Anesthesia and analgesia最新文献

{"title":"Previous Coronavirus Disease-2019 Infection and Lung Mechanics in Surgical Patients: A Hospital Registry Study.","authors":"Aiman Suleiman, Ricardo Munoz-Acuna, Simone Redaelli, Elena Ahrens, Tim M Tartler, Sarah Ashrafian, May M Hashish, Abeer Santarisi, Guanqing Chen, Stefan Riedel, Daniel Talmor, Elias N Baedorf Kassis, Maximilian S Schaefer, Valerie Goodspeed","doi":"10.1213/ANE.0000000000007015","DOIUrl":"10.1213/ANE.0000000000007015","url":null,"abstract":"<p><strong>Background: </strong>Long-term pulmonary complications have been reported after a coronavirus disease-2019 (COVID-19). We hypothesized that a history of COVID-19 is associated with a measurable decrease in baseline respiratory system compliance in patients undergoing general anesthesia.</p><p><strong>Methods: </strong>In this hospital registry study, we included adult patients undergoing general anesthesia between January 2020 and March 2022 at a tertiary health care network in Massachusetts. We excluded patients with an American Society of Anesthesiologists physical status >IV, laryngoscopic surgeries, and patients who arrived intubated. The primary exposure was a history of COVID-19. The primary outcome was baseline respiratory system compliance (mL/cmH 2 O). Effects of severity of infection, surges (Alpha 1 , Alpha 2 , Delta, and Omicron), patient demographics, and time between infection and assessment of compliance were investigated.</p><p><strong>Results: </strong>A total of 19,921 patients were included. Approximately 1386 (7.0%) patients had a history of COVID-19. A history of COVID-19 at any time before surgery was associated with a measurably lower baseline respiratory system compliance (ratio of means adj = 0.96; 95% confidence interval [CI], 0.94-0.97; P < .001; adjusted compliance difference: -1.6 mL/cmH 2 O). The association was more pronounced in patients with a severe form of COVID-19 (ratio of means adj = 0.95; 95% CI, 0.90-0.99; P = .02, adjusted compliance difference: -2 mL/cmH 2 O). Alpha 1 , Alpha 2 , and Delta surges, but not Omicron, led to a lower baseline respiratory system compliance ( P < .001, P = .02, and P < .001). The Delta surge effect was magnified in Hispanic ethnicity ( P -for-interaction = 0.003; ratio of means adj = 0.83; 95% CI, 0.74-0.93; P = .001; adjusted compliance difference: -4.6 mL/cmH 2 O).</p><p><strong>Conclusions: </strong>A history of COVID-19 infection during Alpha 1 , Alpha 2 , and Delta surges was associated with a measurably lower baseline respiratory system compliance.</p>","PeriodicalId":7784,"journal":{"name":"Anesthesia and analgesia","volume":" ","pages":"997-1005"},"PeriodicalIF":4.6,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141764889","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Evaluating Neurological Biomarkers in Serum After Major Cardiac Surgery: A Study of Tau, Neurofilament Light Chain, Glial Fibrillary Acidic Protein, and Ubiquitin C-terminal Hydrolase L1.","authors":"Kwame Wiredu, Tina B McKay, Jason Qu, Oluwaseun Akeju","doi":"10.1213/ANE.0000000000007053","DOIUrl":"10.1213/ANE.0000000000007053","url":null,"abstract":"","PeriodicalId":7784,"journal":{"name":"Anesthesia and analgesia","volume":" ","pages":"1122-1124"},"PeriodicalIF":4.6,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11493520/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141874001","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Assessing the Utility of a Machine-Learning Model to Assist With the Assignment of the American Society of Anesthesiology Physical Status Classification in Pediatric Patients.","authors":"Lynne R Ferrari, Izabela Leahy, Steven J Staffa, Peter Hong, Isabel Stringfellow, Jay G Berry","doi":"10.1213/ANE.0000000000006761","DOIUrl":"10.1213/ANE.0000000000006761","url":null,"abstract":"&lt;p&gt;&lt;strong&gt;Background: &lt;/strong&gt;The American Society of Anesthesiologists Physical Status Classification System (ASA-PS) is used to classify patients' health before delivering an anesthetic. Assigning an ASA-PS Classification score to pediatric patients can be challenging due to the vast array of chronic conditions present in the pediatric population. The specific aims of this study were to (1) suggest an ASA-PS score for pediatric patients undergoing elective surgical procedures using machine-learning (ML) methods; and (2) assess the impact of presenting the suggested ASA-PS score to clinicians when making their final ASA-PS assignment. The intent was not to create a new ASA-PS score but to use ML methods to generate a suggested score, along with information on how the score was generated (ie, historical information on patient comorbidities) to assist clinicians when assigning their final ASA-PS score.