Kansas journal of medicine最新文献

{"title":"Improving Electronic Patient Handoff in an Orthopaedic Residency using the Listrunner© Application","authors":"Justin A. Cline, Jack A. Nolte, Gregory M. Mendez, Jordan T. Willis, S. Tarrant, R. Zackula, Bradley R. Dart","doi":"10.17161/kjm.vol15.15856","DOIUrl":"https://doi.org/10.17161/kjm.vol15.15856","url":null,"abstract":"Introduction Miscommunication during shift change and other handoff events is a common source of malpractice claims and patient-care errors. An efficient patient handoff system is imperative to prevent miscommunication. Owning to limitations with our current handoff system and to an ever-increasing reliance on electronic health information, our residency program sought to modernize our handoff method. Methods To improve handoff communication, the HIPAA-compliant application Listrunner© was adopted. Members of the orthopaedic trauma team were oriented to the new application. Change-of-shift patient handoff was transitioned from the current email system to List-runner©. After three months of using the new application, a web-based questionnaire was administered to all members of the care team to assess their experiences, including perceived benefits and limitations of the Listrunner© application. Results Seventeen orthopaedic resident physicians and three orthopaedic trauma attending physicians completed the survey. While almost half of the respondents were satisfied using email as a checkout tool, more than half of study participants indicated that it lacked security and several users believed there was a need for improvement. Most indicated that Listrunner© was easy to use, improved clinical efficiency, and improved patient care and safety. Seventeen of 20 respondents reported that they would like to continue using Listrunner© as a check-out tool. Conclusions The Listrunner© application was adopted quickly by our orthopaedic trauma team, whose members opined that the application increased the efficiency and accuracy of handoff when compared to the previous secure email system.","PeriodicalId":94121,"journal":{"name":"Kansas journal of medicine","volume":"15 1","pages":"97 - 100"},"PeriodicalIF":0.0,"publicationDate":"2022-03-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41350684","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Lamotrigine Drug Interactions: Ignorance is not Bliss","authors":"Austin Armstrong, Rachna Kalia, M. Troutman","doi":"10.17161/kjm.vol15.15798","DOIUrl":"https://doi.org/10.17161/kjm.vol15.15798","url":null,"abstract":"109 Lamotrigine Drug Interactions: Ignorance is not Bliss Austin G. Armstrong, M.D.1, Rachna Kalia, M.D.1, Megan Troutman, Pharm.D.2 1University of Kansas School of Medicine-Wichita, Wichita, KS Department of Psychiatry and Behavioral Sciences 2Ascension Via Christi Hospital, Wichita, KS Received Sept. 16, 2021; Accepted for publication Feb. 23, 2022; Published online March 15, 2022 https://doi.org/10.17161/kjm.vol15.15798","PeriodicalId":94121,"journal":{"name":"Kansas journal of medicine","volume":"15 1","pages":"109 - 111"},"PeriodicalIF":0.0,"publicationDate":"2022-03-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"46572551","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Suture Education with Soft-Embalmed Cadavers: A Cut Above the Rest","authors":"Maxwell C. Braasch, Heather M. Minchew, Justin Riffel, German Berbel","doi":"10.17161/kjm.vol15.15984","DOIUrl":"https://doi.org/10.17161/kjm.vol15.15984","url":null,"abstract":"Introduction The efficacy of a surgical skills curriculum was assessed for third-year medical students focused on suturing training on soft embalmed cadavers, which simulate natural tissue more effectively for surgical procedures than traditionally preserved cadavers or surgical practice pads. Methods A retrospective cohort study compared pre- and post-survey results at a premier, accredited, nationally ranked academic medical center. Study participants were third-year medical students completing their required surgical clerkship rotation who participated in suturing sessions on both synthetic suture practice pads and soft-embalmed cadavers prior to beginning their operating room experience. Results A total of 40 participants were included, with slightly more male participants. The majority of participants (52%) were interested in pursuing a non-surgical career. After participating in Clinical Anatomy