Annals of Medicine and Surgery最新文献

{"title":"Adhesion molecules in focus: mechanistic pathways and therapeutic avenues in sickle cell vaso-occlusion - a narrative review.","authors":"Emmanuel Ifeanyi Obeagu","doi":"10.1097/MS9.0000000000003619","DOIUrl":"10.1097/MS9.0000000000003619","url":null,"abstract":"<p><p>Sickle cell disease (SCD) is a genetic disorder characterized by the presence of sickle-shaped red blood cells (sRBCs), which are prone to occluding small blood vessels, leading to severe pain and organ damage. One of the critical mechanisms driving vaso-occlusion in SCD is the interaction between sRBCs, leukocytes, platelets, and endothelial cells, mediated by adhesion molecules. These molecules, including intercellular adhesion molecule-1, vascular cell adhesion molecule-1, selectins, and integrins, play a significant role in promoting the adhesion of these cells to the vascular endothelium, exacerbating inflammation, and contributing to the obstruction of blood flow. Understanding how these adhesion molecules participate in the pathophysiology of vaso-occlusion offers valuable insights into potential therapeutic strategies to mitigate the impact of this debilitating condition. The role of adhesion molecules in SCD-induced vaso-occlusion has been well-documented, with multiple studies showing that their upregulation enhances the interaction between sickled and non-sickled cells and the endothelium. This interaction initiates a cascade of inflammatory responses that worsen microvascular occlusion, leading to tissue ischemia and chronic complications. The expression of adhesion molecules such as E-selectin, P-selectin, and integrins on both the endothelial surface and the sickle cell membrane is critical for the progression of these vaso-occlusive events. Inflammation-induced overexpression of these molecules increases cell adhesion, exacerbating the frequency and severity of vaso-occlusive crises and contributing to long-term organ damage in SCD patients.</p>","PeriodicalId":8025,"journal":{"name":"Annals of Medicine and Surgery","volume":"87 9","pages":"5775-5783"},"PeriodicalIF":1.6,"publicationDate":"2025-07-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12401344/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144991155","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 nutritional equation: decoding diet's influence on breast cancer risk and progression - a perspective.","authors":"Emmanuel Ifeanyi Obeagu","doi":"10.1097/MS9.0000000000003612","DOIUrl":"10.1097/MS9.0000000000003612","url":null,"abstract":"<p><p>Breast cancer is the most commonly diagnosed cancer among women worldwide, with rising incidence influenced not only by genetic and hormonal factors but also by lifestyle determinants, particularly diet. Mounting evidence indicates that nutrition plays a significant role in both the risk and progression of breast cancer through mechanisms involving hormonal modulation, inflammation, oxidative stress, and immune regulation. As dietary patterns can either mitigate or exacerbate oncogenic pathways, understanding the nutritional impact on breast carcinogenesis is essential for developing preventive and adjunctive therapeutic strategies. Specific nutrients and dietary components have shown variable effects on breast cancer development. Diets high in saturated fats, processed foods, and alcohol have been consistently associated with increased risk, while consumption of fiber, omega-3 fatty acids, antioxidants, and plant-based foods appears protective. Additionally, bioactive compounds such as phytochemicals, probiotics, and nutraceuticals like curcumin and resveratrol have demonstrated promising anti-cancer properties by influencing key molecular pathways involved in tumor growth and immune modulation.</p>","PeriodicalId":8025,"journal":{"name":"Annals of Medicine and Surgery","volume":"87 9","pages":"5528-5534"},"PeriodicalIF":1.6,"publicationDate":"2025-07-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12401440/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144991154","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":"Anemia and hematocrit decline in cervical cancer: unveiling clinical consequences and management strategies.","authors":"Emmanuel Ifeanyi Obeagu","doi":"10.1097/MS9.0000000000003620","DOIUrl":"10.1097/MS9.0000000000003620","url":null,"abstract":"<p><p>Anemia, characterized by a decline in hematocrit (Hct) levels, is a common and significant