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methods: &lt;/strong&gt;A retrospective analysis of 146,784 pediatric surgical encounters from January 1, 2016, to December 31, 2019, using eXtreme Gradient Boosting (XGBoost) methods to predict ASA-PS scores using patients' age, weight, and chronic conditions. SHapley Additive exPlanations (SHAP) were used to assess patient characteristics that contributed most to the predicted ASA-PS scores. The predicted ASA-PS model was presented to a prospective cohort study of 28,677 surgical encounters from December 1, 2021, to October 31, 2022. The predicted ASA-PS score was presented to the anesthesiology provider for review before entering the final ASA-PS score. The study focused on summarizing the available information for the anesthesiologist by using ML methods. The goal was to explore the potential for ML to provide assistance to anesthesiologists by highlighting potential areas of discordance between the variables that generated a given ML prediction and the physician's mental model of the patient's medical comorbidities.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results: &lt;/strong&gt;For the retrospective analysis, the distribution of predicted ASA-PS scores was 22.7% ASA-PS I, 48.5% II, 23.6% III, 5.1% IV, and 0.04% V. The distribution of clinician-assigned ASA-PS scores was 24.3% for ASA-PS I, 44.5% for ASA-PS II, 24.9% for ASA III, 6.1% for ASA-PS IV, and 0.2% for ASA-V. In the prospective analysis, the final ASA-PS score matched the initial ASA-PS 90.7% of the time and 9.3% were revised after viewing the predicted ASA-PS score. When the initial ASA-PS score and the ML ASA-PS score were discrepant, 19.5% of the cases have a final ASA-PS score which is different from the initial clinician ASA-PS score. The prevalence of multiple chronic conditions increased with ASA-PS score: 34.9% ASA-PS I, 73.2% II, 92.3% III, and 94.4% IV.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions: &lt;/strong&gt;ML derivation of predicted pediatric ASA-PS scores was successful, with a strong agreement between predicted and clinician-entered ASA-PS scores. Presentation of predicted ASA-PS scores was associated with revis","PeriodicalId":7784,"journal":{"name":"Anesthesia and analgesia","volume":" ","pages":"1017-1026"},"PeriodicalIF":4.6,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138798489","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"A Qualitative Study of the Work Systems and Culture Around End-of-Day Intraoperative Anesthesia Handoffs in a Tertiary Care Center.","authors":"Aubrey Samost-Williams, Samantha L Bernstein, A Taylor Thomas, Anastasia P Piersa, Jessica E Hawkins, May C M Pian-Smith","doi":"10.1213/ANE.0000000000006751","DOIUrl":"10.1213/ANE.0000000000006751","url":null,"abstract":"<p><strong>Background: </strong>Intraoperative handoffs have been implicated as a contributing factor in many perioperative adverse events. Despite conflicting data around their impact on perioperative outcomes, they remain a vulnerable point in the perioperative system with significant attention focused on improving them. This study aimed to understand the processes in place surrounding the point of information transfer in intraoperative handoffs.</p><p><strong>Methods: </strong>We used semistructured interviews with anesthesia clinicians to understand the processes and systems surrounding intraoperative handoffs. Interview data were coded deductively using the Systems Engineering Initiative for Patient Safety model as a framework, with subthemes developed inductively.