Mentorship Program (CAMP), participants felt significantly more confident in their ability to suture in the operating room (median 4 [3–4] vs. 2 [1–3], p < 0.001); in their knowledge of basic suturing supplies and instruments (median 4 [4-4] vs. 3 [2–3], p < 0.001); and in their ability to determine when different suture techniques are appropriate in the operating room (median 3 [3–4] vs. 1 [1–2], p < 0.001). Participants felt more confident in their ability to suture in the operating room after their experience suturing on soft-embalmed cadavers compared to suture practice pads (median 5 [4–5] vs. 4 [4-4], p = 0.002). Conclusions Medical students’ confidence in suturing skills and in the knowledge of important characteristics of suturing practice was improved significantly after a suture training session on soft-embalmed cadavers.","PeriodicalId":94121,"journal":{"name":"Kansas journal of medicine","volume":"15 1","pages":"78 - 81"},"PeriodicalIF":0.0,"publicationDate":"2022-03-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"43048484","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Assessing Provider Utilization of COVID-19 Inflammatory Marker Trends in Hospitalized Patients and Implications in Optimizing Value-Based Care During a Pandemic","authors":"P. Subramanian, Lucy Stun, Kellie Wark, N. Bahr, W. El Atrouni, L. Satterwhite, Maharshi Bhakta, F. Plapp, Jessica Newman","doi":"10.17161/kjm.vol15.15201","DOIUrl":"https://doi.org/10.17161/kjm.vol15.15201","url":null,"abstract":"Introduction Numerous inflammatory markers may serve a role in prognostication of patients hospitalized with COVID-19 infection. Early in the pandemic, our health system created an admission order set which included daily d-dimer, c-reactive protein (CRP), lactate dehydrogenase (LDH), and ferritin. Given more available outcomes data, limiting standing order of labs that do not affect daily management could result in significant cost savings to the health system without adverse patient outcomes. The purpose of this study was to determine ordering and utilization patterns of inflammatory markers by physicians caring for patients hospitalized with COVID-19 infection. Methods An anonymous 10-question survey was distributed to 125 physicians (Infectious Disease, Hospitalist, Pulmonary and Critical Care faculty). Responses were tallied and values greater than 50% were identified as the majority of the surveyed group. Results Of the 125 physicians surveyed, 77 (62%) responded. A total of 57.1% (44/77) of physicians reported ordering daily inflammatory markers for 3 – 10 days from admission. Another 31.2% (24/77) ordered markers until clinical improvement or hospital discharge. D-dimer was used for care decisions by 83.1% (64/77) of respondents; 93.8% (60/64) of those reported utilizing it in determining anticoagulation dose. CRP was used by 61% (47/77) of physicians to help identify a secondary infection or determine steroid dose or duration. LDH and ferritin were not used for management decisions by the majority of physicians. Inflammatory markers were not used routinely after isolation precautions had been discontinued, even when ongoing care required mechanical ventilation. Conclusions Of the markers studied, both d-dimer and CRP were considered useful by most respondents. LDH and ferritin were used less frequently and were not considered as useful in guiding medical decision making. Discontinuation of standing daily LDH and ferritin orders is believed to have potential to result in cost savings to the health care system with no adverse patient outcomes.","PeriodicalId":94121,"journal":{"name":"Kansas journal of medicine","volume":"15 1","pages":"91 - 96"},"PeriodicalIF":0.0,"publicationDate":"2022-03-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"43943751","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Psychological State of Camp Counselors with Type 1 Diabetes who Have Attended Diabetes Camp","authors":"Stephanie Hassouneh, E. Ablah, H. Okut, M. Harrison","doi":"10.17161/kjm.vol15.14846","DOIUrl":"https://doi.org/10.17161/kjm.vol15.14846","url":null,"abstract":"Introduction By 2050, more than 580,000 children in the United States will be diagnosed with type 1 diabetes (T1D). Management of T1D requires careful and continuous intervention, and children with T1D experience unique challenges in disease management compared to their adult counterparts. Diabetes