complication in cervical cancer. It often results from tumor-induced blood loss, chemotherapy, and inflammation. This review explores the clinical implications of anemia and Hct decline in cervical cancer, emphasizing their role in prognosis and treatment. We examine the pathophysiological mechanisms driving these changes, including tumor-associated blood loss and chemotherapy-induced bone marrow suppression. Additionally, the review highlights the impact of anemia on cancer progression, treatment resistance, and patient quality of life. Declining Hct levels in cervical cancer are associated with worse survival outcomes, reduced chemotherapy efficacy, and increased morbidity. Studies show that low Hct levels correlate with advanced disease stages and higher tumor burden, suggesting their potential as prognostic markers. Anemia in these patients can exacerbate symptoms such as fatigue and weakness, further affecting their overall well-being. The importance of early detection and treatment of anemia is emphasized, with therapies such as erythropoiesis-stimulating agents, iron supplementation, and blood transfusions being commonly employed to manage these changes.</p>","PeriodicalId":8025,"journal":{"name":"Annals of Medicine and Surgery","volume":"87 9","pages":"5784-5791"},"PeriodicalIF":1.6,"publicationDate":"2025-07-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12401278/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144991105","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":"Diverticular perforation with exclusive local invasion in cytomegalovirus infection during ganciclovir treatment: an autopsy case report.","authors":"Yoshitaka Ishiguro, Akira Kuriyama, Shingo Ishiguro","doi":"10.1097/MS9.0000000000003573","DOIUrl":"10.1097/MS9.0000000000003573","url":null,"abstract":"<p><strong>Introduction and importance: </strong>Cytomegalovirus (CMV) can cause severe colitis in immunocompromised patients. While its morphological manifestations vary, diverticular perforation is rare, with most lesions remaining intact. We report a rare case of CMV-related diverticular perforation in an elderly woman undergoing ganciclovir treatment. Despite intensive care, she died during hospitalization. Autopsy findings showed a congested small intestine without significant erosion or ulceration.</p><p><strong>Clinical presentation: </strong>An 83-year-old woman with prolonged methotrexate and steroid use for rheumatoid arthritis was referred to our hospital due to hypotension, hypoxemia, and altered mental status following bloody stools. Endoscopy revealed a rectal hemorrhage. After hemostasis, the patient developed septic shock and diarrhea, raising suspicion of CMV colitis, which was confirmed by CMV antigenemia. Despite treatment with ganciclovir, the patient developed a diverticular perforation. Histological examination of the surgical specimen revealed localized infiltration of CMV-infected cells in the granulation tissue at the perforation site, without other inflammatory changes. The patient died from liver failure on the 28th day of hospitalization.</p><p><strong>Clinical discussion: </strong>CMV colitis is reported in patients with autoimmune diseases and, in severe cases, can lead to gastrointestinal perforation. In this case, CMV infection caused diverticular perforation; however, autopsy revealed no significant inflammatory changes throughout the gastrointestinal tract. This suggests a highly localized CMV invasion, a rare clinical presentation.</p><p><strong>Conclusion: </strong>Ganciclovir failed to prevent focal bowel perforation, although it may have eradicated CMV within rectal ulcer lesions. Clinicians should be aware that CMV infection can present as diverticular perforation due to localized invasion, even during antiviral therapy.</p>","PeriodicalId":8025,"journal":{"name":"Annals of Medicine and Surgery","volume":"87 9","pages":"6083-6087"},"PeriodicalIF":1.6,"publicationDate":"2025-07-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12401353/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144991176","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":"Cross-continental immunity: unraveling hematological markers of HIV in Africa and Russia- a perspective.","authors":"Emmanuel Ifeanyi Obeagu","doi":"10.1097/MS9.0000000000003617","DOIUrl":"10.1097/MS9.0000000000003617","url":null,"abstract":"<p><p>Hematological abnormalities are common in individuals living with HIV, and these