</p><p><strong>Results: </strong>Clinicians do a significant amount of work before and after the point of information transfer to ensure a smooth handoff and safe patient care. Despite not having standardization of handoffs, most clinicians have a typical handoff organization and largely agree on content that should be included. However, there is variability based on clinician and patient characteristics, including clinician discipline and patient acuity. These handoffs are additionally impacted by the overall culture in the operating room, including the teamwork and hierarchies present among the surgical and anesthesia teams. Finally, the broader operating room logistics, including scheduling practices for surgical cases and anesthesia teams, impact the quality of intraoperative handoffs and the ability of clinicians to prepare for these handoffs.</p><p><strong>Conclusions: </strong>Handoffs involve processes beyond the point of information transfer and are embedded in the systems and culture of the operating rooms. These considerations are important when seeking to improve the quality of intraoperative handoffs.</p>","PeriodicalId":7784,"journal":{"name":"Anesthesia and analgesia","volume":" ","pages":"1056-1063"},"PeriodicalIF":4.6,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138443528","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Effect of Changing Estimated Glomerular Filtration Rate Formula on Sugammadex Use and Pulmonary Complications for African American and non-African American Patients.","authors":"Milo Engoren, Michael Heung","doi":"10.1213/ANE.0000000000006896","DOIUrl":"10.1213/ANE.0000000000006896","url":null,"abstract":"<p><strong>Background: </strong>Sugammadex is associated with fewer postoperative pulmonary complications than is neostigmine reversal of neuromuscular blockade. However, the Food and Drug Administration-approved package insert states that its use is \"not recommended\" in severe renal impairment, separately defined as creatinine clearance <30 mL/min. Recently, the formula for estimating glomerular filtration rate (GFR) was updated to remove the race variable. Compared to the prior formula, the new consensus equation lowers the estimated GFR for African American patients and raises it for everyone else. We sought to determine how this change could differently impact the use of sugammadex, and thus the rate of pulmonary complications, for both African American and non-African American patients.</p><p><strong>Methods: </strong>We used Monte Carlo simulation models to estimate the difference in pulmonary complications that would be suffered by patients when the change in creatine clearance calculated from the estimated GFR (using the old race-based and new race-neutral Chronic Kidney Disease Epidemiology Collaboration formulas) crossed the 30 mL/min threshold, which would require a change in sugammadex or neostigmine use.</p><p><strong>Results: </strong>We found that 0.22% (95% confidence interval 0.14%-0.36%) of African American patients' creatinine clearance would drop from above to below 30 mL/min making sugammadex not recommended and 0.19% (0.16%-0.22%) of non-African American patients would have creatinine clearance increase to >30 mL/min making sugammadex now recommended. Based on our model, we estimate that African American patients would suffer (count [95% confidence interval]) 3 [0.4-6] more pulmonary complications per 100,000 African American patients who received rocuronium or vecuronium through the change from sugammadex to neostigmine reversal to comply with labeling recommendations. Conversely, the same change in formulas would reduce the number of non-African American patients suffering pulmonary complications by 3 [2-4] per 100,000.</p><p><strong>Conclusions: </strong>The recent change in GFR formulas may potentially be associated with an increase in postoperative pulmonary complications in African American patients and a decrease in postoperative pulmonary complications in non-African American patients through GFR-driven changes in sugammadex use.