraping glass slides and centrifugal direct smears were predominant cytopreparation methods in 31 (51%) and 22 (36%) institutions, respectively, and ethanol fixation was employed in 53 (87%). In 61 institutions (11,367 patients), the median cytological positivity rate for clinical T3 to T4 gastric cancer was 8.5% (2.1%-28.3%). Institutions with higher positivity rates more often employed ethanol fixation (97% vs. 77%, <i>P</i> = 0.026) and used ≤50 mL of normal saline for injection (61% vs. 37%, <i>P</i> = 0.074).</p><p><strong>Conclusions: </strong>Even among Japanese high-volume centers, cytological methodologies for gastric cancer lack uniformity, thereby leading to substantial variability in the proportion of positive cytology.</p>","PeriodicalId":72231,"journal":{"name":"Annals of surgery open : perspectives of surgical history, education, and clinical approaches","volume":"6 3","pages":"e607"},"PeriodicalIF":0.0,"publicationDate":"2025-09-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12453321/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145132878","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":"Increasing access for underrepresented learners in surgery: A perspective from building the UpSurge program.","authors":"Adom Bondzi-Simpson, Betel Yibrehu, David-Dan Nguyen, Armaan K Malhotra, Kennedy Ayoo, Ike Okafor, Najma Ahmed, Savtaj Brar","doi":"10.1097/AS9.0000000000000605","DOIUrl":"10.1097/AS9.0000000000000605","url":null,"abstract":"","PeriodicalId":72231,"journal":{"name":"Annals of surgery open : perspectives of surgical history, education, and clinical approaches","volume":"6 3","pages":"e605"},"PeriodicalIF":0.0,"publicationDate":"2025-09-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12453320/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145132889","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":"Patient-Reported Outcomes After Neoadjuvant Therapy and Watch-and-Wait for Rectal Cancer: A Systematic Review and Meta-Analysis.","authors":"Bailey K Hilty Chu, Anthony Loria, Totadri Dhimal, Lydia Rafferty, Marie Jacobs, Megan Boyer, Paula Cupertino, Fernando Colugnati, Erika Ramsdale, Fergal Fleming","doi":"10.1097/AS9.0000000000000602","DOIUrl":"10.1097/AS9.0000000000000602","url":null,"abstract":"<p><strong>Objective: </strong>To evaluate patient-reported outcomes (PROs) in rectal cancer patients who underwent neoadjuvant therapy followed by watch-and-wait.</p><p><strong>Background: </strong>Advancements in rectal cancer therapies have improved oncologic outcomes and increased focus on long-term treatment effects. Watch-and-wait, which aims for organ preservation in patients with a clinical complete response to neoadjuvant therapy, is used more frequently. While watch-and-wait may reduce functional impairments associated with proctectomy, its association with PROs is poorly understood.</p><p><strong>Methods: </strong>We performed a systematic review and meta-analysis of studies reporting PROs for patients with stage I-III rectal adenocarcinoma treated with neoadjuvant therapy and watch-and-wait. Random-effects model meta-analysis was performed when feasible; otherwise, data were synthesized through a narrative review.</p><p><strong>Results: </strong>Twenty-five studies (3139 patients) reported PROs for patients receiving neoadjuvant therapy followed by watch-and-wait (n = 1283), proctectomy (n = 1583), local excision (n = 263), or declined surgery (n = 10). Most studies (64.0%) excluded patients with local regrowth, leaving PRO data for 103 such patients. Fourteen studies compared PROs between treatment groups after neoadjuvant therapy. Meta-analyses demonstrated fewer bowel symptoms and improved quality of life (QoL) in 1/6 subscales for watch-and-wait. Across 24 QoL comparisons, 14 showed improvement in some subscales for watch-and-wait, while 10 found no difference. For 24 symptom scale comparisons, 11 indicated some improvement with watch-and-wait, and 13 found no differences between groups.</p><p><strong>Conclusions: </strong>Watch-and-wait offers the potential to avoid permanent ostomy and surgical morbidity. However, more robust data are needed to assess its association with PROs compared to proctectomy or local excision. Researchers should prioritize publishing QoL data to better inform shared decision-making.