complications vary significantly across global populations due to diverse genetic, environmental, and socio-economic factors. This review explores the divergent immunohematological trends observed in HIV-infected populations in Africa and Russia, focusing on key hematological markers such as anemia, thrombocytopenia, and neutropenia. While both regions experience high burdens of HIV, their populations present with distinct hematological manifestations influenced by co-infections, lifestyle factors, and local healthcare systems. In Africa, HIV-associated hematological abnormalities are often compounded by endemic co-infections such as malaria and tuberculosis, which exacerbate anemia and thrombocytopenia. Additionally, poor nutritional status in many sub-Saharan African countries contributes to the severity of these complications. Conversely, in Russia, hematological complications in HIV-positive individuals are frequently linked to alcohol use and liver disease, with these factors playing a significant role in the pathogenesis of anemia and thrombocytopenia. The combination of HIV, alcohol-related comorbidities, and intravenous drug use complicates the immunohematological landscape in this region, requiring a more multifaceted approach to treatment.</p>","PeriodicalId":8025,"journal":{"name":"Annals of Medicine and Surgery","volume":"87 9","pages":"5522-5527"},"PeriodicalIF":1.6,"publicationDate":"2025-07-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12401369/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144990902","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":"Artificial intelligence in interventional cardiology: a review of its role in diagnosis, decision-making, and procedural precision.","authors":"Tochukwu R Nzeako, Chukwuka Elendu, Gift Echefu, Olawale Olanisa, Adekunle Kiladejo, Emi Disrael Bob-Manuel","doi":"10.1097/MS9.0000000000003602","DOIUrl":"10.1097/MS9.0000000000003602","url":null,"abstract":"<p><p>Cardiovascular diseases significantly burden healthcare systems globally, necessitating innovative solutions to enhance diagnosis, treatment, and patient management. Artificial intelligence (AI) is no longer a distant promise in interventional cardiology but a rapidly emerging tool with growing clinical impact. AI-driven technologies can analyze vast amounts of clinical data, recognize intricate patterns, and generate clinically relevant, evidence-based recommendations, augmenting physician expertise and streamlining care. In diagnostics, AI enhances imaging interpretation and lesion assessment, while procedurally, it supports real-time guidance and catheter-based interventions. Its integration into decision support systems has improved risk stratification, early disease detection, and individualized treatment planning. AI also advances personalized medicine using predictive models to tailor interventions to patient-specific needs. Despite its promise, challenges such as costs, ethical issues, and the need for rigorous validation remain barriers to widespread adoption. Nevertheless, as AI advances, its integration into interventional cardiology is expected to transform care delivery, optimize outcomes, and improve system efficiency.</p>","PeriodicalId":8025,"journal":{"name":"Annals of Medicine and Surgery","volume":"87 9","pages":"5720-5734"},"PeriodicalIF":1.6,"publicationDate":"2025-07-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12401291/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144991179","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":"Navigating high-risk PCI with axillary impella support: a case report.","authors":"Ahmed Mahmoud, Pukar Gupta, Nishchal Regmi, Pradeep Adhikari, Rohit Pandit, Roshni Thapa, Amir Kaki","doi":"10.1097/MS9.0000000000003550","DOIUrl":"10.1097/MS9.0000000000003550","url":null,"abstract":"<p><strong>Introduction and importance: </strong>Percutaneous coronary intervention (PCI) in high risk patients with complex coronary artery disease and impaired left ventricular function pose significant procedural challenges. During such interventions. Mechanical circulatory support with the Impella device has become an effective strategy to maintain hemodynamic stability. While femoral access is traditionally used, alternative routes like axillary artery access may be necessary in patients with peripheral vascular disease.