camps are designed to help those with T1D learn diabetes management skills while experiencing summer camp. Psychological aspects are not addressed explicitly in diabetes camps located in Kansas. The purpose of this study was to evaluate the psychological state of past campers and camp counselors from one diabetes camp in Kansas. Methods Campers and counselors, all of whom had T1D, and attended diabetes camp from 2015 to 2019 in Kansas were recruited to complete a survey about diabetes-related stress, diabetes management self-efficacy, and symptoms of depression. A link to the online survey was distributed to previous campers and counselors by email and through Facebook. Results A total of 24 camp counselors and 10 campers were surveyed, 100% of whom reported having T1D and attending camp at least once. One-third of respondents (n = 8) reported having severe diabetes-related stress, and 100% (n = 34) reported high levels of diabetes management self-efficacy. Most participants reported moderate levels of depression, and 9% (n = 3) reported a past suicide attempt. These results suggested a relatively high prevalence in signs of psychological distress from former campers and camp counselors with T1D. Conclusions This study suggested that campers and counselors with T1D have high levels of diabetes-related stress, high diabetes management self-efficacy, and many signs of depression.","PeriodicalId":94121,"journal":{"name":"Kansas journal of medicine","volume":"15 1","pages":"86 - 90"},"PeriodicalIF":0.0,"publicationDate":"2022-03-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"43401137","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Academic Impact of COVID-19 in Collegiate Athletes.","authors":"Jordan C Smith, Robert Klug, Thomas Dagg, Elizabeth Lewis, Paul Cleland, Andrew S T Porter, Samuel Ofei-Dodoo","doi":"10.17161/kjm.vol15.16327","DOIUrl":"10.17161/kjm.vol15.16327","url":null,"abstract":"<p><strong>Introduction: </strong>The COVID-19 pandemic caused a pause to nearly all sporting activities in the spring of 2020, and collegiate athletes at the National Collegiate Athletic Association (NCAA)-affiliated universities whose sporting seasons were affected by the pandemic were granted an extra year of athletic eligibility. This study was conducted to determine how collegiate athletes planned to use an additional year of eligibility granted by the NCAA.</p><p><strong>Methods: </strong>The authors conducted a cross-sectional survey of 632 athletes from two universities in the Midwestern United States, between August and September 2021. The athletes completed an anonymous, nine-item survey to assess the effect of the pandemic on the athletic season, athletic eligibility, and potential change in an academic or professional career. Chi-square tests, generalized linear mixed models, and adjusted odds ratio were used for the analyses.</p><p><strong>Results: </strong>The participation rate was 74.5% (471 of 632). Nearly 63% (290 of 461) of the athletes received an additional year of eligibility because of the pandemic, with 193 (66.6%) planned to use their extra year for scholastic development. Male athletes (65.3% vs. 34.7%; χ²[1, n = 290] = 11.66, p < 0.001, Φ = 0.20), Division II athletes (59.6% vs. 40.4%; χ²[1, n = 290] = 13.93, p < 0.001, Φ = 0.22), and athletes who had not previously used redshirt (73.1% vs. 26.9%; χ²[1, n = 290] = 4.79, p = 0.029, Φ = 0.32) where more likely to use their extra year of eligibility academically.</p><p><strong>Conclusions: </strong>Our findings suggested that most of the athletes planned to use their extra year of eligibility to pursue further scholastic or professional development, highlighting the positive part of the COVID-19 pandemic. Future studies should investigate how these findings relate to athletes from universities in different geographical locations and intra-division schools.