</p>","PeriodicalId":72231,"journal":{"name":"Annals of surgery open : perspectives of surgical history, education, and clinical approaches","volume":"6 3","pages":"e602"},"PeriodicalIF":0.0,"publicationDate":"2025-09-08","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12453364/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145132717","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":"Cardiometabolic Health and Bariatric Surgery: A 25-Year Longitudinal Cohort Study in CARDIA Participants.","authors":"Brian T Steffen, Sayeed Ikramuddin, David R Jacobs, Kristi L Kopacz, Daniel Duprez, Ankeet S Bhatt, Jamal S Rana, John J Carr, Xia Zhou, Lyn M Steffen","doi":"10.1097/AS9.0000000000000609","DOIUrl":"10.1097/AS9.0000000000000609","url":null,"abstract":"<p><strong>Objective: </strong>Compare longitudinal cardiometabolic health outcomes among individuals who underwent bariatric surgery (BarS) with nonsurgical controls.</p><p><strong>Background: </strong>BarS is well-established for inducing profound weight loss and improving cardiometabolic health, but it remains unclear whether patients achieve long-term cardiometabolic health consistent with the attained lower weight status.</p><p><strong>Methods: </strong>Cohort study participants who underwent any BarS procedure between 1987 and 2021 (n = 94) were paired with sex- and body mass index (BMI)-matched nonsurgical controls (n = 282) at the nearest postoperative cohort exam visit (2.8 ± 1.7 years following surgery). A mixed model tested differences between BarS cases and nonsurgical matched controls, adjusting for age, sex, race, field center, and maximal education attainment. Intermediate cardiometabolic endpoints and incident diabetes and metabolic syndrome, were examined at follow-up exam visits.</p><p><strong>Results: </strong>Approximately 7.5 years following their procedures, those who underwent BarS showed higher BMIs than matched controls (+2.8 kg/m²); however, the BarS group showed significantly lower mean fasting levels of glucose (-6.5 mg/dL; <i>P</i> = 0.03), insulin (-2.75 μU/mL; <i>P</i> = 0.01), low density lipoprotein cholesterol (-20.0 mg/dL; <i>P</i> < 0.001), C-reactive protein (log-transformed) (-0.42; <i>P</i> = 0.002), homeostasis model assessment-estimated insulin resistance (-0.75; <i>P</i> = 0.02), and higher mean high density lipoprotein cholesterol (+11.4 mg/dL; <i>P</i> < 0.001) compared to matched controls. BarS cases showed lower incidence of diabetes (1.8% vs 11.7%; <i>P</i> = 0.007) and nominally lower MetS (13.7% vs 22.3%; <i>P</i> = 0.23).</p><p><strong>Conclusions: </strong>We found no evidence of lasting adverse cardiometabolic health consequences of severe obesity in a sample of cohort participants who underwent a BarS procedure. On average, BarS cases showed features of better cardiometabolic health than postoperative-matched nonsurgical controls who followed a more moderate trajectory of obesity.</p>","PeriodicalId":72231,"journal":{"name":"Annals of surgery open : perspectives of surgical history, education, and clinical approaches","volume":"6 3","pages":"e609"},"PeriodicalIF":0.0,"publicationDate":"2025-09-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12453380/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145132909","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":"Task Shifting and Task Sharing in Surgical Care.","authors":"Parth K Modi, David O Meltzer, Anne E Sales, Ted A Skolarus","doi":"10.1097/AS9.0000000000000603","DOIUrl":"10.1097/AS9.0000000000000603","url":null,"abstract":"","PeriodicalId":72231,"journal":{"name":"Annals of surgery open : perspectives of surgical history, education, and clinical approaches","volume":"6 3","pages":"e603"},"PeriodicalIF":0.0,"publicationDate":"2025-09-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12453308/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145132720","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":"Long-Term Survival After Surgical Resection for Rectal Cancer Is Associated With Textbook Outcome but Not Surgical Case Volume.","authors":"Mohamed Aly, Yu-Hui Chang, Chee-Chee Stucky, Zhi Ven Fong, David Etzioni, Nabil Wasif","doi":"10.1097/AS9.0000000000000601","DOIUrl":"10.1097/AS9.0000000000000601","url":null,"abstract":"<p><strong>Objective: </strong>Analyzing textbook outcome (TO) following rectal cancer resection and its association with long-term survival when compared to hospital case volume alone.