</p><p><strong>Case presentation: </strong>We present the case of a 68-year-old male with severe multivessel coronary artery disease with reduced left ventricular ejection fraction, and bilateral iliofemoral artery disease. Since there was difficulty in accessing the femoral arteries, axillary artery access was used to insert an Impella CP device to support high-risk PCI. The procedure involved successful revascularization of complex lesions using rotational atherectomy and stenting. The patient remained hemodynamically stable throughout and recovered without complications.</p><p><strong>Discussion: </strong>In patients with contraindications to femoral access this case highlights the feasibility and clinical utility of axillary access for Impella insertion despite requiring surgical expertise and meticulous planning, the axillary route offers a safe and effective alternative for mechanical circulatory support during complex coronary interventions.</p><p><strong>Conclusion: </strong>Axillary artery access for Impella-assisted high-risk PCI is a viable and underutilized option in select patients with complex coronary anatomy and peripheral vascular disease, expanding the therapeutic possibilities in advanced interventional cardiology. This report highlights a safe, effective alternative for patients with contraindications to femoral access and emphasizes the importance of multidisciplinary planning.</p>","PeriodicalId":8025,"journal":{"name":"Annals of Medicine and Surgery","volume":"87 8","pages":"5273-5276"},"PeriodicalIF":1.6,"publicationDate":"2025-07-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12333735/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144815609","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":"Juvenile ossifying fibroma in a 24-year-old female with systemic comorbidities: a rare case report.","authors":"Abdulnour Hajjat, Mhd Yasser Osama Al Burghli, Abdallah Alqudah, Mohammad Obada Alsadi","doi":"10.1097/MS9.0000000000003613","DOIUrl":"10.1097/MS9.0000000000003613","url":null,"abstract":"<p><strong>Introduction: </strong>Juvenile ossifying fibroma (JOF) is a rare, benign, fibro-osseous lesion characterized by aggressive growth and potential for recurrence. It primarily affects children and adolescents, with two histopathological subtypes: trabecular JOF (TrJOF) and psammomatoid JOF (PsJOF). TrJOF typically presents in the jaws of younger individuals, often before the age of 15.</p><p><strong>Case presentation: </strong>A 24-year-old female with chronic kidney disease (CKD) and hypertension presented with progressive teeth displacement, mobility, and facial asymmetry. Radiographic evaluation revealed a well-defined radiolucent lesion affecting both jaws, displacing teeth, and perforating the cortical bone. Biopsy confirmed the diagnosis of TrJOF. Due to the aggressive growth and contraindications for chemotherapy or radiation therapy, surgical excision was performed. Postoperatively, the patient remains under observation, with ongoing management of CKD to prevent complications and ensure recovery.</p><p><strong>Discussion: </strong>TrJOF is an uncommon and aggressive variant of JOF that typically affects younger patients. This case is atypical due to the patient's age and the involvement of both jaws. While JOF usually grows slowly, the lesions in this patient expanded rapidly, emphasizing the importance of prompt diagnosis and intervention. Surgical management remains the preferred approach, especially in cases complicated by systemic conditions like CKD. Recurrence rates vary widely, necessitating long-term follow-up.</p><p><strong>Conclusion: </strong>This case underscores the significance of early detection and multidisciplinary care in managing rare, aggressive jaw lesions such as TrJOF, particularly in patients with systemic comorbidities. Tailored surgical interventions and vigilant postoperative monitoring are crucial to achieving optimal outcomes and preventing recurrence.