American Surgeon最新文献_第5页

Results of Open and Endovascular Repair of Complex Aortic, Iliac, and Femoral Anastomotic Aneurysms. 血管内切开修复复杂的主动脉、髂、股吻合动脉瘤的结果。

IF 0.9 4区医学

American Surgeon Pub Date : 2025-07-28 DOI: 10.1177/00031348251363809

Shyamal Pansuriya, Sachinder Hans

{"title":"Results of Open and Endovascular Repair of Complex Aortic, Iliac, and Femoral Anastomotic Aneurysms.","authors":"Shyamal Pansuriya, Sachinder Hans","doi":"10.1177/00031348251363809","DOIUrl":"https://doi.org/10.1177/00031348251363809","url":null,"abstract":"Anastomotic aneurysms (AA) manifest as late complications of aortic-iliac-femoral reconstruction with a prosthetic graft. We studied open and endovascular repair of complex aortic iliac and femoral AA was performed for (A) Rupture, (B) Large symptomatic aneurysms, (C) Recurrent, (D) Femoral AA requiring simultaneous arterial reconstruction for critical limb ischemia in two teaching hospitals. Between 1990 and 2024, 100 aorto-femoral-iliac AA were repaired with 32 representing complex AA involving aorta (n = 6), iliac (n = 3), femoral (n = 23). Aortic and iliac anastomotic aneurysms underwent endovascular repairs in 5 patients and open repair in 4 patients with satisfactory outcomes in all. All 23 patients presenting with complex femoral anastomotic aneurysms were repaired via open technique, including five presenting with rupture with mortality in two, and one mortality among those presenting with large aneurysms. Complex femoral AA take longer to present after index operative, showed greater operative time, intra-operative blood loss but had similar mortality to patients with non-complex AAs. Most aortic and iliac AA can be repaired with endovascular and open techniques with satisfactory results, while complex femoral AA required open repair.","PeriodicalId":7782,"journal":{"name":"American Surgeon","volume":" ","pages":"31348251363809"},"PeriodicalIF":0.9,"publicationDate":"2025-07-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144726502","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

Increasing Tube Thoracostomy Output Threshold to Less Than 300 mL Per Day is Not Associated With Increased Complications after Removal in Trauma Patients. 增加胸腔插管输出阈值至每天小于300 mL与创伤患者切除后并发症的增加无关。

IF 0.9 4区医学

American Surgeon Pub Date : 2025-07-28 DOI: 10.1177/00031348251363533

Lee C Givens, Chase A Jordan, James W Herrin, Yann-Leei L Lee, Steven G Miller, Thomas Capasso, Maryann Mbaka, Christopher M Kinnard, Andrew C Bright, Ashley Y Williams, Nathan M Polite, Jon D Simmons, Charles C Butts

{"title":"Increasing Tube Thoracostomy Output Threshold to Less Than 300 mL Per Day is Not Associated With Increased Complications after Removal in Trauma Patients.","authors":"Lee C Givens, Chase A Jordan, James W Herrin, Yann-Leei L Lee, Steven G Miller, Thomas Capasso, Maryann Mbaka, Christopher M Kinnard, Andrew C Bright, Ashley Y Williams, Nathan M Polite, Jon D Simmons, Charles C Butts","doi":"10.1177/00031348251363533","DOIUrl":"https://doi.org/10.1177/00031348251363533","url":null,"abstract":"BackgroundTube thoracostomy (TT) is a life-saving intervention that has a high complication rate. While many institutions continue drainage until <200 mL/day, there is little data on removal with higher output. This study aimed to determine whether TT removal with higher output on the day of removal is associated with complication of tube thoracostomy (CTT).Materials and MethodsThis was a retrospective study of patients who underwent TT due to traumatic hemothorax/pneumothorax. Data on demographics, admission vital signs, injury details, treatment course, and output on day of removal was collected. Output was classified as HIGH (200-299 mL at removal) or LOW (<200 mL). The primary outcome variable was development of CTT, which was defined as re-accumulation of HTX/PTX, development of an empyema, subsequent TT, or need for thoracic surgery following tube removal.ResultsAfter applying exclusion criteria, we identified 315 patients for analysis. The average age was 41 years old, and 74% (233) were male. The mean duration of treatment with TT was 5 days. The mean output on the day of removal was 80 mL, with 10% having a volume between 200-299 mL on day of removal. Overall, 16% developed CTT. There was no difference in the rate of CTT after removal between HIGH and LOW groups. Multiple variable logistic regression showed only chest AIS was statistically significantly associated with CTT.DiscussionComplications after tube thoracostomy are common (16%), but patients with higher output were not more likely to develop a complication. Chest tubes can be safely removed with an output <300 mL/day.","PeriodicalId":7782,"journal":{"name":"American Surgeon","volume":" ","pages":"31348251363533"},"PeriodicalIF":0.9,"publicationDate":"2025-07-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144726497","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