</p><p><strong>Background: </strong>TO is a quality metric representing the ideal result following complex cancer surgery. Prior studies have suggested improved long-term survival for rectal cancer patients undergoing surgery at HV institutions.</p><p><strong>Methods: </strong>Patients undergoing surgery for rectal adenocarcinoma from 2014 to 2015 were identified using the National Cancer Database. Low (LV), medium (MV), and high-volume (HV) hospital strata were defined by quartile cutoffs (low <25th, high >75th, and 25-75th medium volume). TO was achieved with adequate lymph node count (≥12), negative margins (R0 resection), length of stay <75th percentile, absence of 30-day readmission/mortality event, and appropriate plus timely systemic therapy. Adjusted analyses for long-term survival were performed using a hierarchical multivariable Cox regression model.</p><p><strong>Results: </strong>TO was achieved in 28.5% of 48,484 patients. LV or MV hospital patients were more likely to be older, uninsured/Medicaid, and less likely to achieve a TO (HV 31.2% vs MV 29.6% vs LV 23.2%, <i>P</i> < 0.001). TO was associated with improved 5-year survival (84.0% vs 72.0%, <i>P</i> < 0.001). On multivariable analyses, TO was the strongest protective factor against mortality (HR 0.60, 95% confidence interval = 0.56-0.64), even after controlling for case volume.</p><p><strong>Conclusions: </strong>Only 28.5% of patients undergoing resection for rectal cancer achieve TO. However, they had a 40% reduction in long-term mortality independent of hospital volume. Optimizing long-term survival in patients with rectal cancer can be achieved by TO criteria rather than increasing surgical case volume.</p>","PeriodicalId":72231,"journal":{"name":"Annals of surgery open : perspectives of surgical history, education, and clinical approaches","volume":"6 3","pages":"e601"},"PeriodicalIF":0.0,"publicationDate":"2025-08-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12453300/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145132905","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":"Gloving the Surgeon: <i>A Practical Review of Surgical Glove Material Properties, Safety, and Waste</i>.","authors":"Jay J Patel, Keenan S Fine, Aidan W O'Shea, Peter J Wirth, Ellen C Shaffrey, Pradeep K Attaluri, Venkat K Rao","doi":"10.1097/AS9.0000000000000600","DOIUrl":"10.1097/AS9.0000000000000600","url":null,"abstract":"<p><p>Surgical gloves are a staple in every surgeon's daily routine, yet their full lifecycle is not always well understood. This paper outlines the journey of a surgical glove from manufacturing to disposal, with particular emphasis on clinically relevant properties such as durability, perforation rates, and allergy risk. It begins with a review of the historical context of sterile surgical gloves, followed by a detailed overview of the manufacturing process and the materials used, including latex and various synthetic alternatives. These various materials may differ in barrier protection, fit, tactile sensitivity, and allergenic potential. Data presented here suggests that synthetic alternatives to latex, while hypoallergenic, may be more prone to microperforations or decreased dexterity. The logistics of glove sourcing and inventory management are also examined, providing insights to help surgical teams and hospital administrators prepare for supply chain disruptions, such as those experienced during the COVID-19 pandemic. Finally, best practices for glove disposal and the environmental impact of surgical gloves are explored. By examining the clinical and logistical aspects of glove use, this article offers insights to optimize surgical safety, resource management, and sustainability.</p>","PeriodicalId":72231,"journal":{"name":"Annals of surgery open : perspectives of surgical history, education, and clinical approaches","volume":"6 3","pages":"e600"},"PeriodicalIF":0.0,"publicationDate":"2025-08-04","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12453325/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"145132874","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}