</p>","PeriodicalId":94121,"journal":{"name":"Kansas journal of medicine","volume":"15 1","pages":"101-105"},"PeriodicalIF":0.0,"publicationDate":"2022-03-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8942400/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48370997","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":"Comparative Analysis of Topical Versus Intravenous Administration of Epsilon-Aminocaproic Acid on Blood Management in Total Knee Arthroplasty","authors":"Benjamin Lancaster, Alexander Wendling, Tanner Poppe, Rosalee Zackula, Wade Massey, R. Cusick, Paul C Pappademos","doi":"10.17161/kjm.vol15.16036","DOIUrl":"https://doi.org/10.17161/kjm.vol15.16036","url":null,"abstract":"Introduction Although the use of antifibrinolytics to reduce perioperative blood loss during total knee arthroplasty (TKA) has shown unequivocal benefit in regard to blood conservation, the best route of administration remains in question. This study tested the hypothesis that topical delivery of epsilon-aminocaproic acid (EACA) was superior to intravenous (IV) administration in the setting of primary TKA. Methods This cross-sectional study included a six-year retrospective chart review of TKA patients done by a single surgeon. Post-operative hemoglobin levels and the incidence of blood transfusions were compared among three patient subgroups: no EACA, topical EACA, or IV EACA. Key outcome measures included post-operative hemoglobin, need for post-operative transfusion, and length of hospital stay. Results Of the 668 patients included in this study, 351 (52.5%) received IV EACA, 298 (44.6%) received topical EACA, and 19 (2.8%) received no EACA. For the three-way comparisons, significant differences were observed for post-operative mean hemoglobin on day one (p < 0.001), day two (p < 0.001), and day three (p = 0.004), with consistently higher means for participants in the topical group. Eight patients required transfusions in the IV EACA group, but none were needed in the topical EACA group (p = 0.027). Length of stay was shortest for patients in the topical group, with 66% hospitalized for two days, while 84% of the IV group remained hospitalized for three days (p < 0.001). Conclusions The topical delivery of EACA is superior to IV administration with respect to blood conservation for patients undergoing primary TKA.","PeriodicalId":94121,"journal":{"name":"Kansas journal of medicine","volume":"15 1","pages":"73 - 77"},"PeriodicalIF":0.0,"publicationDate":"2022-03-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48382163","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Activity-Based Checks (ABCs) of Pain: A Functional Pain Scale Used by Surgical Patients","authors":"B. Ho, S. Beatty, David Warnky, Kevin Sykes, Jennifer A. Villwock","doi":"10.17161/kjm.vol15.15831","DOIUrl":"https://doi.org/10.17161/kjm.vol15.15831","url":null,"abstract":"Introduction Increased rates of surgery, combined with concerns about high-risk pain medications, have highlighted the need for improved methods of meaningfully assessing pain. In response to lack of medical context and functional data in existing scales, the Activity-Based Checks (ABCs) was developed. Methods This prospective, cohort study was deployed at a single-institution, academic center. The primary outcome was to correlate the ABCs to the 0 – 10 numeric rating scale (NRS) in post-operative general surgery patients. Secondary outcomes included assessing the impact of patient factors and prescribing patterns on opioid consumption, in milligrams of morphine equivalents (MME), after discharge. Results The function that correlated most to the NRS at discharge was “Out of Bed to Chair”. Indicators of better mental health were correlated inversely with MME consumption. Interestingly, the largest predictor of MME taken was MME prescribed. Over 40% of prescribed opioids goes unused. Conclusions Functional pain scales, like the ABCs, may be useful adjuncts to evaluate pain. Individual functions, such as, “Out of Bed to Chair”, may be of particular importance. Clinicians must be aware that the strongest predictor of MMEs taken by patients was MMEs prescribed, highlighting the importance of better pain assessments and opioid stewardship.","PeriodicalId":94121,"journal":{"name":"Kansas journal of medicine","volume":"15 1","pages":"82 - 85"},"PeriodicalIF":0.0,"publicationDate":"2022-03-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"45582539","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The COVID-19 Vaccines: A Description of Adverse Events of Reactions Reported in Kansas","authors":"K. Mills, Anna Tri, K. Nilsen","doi":"10.17161/kjm.vol15.15825","DOIUrl":"https://doi.org/10.17161/kjm.vol15.15825","url":null,"abstract":"Introduction Coronavirus disease 2019 (COVID-19) is caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) and has spread rapidly throughout the world since its discovery in 2019. Three vaccines (Pfizer-BioNTech, Moderna/NIAID/BARDA, and Johnson & Johnson’s Janssen) have been developed for use in the U.S. to aid in the fight against this virus, but have been scrutinized intensely for their efficacy and safety. It is important to understand and interpret the adverse events or reactions (AERs) associated with these vaccines in an objective and analytical manner. The goal of this descriptive study was to provide a resource outlining AERs associated with the three available vaccines in Kansas. Methods Reports were obtained from the Vaccine Adverse Event Reporting System (VAERS), representing AERs observed in Kansas from December 11, 2020 to May 13, 2021. All data were screened and coded, and descriptive statistics were used to describe AERs based on vaccine manufacturer, patient age and biological sex, and reported deaths. Results Only 0.00068% of COVID-19 vaccine doses given in Kansas were associated with an AER (1,445/2,120,350). There were 4,297 individual AERs reported, and the most common were fatigue/tiredness (266; 6.2%), tingling/itching (251; 5.9%), fever (226; 5.3%), hives (223; 5.2%), and muscle/joint pain (209; 4.9%). Only 0.002% of COVID-19 vaccine doses in Kansas were associated with a death (38/2,120,350). The majority of VAERS reports were by females (1,139; 78.8%) and those aged 30 to 39 years (297; 20.6%). Conclusions No reported AERs were unexpected compared to national data, and no VAERs report provided a causal relationship between vaccine administration and death. Vaccines are, and will continue to be, essential tools to fight COVID-19 in the quest to reach herd immunity. Providing a resource of potential AERs could aid in individual decisions to receive a vaccine and may help in the control of COVID-19. Future studies may include describing reported AERs for children under age 12 as the vaccines become available for those age groups, as well as reporting AERs for those who have received the vaccine after our study time period.","PeriodicalId":94121,"journal":{"name":"Kansas journal of medicine","volume":"15 1","pages":"39 - 47"},"PeriodicalIF":0.0,"publicationDate":"2022-02-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"49386436","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Stacked 1/3 Tubular Plates for Fixation of Pediatric Forearm Fractures: A Biomechanical Study","authors":"B. Cooper, Alexander Wendling, Sharon R Isaacs-Pullins, J. White, S. Hollenbeck","doi":"10.17161/kjm.vol15.16207","DOIUrl":"https://doi.org/10.17161/kjm.vol15.16207","url":null,"abstract":"Introduction Among operatively treated pediatric forearm fractures, many different fixation constructs are described. The goal of this study was to define the biomechanical properties of a double stacked 1/3 tubular plate construct used by the senior author for some fractures and to review available literature regarding the use of stacked plates. Methods Biomechanical testing was performed by 4-point bending of three different plate constructs: 1/3 tubular plate, stacked 1/3 tubular plates, and 2.7 mm LC-DCP plate. Five test specimens were evaluated for each of the three plate constructs. From stress-strain curves, flexural stiffness (N/mm), force to cause plastic deformation (N), and force to cause 10° bend (N) were calculated and compared using standard t-test statistics. Results Key outcome parameter means (± SD) for the three plate constructs (1/3 tubular plate, stacked 1/3 tubular plates, and 2.7 mm LC-DCP plate) were reported respectively as follows: flexural stiffness (55.4 ± 3.5 N/mm, 131.7 ± 3.5 N/mm, 113.3 ± 12.1 N/mm), force to cause plastic deformation (113.6 ± 11.0 N, 242.1 ± 13.0 N, 192.2 ± 17.9 N), and force to cause a 10° bend (140.0 ± 8.4 N, 299.4 ± 14.1 N, 265.5 ± 21.2 N). Mean values of all three measures were significantly larger for the stacked 1/3 tubular plates than for the other plate constructs. Conclusions The stacked 1/3 tubular plate construct was biomechanically superior to the other plate constructs tested. Stacked plating significantly improved stiffness of the fracture fixation construct supporting the use of this technique in selected trauma cases.","PeriodicalId":94121,"journal":{"name":"Kansas journal of medicine","volume":"15 1","pages":"63 - 66"},"PeriodicalIF":0.0,"publicationDate":"2022-02-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"49130510","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}