Statewide Discharge Data Supports Development of Inclusive Trauma System. 全州范围的出院数据支持包容性创伤系统的发展。

IF 0.9 4区医学

American Surgeon Pub Date : 2025-07-28 DOI: 10.1177/00031348251363513

Pascal Osita Udekwu, William Luo, Anquonette Stiles, Sharon Schiro

{"title":"Statewide Discharge Data Supports Development of Inclusive Trauma System.","authors":"Pascal Osita Udekwu, William Luo, Anquonette Stiles, Sharon Schiro","doi":"10.1177/00031348251363513","DOIUrl":"https://doi.org/10.1177/00031348251363513","url":null,"abstract":"IntroductionVerification by the American College of Surgeons and state designation of trauma centers improve outcomes in trauma care. In regions where participation in trauma systems is optional, legislation requiring inclusion may need evidence of outcome differences. Given the distinct populations treated at trauma centers vs non-trauma centers, validated risk adjustment is essential for fair comparison. The International Classification of Diseases, 10th Revision injury severity score (ICISS) has been validated for such assessments.MethodsWith institutional review board approval, data from the state Healthcare Cost and Utilization Project from 2018 to 2020 was analyzed. Using ICISS for risk adjustment, outcomes were compared across overall, age-specific, and diagnosis-specific groups.ResultsAmong 3,316,016 discharges, 245,404 (7.4 percent) included at least one injury diagnosis. After excluding transfers out, 151,855 cases remained. Patients at trauma centers had lower risk-adjusted mortality and fewer occurrences of acute kidney injury and pulmonary embolism but higher rates of ventilator-associated pneumonia and surgical site infections. Subgroup analyses revealed that pediatric patients and those with traumatic brain injuries or shock were predominantly treated at trauma centers. Increased age, higher injury severity, male gender, and non-trauma center treatment were associated with lower survival rates. Among geriatric patients with proximal femur fractures, 63 percent were treated at non-trauma centers, with no observed mortality benefit from trauma center care.ConclusionsTrauma center care is associated with improved outcomes supporting the development of more inclusive trauma systems.","PeriodicalId":7782,"journal":{"name":"American Surgeon","volume":" ","pages":"31348251363513"},"PeriodicalIF":0.9,"publicationDate":"2025-07-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144726503","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

The Last Scalpel: Ghosts in the Operating Room. 《最后的手术刀：手术室里的鬼魂》

IF 0.9 4区医学

American Surgeon Pub Date : 2025-07-28 DOI: 10.1177/00031348251363545

Amir Farah

引用次数: 0

Reported Ventilator Associated Pneumonia Rates in the Trauma Population do not Reflect Clinically Significant Respiratory Infection. 创伤人群中呼吸机相关肺炎的报道率并不能反映临床显著的呼吸道感染。

IF 0.9 4区医学

American Surgeon Pub Date : 2025-07-28 DOI: 10.1177/00031348251363531

Alison K Mortemore, Prashanth Balaraman, Emily McGee, Kenneth Chiep, Andrew Gross, Andrew Suh, Danielle Tatum, Patrick McGrew, Jeanette Zhang, Sharven Taghavi, Kevin N Harrell