</p>","PeriodicalId":8025,"journal":{"name":"Annals of Medicine and Surgery","volume":"87 9","pages":"6131-6134"},"PeriodicalIF":1.6,"publicationDate":"2025-07-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12401378/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144991335","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":"Optimizing ketamine dosing strategies across diverse clinical applications: a comprehensive review.","authors":"Ahmed M Kedwany, Reem Sayad, Nada S Jibril, Eslam A Hawash, Amna M Anis, Nardein John Wadie Danial, Ahmed Saad Elsaeidy, Neveen A Kohaf","doi":"10.1097/MS9.0000000000003580","DOIUrl":"10.1097/MS9.0000000000003580","url":null,"abstract":"<p><p>Ketamine has emerged as a versatile therapeutic agent with applications spanning anesthesia, pain management, and psychiatric disorders. This review examines ketamine's clinical utility across diverse administration routes, including intravenous, intramuscular, intranasal, and oral, emphasizing the need to individualize dosing regimens. We explore factors influencing ketamine dosing, such as patient characteristics (age, weight, comorbidities), concomitant medications, and desired clinical effects, while balancing efficacy and side effects. The impact of dose, infusion rate, and administration frequency on therapeutic outcomes is analyzed to provide a comprehensive understanding of its clinical implications. The review highlights the critical role of individualized dosing regimens tailored to patient-specific factors. The therapeutic effects of ketamine are dose-dependent, with infusion rate and administration frequency significantly influencing both efficacy and safety. Achieving a balance between clinical benefits and potential side effects remains paramount. There are gaps in knowledge, necessitating for further research into long-term effects, alternative administration routes, and personalized approaches informed by pharmacokinetic variability. Developing standardized, evidence-based protocols and exploring alternative strategies will improve ketamine's therapeutic potential while addressing safety, misuse, and availability concerns.</p>","PeriodicalId":8025,"journal":{"name":"Annals of Medicine and Surgery","volume":"87 9","pages":"5678-5687"},"PeriodicalIF":1.6,"publicationDate":"2025-07-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12401397/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144991441","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":"Solitary brain metastasis from laryngeal squamous cell carcinoma in a 68-year-old male: A Case Report.","authors":"Allahdad Khan, Abdul Ahad Riaz, Shahroze Ahmed, Anam Malik, Mohamed Antar, Raheel Ahmed","doi":"10.1097/MS9.0000000000003549","DOIUrl":"10.1097/MS9.0000000000003549","url":null,"abstract":"<p><strong>Introduction and importance: </strong>Laryngeal squamous cell carcinoma (LSCC) commonly metastasizes to regional lymph nodes, lungs, liver, and bones. Intracranial metastasis from LSCC is exceedingly rare, reported in only 0.4% of cases. The atypical presentation can delay diagnosis and negatively impact prognosis. We report a rare case of solitary brain metastasis from LSCC, highlighting the diagnostic challenges and clinical considerations.</p><p><strong>Case presentation: </strong>A 68-year-old Pakistani male with a prior diagnosis of LSCC presented with new-onset generalized tonic-clonic seizures. He had previously undergone total laryngectomy, radiotherapy, and chemotherapy. Brain MRI revealed a right frontal lobe lesion with surrounding edema, consistent with a solitary metastasis. Histopathology following craniotomy confirmed metastatic squamous cell carcinoma. The patient was managed with antiepileptics and referred for palliative whole-brain radiotherapy. He and his family opted for palliative care, declining further aggressive treatment.</p><p><strong>Clinical discussion: </strong>Distant brain metastasis in LSCC is rare and may occur without prior systemic spread. The mechanism may involve perineural invasion, although the exact pathophysiology remains unclear. Current diagnostic approaches include MRI and FDG-PET/CT. Due to limited cases, standardized treatment protocols are lacking. Management options include surgery, radiotherapy, chemotherapy, and palliative care, depending on disease progression and patient preference. Seizures as a presenting symptom are uncommon but may indicate intracranial involvement.</p><p><strong>Conclusion: </strong>This case emphasizes the need for high clinical suspicion and comprehensive neurological assessment in patients with advanced LSCC. Early diagnosis and multidisciplinary management are essential for improving outcomes in this rare but serious manifestation.</p>","PeriodicalId":8025,"journal":{"name":"Annals of Medicine and Surgery","volume":"87 8","pages":"5296-5299"},"PeriodicalIF":1.6,"publicationDate":"2025-07-18","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12333697/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144815718","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}