</p>","PeriodicalId":7784,"journal":{"name":"Anesthesia and analgesia","volume":" ","pages":"1038-1046"},"PeriodicalIF":4.6,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139721241","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"A Behavioral and Electroencephalographic Study of Anesthetic State Induced by MK-801 Combined with Haloperidol, Ketamine and Riluzole in Mice.","authors":"Yuka Kikuchi, Masahiro Irifune, Taiga Yoshinaka, Kana Oue, Tamayo Takahashi, Aya Oda, Hisanobu Kamio, Serika Imamura, Utaka Sasaki, Eiji Imado, Yukio Ago, Yoshiyuki Okada","doi":"10.1213/ANE.0000000000006900","DOIUrl":"10.1213/ANE.0000000000006900","url":null,"abstract":"<p><strong>Background: </strong>Ketamine is an intravenous anesthetic that acts as a channel blocker on the N-methyl- d -aspartate (NMDA) receptor, a glutamate receptor subtype. MK-801 is the most potent compound among noncompetitive NMDA receptor antagonists. Ketamine induces loss of the righting reflex (LORR) in rodents, which is one of the indicators of unconsciousness, whereas high doses of MK-801 produce ataxia, but not LORR. In contrast, we previously reported that MK-801 combined with a low dose of the dopamine receptor antagonist haloperidol-induced LORR in mice. To assess a neurophysiologically distinct brain state and demonstrate unconsciousness, electroencephalograms (EEG) need to be examined together with LORR. Therefore, we herein investigated EEG changes after the systemic administration of MK-801 alone or in combination with haloperidol, and compared them with those induced by ketamine, the glutamate release inhibitor riluzole, and the γ-aminobutyric acid type A receptor agonist propofol.</p><p><strong>Methods: </strong>All drugs were intraperitoneally administered to adult male ddY mice (n = 168). General anesthesia was evaluated based on the righting reflex test. Animals who exhibited no righting for more than 30 seconds were considered to have LORR. In a separate group of mice, EEG of the primary visual cortex was recorded before and after the administration of MK-801 (3.0 mg/kg) alone or in combination with haloperidol (0.2 mg/kg), ketamine (150 mg/kg), riluzole (30 mg/kg), or propofol (240 mg/kg). The waveforms recorded were analyzed using EEG power spectra and spectrograms.</p><p><strong>Results: </strong>The high dose of MK-801 alone did not induce LORR, whereas MK-801 combined with haloperidol produced LORR in a dose-dependent manner. Ketamine, riluzole, and propofol also dose-dependently induced LORR. In the EEG study, MK-801 alone induced a significant increase in δ power, while MK-801 plus haloperidol exerted similar effects on not only δ, but also θ and α power during LORR, suggesting that increases in δ, θ, and α power were necessary for LORR. The results obtained on MK-801 plus haloperidol were similar to those on ketamine in the behavioral and EEG studies, except for an increase in γ power by ketamine during LORR. Propofol significantly increased δ, θ, α, and β power during LORR. However, the EEG results obtained using riluzole, which produced a unique pattern of lower amplitude activity spanning most frequencies, markedly differed from those with the other drugs.</p><p><strong>Conclusions: </strong>This study revealed differences in EEG changes induced by various sedatives. The results obtained on MK-801 alone and MK-801 plus haloperidol suggest the importance of dopamine transmission in maintaining the righting reflex.</p>","PeriodicalId":7784,"journal":{"name":"Anesthesia and analgesia","volume":" ","pages":"1064-1074"},"PeriodicalIF":4.6,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11465758/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139911840","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"In Response.","authors":"Harvey K Rosenbaum, Vincent Van den Eynde, Peter Kenneth Gillman","doi":"10.1213/ANE.0000000000007146","DOIUrl":"https://doi.org/10.1213/ANE.0000000000007146","url":null,"abstract":"","PeriodicalId":7784,"journal":{"name":"Anesthesia and analgesia","volume":"139 5","pages":"e56"},"PeriodicalIF":4.6,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142456252","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Lost in Translation: Cognitive Screening and Outcomes.","authors":"Naveen Nathan","doi":"10.1213/ANE.0000000000007266","DOIUrl":"https://doi.org/10.1213/ANE.0000000000007266","url":null,"abstract":"","PeriodicalId":7784,"journal":{"name":"Anesthesia