{"title":"Reported Ventilator Associated Pneumonia Rates in the Trauma Population do not Reflect Clinically Significant Respiratory Infection.","authors":"Alison K Mortemore, Prashanth Balaraman, Emily McGee, Kenneth Chiep, Andrew Gross, Andrew Suh, Danielle Tatum, Patrick McGrew, Jeanette Zhang, Sharven Taghavi, Kevin N Harrell","doi":"10.1177/00031348251363531","DOIUrl":"https://doi.org/10.1177/00031348251363531","url":null,"abstract":"BackgroundVentilator-associated pneumonia (VAP) is a common intensive care unit (ICU) infection linked to increased morbidity and mortality. Trauma patients may be at a higher risk for VAP due to factors like chest wall injury, pulmonary contusions, and aspiration risk. Limited data exists on this population despite VAP being a quality metric reported to the Trauma Quality Improvement Program (TQIP). We hypothesized that reported VAP rates will be lower than clinically significant infections.MethodsThis retrospective study analyzed intubated adult trauma patients at a single Level 1 trauma center between January 2019 and December 2023. VAP was defined as at least moderate growth of a speciated organism on respiratory culture obtained 2 or more days after intubation. The primary aim of this study is to compare trauma registry reported VAP rates with clinically significant respiratory infection.ResultsOver 5 years, 980 patients had a median age of 42 years, sustaining blunt injuries (71.3%) with a median injury severity score of 20. While the trauma registry reported VAP in 8.3% of patients, clinical VAP was identified in 23.7%. When comparing the trauma registry ability to predict the presence of clinically significant respiratory infection, VAP predicted clinically significant respiratory infection with only 29.2% sensitivity, with an area under the receiver operating characteristic curve of 0.640.ConclusionsVAP is underreported in trauma registries. Improved definitions, reporting standards, and diagnostic use of respiratory cultures are essential to enhance the reliability and utility of VAP as a quality metric and study tool in trauma patients.","PeriodicalId":7782,"journal":{"name":"American Surgeon","volume":" ","pages":"31348251363531"},"PeriodicalIF":0.9,"publicationDate":"2025-07-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144726501","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

Comparative Analysis of Profiles and Outcomes for Elderly Patients with or without Reported Abuse. 有或没有报告虐待的老年患者的资料和结果的比较分析。

IF 0.9 4区医学

American Surgeon Pub Date : 2025-07-27 DOI: 10.1177/00031348251363515

Jiabao Nie, Areg Grigorian, Negaar Aryan, Nicholas Truong, Catherine Kuza, Sigrid Burrus, Jeffry Nahmias

{"title":"Comparative Analysis of Profiles and Outcomes for Elderly Patients with or without Reported Abuse.","authors":"Jiabao Nie, Areg Grigorian, Negaar Aryan, Nicholas Truong, Catherine Kuza, Sigrid Burrus, Jeffry Nahmias","doi":"10.1177/00031348251363515","DOIUrl":"https://doi.org/10.1177/00031348251363515","url":null,"abstract":"BackgroundOlder adult (OA) abuse affects the health and welfare of people ages 65 and older. Although previous research has shown that OA abuse impacts their well-being, there is limited understanding of the injury profiles and outcomes for OAs with or without reported abuse. This study compared OAs who reported abuse ((+)RA) to those who did not ((-)RA), hypothesizing OAs with (+)RA have increased mortality.MethodsThe 2017-2019 Trauma Quality Improvement Program (TQIP) was queried for all OAs ages 65 and older. The primary outcome was mortality. Bivariate analyses were performed to compare OAs with (+)RA and (-)RA. Separate multivariable analyses were performed to determine if (+)RA was associated with risk of complications or mortality.ResultsOut of 937 465 OAs, 1552 (0.2%) had (+)RA. OAs with (+)RA had increased rates of gunshot wounds (5.7% vs 0.7%, P < .001) and stab wounds (1.9% vs 0.4%, P < .001) compared to (-)RA patients. (+)RA patients also had increased mortality (6.7% vs 4.2%, P < .001), hospital LOS (5 vs 5, P < .001), and more often underwent surgical interventions (19.0% vs 14.3%, P < .001). On multivariable analysis, OAs with (+)RA had an increased associated risk of complications (OR 1.41, CI 1.16-1.71, P < .001) and mortality (OR 1.35, CI 1.06-1.70, P = .012) compared to OAs with (-)RA.DiscussionThis national analysis demonstrated that OAs with (+)RA had increased rates of penetrating trauma, surgical interventions, ventilator days, and death compared to (-)RA patients. Future prospective studies are needed to ascertain if primary prevention efforts can mitigate the increased morbidity and mortality seen in this vulnerable population.","PeriodicalId":7782,"journal":{"name":"American Surgeon","volume":" ","pages":"31348251363515"},"PeriodicalIF":0.9,"publicationDate":"2025-07-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144726495","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

Paul Kaznelson, Immune Thrombocytopenic Purpura, and Splenectomy: The Tragic Story of a Medical Prodigy. Paul Kaznelson，免疫性血小板减少性紫癜和脾切除术：一个医学奇才的悲剧故事。

IF 0.9 4区医学

American Surgeon Pub Date : 2025-07-27 DOI: 10.1177/00031348251363850

Don K Nakayama

{"title":"Paul Kaznelson, Immune Thrombocytopenic Purpura, and Splenectomy: The Tragic Story of a Medical Prodigy.","authors":"Don K Nakayama","doi":"10.1177/00031348251363850","DOIUrl":"https://doi.org/10.1177/00031348251363850","url":null,"abstract":"In 1916 Paul Kaznelson (1892-1959), a 26-year-old medical student at German University in Prague, was the first to describe splenectomy for what would be recognized today as immune thrombocytopenic purpura (ITP). From his physical examination, microscopy of a blood smear, and what was then known about the life cycle of platelets, he concluded that his patient's bleeding diathesis and enlarged spleen were linked: she had no platelets because they were being destroyed by the organ. He convinced the chief of surgery to remove the patient's spleen, a landmark operation that succeeded beyond \"the wildest expectations\". He stayed on faculty, but his promising academic career was derailed by virulent antisemitism, first in his own university medical school, then his home country. Forced into exile in 1939 he found refuge in the United Kingdom, which allowed him to practice medicine but denied him formal residency. At war's end he found himself unwanted in the West by his Russian heritage and citizenship in an Iron Curtain country. Czechoslovakia's newly installed communist regime barred his repatriation due to the ambiguous circumstances of his wartime residency in England. Today treatment of ITP is directed toward controlling autoimmune reaction against platelet antigens. Splenectomy is done only after nonsurgical options have been exhausted. The operation and its history are a fading coda to the story of a medical prodigy whose career was crushed by prejudice and world events.","PeriodicalId":7782,"journal":{"name":"American Surgeon","volume":" ","pages":"31348251363850"},"PeriodicalIF":0.9,"publicationDate":"2025-07-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144726499","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

Management of Traumatic Liver Failure Using Molecular Adsorbent Recirculating System (MARS) Treatment. 应用分子吸附剂再循环系统（MARS）治疗外伤性肝衰竭。

IF 0.9 4区医学

American Surgeon Pub Date : 2025-07-27 DOI: 10.1177/00031348251363522

Theresa A Johnson, Rachel L Warner, Marie L Crandall, David J Skarupa, Joseph R Shiber

引用次数: 0

Surveillance of Posttraumatic Abdominal Pseudoaneurysms. 创伤后腹部假性动脉瘤的监测。

IF 0.9 4区医学

American Surgeon Pub Date : 2025-07-27 DOI: 10.1177/00031348251363534

Katelyn Gill, Jagnoor Benipal, Hector Ferral, Kaden Knecht, Claudia Leonardi, Alexandra H Fairchild, Bahri Ustunsoz, Dan F Laney, John Hunt, Jonathan E Schoen, Alan Marr, Patrick Greiffenstein, Lance Stuke, Alison A Smith