and analgesia","volume":"139 5","pages":"902"},"PeriodicalIF":4.6,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142456254","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Racial and Ethnic Concordance Between the Patient and Anesthesia Team and Patients' Satisfaction With Pain Management During Cesarean Delivery.","authors":"Jose Sanchez, Rohan Prabhu, Jean Guglielminotti, Ruth Landau","doi":"10.1213/ANE.0000000000006764","DOIUrl":"10.1213/ANE.0000000000006764","url":null,"abstract":"<p><strong>Background: </strong>Racial and ethnic concordance between patients and health care providers increases patient satisfaction but has not been examined in obstetric anesthesia care. This study evaluated the association between racial and ethnic concordance and satisfaction with management of pain during cesarean delivery (PDCD).</p><p><strong>Methods: </strong>This was a secondary analysis on a cohort of patients undergoing cesarean deliveries under neuraxial anesthesia that examined PDCD. The outcome was satisfaction, recorded within 48 hours after delivery using the survey question, \"Overall, how satisfied are you with the anesthesia care during the C-section as it relates to pain management?\" Using a 5-point Likert scale, satisfaction was defined with the answer \"very satisfied.\" Participants were also asked, \"If you have another C-section, would you want the same anesthesia team?\" The exposure was racial and ethnic concordance between the patient and anesthesia team members (attending with a resident, nurse anesthetist, or fellow) categorized into full concordance, partial concordance, discordance, and missing. Risk factors for satisfaction were identified using a multivariable analysis.</p><p><strong>Results: </strong>Among 403 participants, 305 (78.2%; 95% confidence interval [CI], 73.8-82.1) were \"very satisfied,\" and 358 of 399 (89.7%; 95% CI, 86.3-92.5) \"would want the same anesthesia team.\" Full concordance occurred in 18 (4.5%) cases, partial concordance in 117 (29.0%), discordance in 175 (43.4%), and missing in 93 (23.1%). Satisfaction rate was 88.9% for full concordance, 71.8% for partial concordance, 81.1% for discordance, and 78.5% for missing ( P value = .202). In the multivariable analysis, there was insufficient evidence for an association of concordance with satisfaction. Compared to full concordance, partial concordance was associated with a nonsignificant 57% (95% CI, -113 to 91) decrease in the odds of being satisfied, discordance with a 29% (95% CI, -251 to 85) decrease, and missing with a 39% (95% CI, -210 to 88) decrease. Risk factors for not being \"very satisfied\" were PDCD, anxiety disorders, pregnancy resulting from in vitro fertilization, intravenous medication administration, intrapartum cesarean with extension of labor epidural, having 3 anesthesia team members (instead of 2), and a higher intraoperative blood loss.</p><p><strong>Conclusions: </strong>Our inability to identify an association between concordance and satisfaction is likely due to the high satisfaction rate in our cohort (78.2%), combined with low proportion of full concordance (4.5%). Addressing elements such as PDCD, anxiety, intravenous medication administration, and use of epidural anesthesia for cesarean delivery, and a better understanding of the interplay between concordance and satisfaction are warranted.</p>","PeriodicalId":7784,"journal":{"name":"Anesthesia and analgesia","volume":" ","pages":"921-930"},"PeriodicalIF":4.6,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141070420","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Exploring the Potential of Evidence-Based Practice on Mitigating Health Care Disparities.","authors":"Brittany N Burton, TimethiaJ Bonner, Abimbola O Faloye, Steven A Bradley, David O Warner, Jean-Francois Pittet, Lisa M McElroy, Adam J Milam","doi":"10.1213/ANE.0000000000006999","DOIUrl":"10.1213/ANE.0000000000006999","url":null,"abstract":"","PeriodicalId":7784,"journal":{"name":"Anesthesia and analgesia","volume":" ","pages":"1106-1111"},"PeriodicalIF":4.6,"publicationDate":"2024-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141282777","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}