{"title":"Surveillance of Posttraumatic Abdominal Pseudoaneurysms.","authors":"Katelyn Gill, Jagnoor Benipal, Hector Ferral, Kaden Knecht, Claudia Leonardi, Alexandra H Fairchild, Bahri Ustunsoz, Dan F Laney, John Hunt, Jonathan E Schoen, Alan Marr, Patrick Greiffenstein, Lance Stuke, Alison A Smith","doi":"10.1177/00031348251363534","DOIUrl":"https://doi.org/10.1177/00031348251363534","url":null,"abstract":"ObjectiveTraumatic pseudoaneurysms are a serious complication following blunt and penetrating trauma, carrying a significant risk of morbidity and mortality if ruptured. However, there is a lack of specific guidelines for their detection and surveillance. This study aimed to evaluate the detection and management of posttraumatic solid organ pseudoaneurysms.Materials and MethodsA prospectively maintained database was created at a Level 1 trauma center from January 2023 to June 2024. All patients aged 15 years and older who presented with a high-grade liver, kidney, or spleen injury were included in the study. Univariate data analyses was utilized with P < 0.05 considered statistically significant.ResultsTwo hundred and five patients were included in the study. Pseudoaneurysms were identified in 10.7% of patients (n = 22/205). Gunshot wounds (n = 8/22, 36.4%) and motor vehicle collisions (n = 7/22, 31.8%) were the most common mechanisms of injury. Pseudoaneurysms were identified in the liver (n = 10/22, 45.5%), spleen (n = 9/22, 40.9%), and kidney (n = 3/22, 13.6%). 90.9% (n = 20/22) of pseudoaneurysms were identified within 5 days of initial injury. Seventeen (n = 17/22, 77.3%) patients underwent endovascular embolization for pseudoaneurysm repair with an 88.2% success rate. Five (n = 5/22, 22.7%) patients with pseudoaneurysms were managed by observation alone with no intervention. Overall, 48.3% (n = 99/205) of patients had a follow-up abdominal CTA prior to discharge.ConclusionAbdominal CTAs provide adequate surveillance for post-traumatic abdominal pseudoaneurysms, allowing for timely repair to decrease the risk of mortality from pseudoaneurysm rupture. Future prospective multi-center studies are needed to establish evidence-based guidelines for pseudoaneurysm detection and management.","PeriodicalId":7782,"journal":{"name":"American Surgeon","volume":" ","pages":"31348251363534"},"PeriodicalIF":0.9,"publicationDate":"2025-07-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144726504","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0

Futility of Radiographs After Chest Tube Removal (FRACTR) Trial. 胸管拔除（FRACTR）试验后x线片无效。

IF 1 4区医学

American Surgeon Pub Date : 2025-07-21 DOI: 10.1177/00031348251358423

Ashton E Norris, Gunnar J Orcutt, Andrew Hendrix, Cameron McQuillen, Callie Clarke, Deborah M Hurley, James N Conner, Christopher M Watson, Jacob Hessey

{"title":"Futility of Radiographs After Chest Tube Removal (FRACTR) Trial.","authors":"Ashton E Norris, Gunnar J Orcutt, Andrew Hendrix, Cameron McQuillen, Callie Clarke, Deborah M Hurley, James N Conner, Christopher M Watson, Jacob Hessey","doi":"10.1177/00031348251358423","DOIUrl":"https://doi.org/10.1177/00031348251358423","url":null,"abstract":"BackgroundRoutine post-pull chest X-rays (CXR) are still utilized after chest tube removal in trauma patients, though their necessity in asymptomatic individuals remains debated. This study aimed to identify predictors of chest tube reinsertion and evaluate a selective, symptom-based approach to post-pull imaging.MethodsA retrospective cohort study was conducted at a Level 1 trauma center, including 650 trauma patients who underwent chest tube placement between 2021 and 2024. Demographic and clinical variables were collected, including ICU and ventilator days, Injury Severity Score (ISS), waterseal use, and post-pull symptoms and CXR findings. Bivariate and multivariable logistic regression analyses were performed to identify predictors of reinsertion.ResultsAmong 539 eligible patients and 572 chest tubes, the reinsertion rate was 10%. Post-pull symptoms were the strongest predictor of reinsertion (OR 28.38, P < 0.001), followed by shorter chest tube duration and absence of waterseal, which decreased reinsertion odds by 89.9% (OR 0.101, P = 0.008). While post-pull CXR findings were associated with reinsertion, their positive predictive value (16.9%) was markedly lower than that of clinical symptoms (56.9%). ICU stay and ventilator days were associated with reinsertion in univariate analysis but not in multivariable modeling. Patients aged ≥65 had significantly lower odds of reinsertion compared to younger patients (OR 0.26, P = 0.031).DiscussionClinical symptoms were the most reliable predictor of reinsertion. A selective approach guided by symptoms, waterseal use, and drainage duration may reduce unnecessary imaging. Prospective validation of this strategy is warranted.","PeriodicalId":7782,"journal":{"name":"American Surgeon","volume":" ","pages":"31348251358423"},"PeriodicalIF":1.0,"publicationDate":"2025-07-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144681897","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

引用次数: 0