Canadian liver journal最新文献

{"title":"Hepatic steatosis as measured by the computed attenuation parameter predicts fibrosis in long-term methotrexate use.","authors":"Marcel Tomaszewski,&nbsp;Monica Dahiya,&nbsp;Seyed Amir Mohajerani,&nbsp;Hanaa Punja,&nbsp;Hin Hin Ko,&nbsp;Muxin Sun,&nbsp;Alnoor Ramji","doi":"10.3138/canlivj-2020-0040","DOIUrl":"https://doi.org/10.3138/canlivj-2020-0040","url":null,"abstract":"<p><strong>Introduction: </strong>To determine predictors of hepatic steatosis by the computed attenuation parameter (CAP) and fibrosis via transient elastography (TE) in persons on methotrexate (MTX) therapy with rheumatologic and dermatologic diseases.</p><p><strong>Methods: </strong>A single-centred retrospective cohort study was performed. Patients on >6 months of MTX for a rheumatologic or dermatologic disease who had undergone TE from January 2015 to September 2019 were included. Multivariate analysis was performed to determine predictors of steatosis and fibrosis.</p><p><strong>Results: </strong>A total of 172 patients on methotrexate were included. Psoriasis was the most frequent diagnosis (<i>n</i> = 55), followed by rheumatoid arthritis (<i>n</i> = 45) and psoriatic arthritis (<i>n</i> = 34). Steatosis (CAP ≥245 dB/m) was present in 69.8% of patients. Multivariate regression analysis revealed that diabetes mellitus (OR 10.47, 95% CI 1.42-75.35), hypertension (OR 5.15, 95% CI 1.75-15.38), and BMI ≥30 kg/m² (OR 16.47, 95% CI 5.56-45.56) were predictors of steatosis (CAP ≥245 dB/m). Predictors of moderate to severe fibrosis (Metavir ≥F2 = TE ≥8.0 kPa) by multivariate regression analysis included moderate to severe steatosis (CAP ≥270 dB/m) (OR 8.36, 95% CI 1.88-37.14), diabetes mellitus (OR 2.85, 95% CI 1.09-7.48), hypertension (OR 5.4, 95% CI 2.23-13.00), dyslipidemia (OR 3.71, 95% CI 1.50-9.18), and moderate alcohol use (OR 3.06, 95% CI 1.2-7.49).</p><p><strong>Conclusions: </strong>In patients on MTX for rheumatologic and dermatologic diseases, hepatic steatosis as measured by CAP was common and moderate to severe steatosis predicted moderate to severe fibrosis.</p>","PeriodicalId":9527,"journal":{"name":"Canadian liver journal","volume":" ","pages":"370-380"},"PeriodicalIF":0.0,"publicationDate":"2021-11-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9235122/pdf/canlivj-2020-0040.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"40712717","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":"Characterizing risk behaviour and reinfection rates for successful programs to engage core transmitters in HCV elimination (C-RESPECT).","authors":"Brian Conway, Dan Smyth, Réjean Thomas, Alex Wong, Giada Sebastiani, Curtis Cooper, Hemant Shah, Ritesh Kumar, Gretty Deutsch, Ted Watson","doi":"10.3138/canlivj-2021-0005","DOIUrl":"10.3138/canlivj-2021-0005","url":null,"abstract":"<p><strong>Background: </strong>Development of robust treatment programs among core transmitters (CT) of hepatitis C virus (HCV) are needed, including strategies to address reinfection risk. The aim of this study was to describe the effectiveness of direct-acting antiviral (DAA) treatment in CT versus non-CT populations and assess reinfection rates after successful treatment.</p><p><strong>Methods: </strong>Characterizing Risk Behaviour and Reinfection Rates for Successful Programs to Engage Core Transmitters in HCV Elimination (C-RESPECT) was a prospective, observational study of HCV-infected Canadian adult patients (genotypes 1, 3, and 4) treated with DAAs between 2017 and 2020.</p><p><strong>Results: </strong>The full analysis set included 429 participants (259 CT, 170 non-CT). Key differences were observed in baseline profiles: CT participants were younger (mean 42.3 [SD 11.2] y versus 55.0 [SD 11.1] y, respectively) and reported higher rates of social assistance (35.7% versus 14.8%), smoking (83.7% versus 52.4%), low socioeconomic status (yearly income <$15,000: 69.6% versus 43.9%), illicit drug use (83.7% versus 34.3%), and previous incarcerations (62.7% versus 36.9%). DAA treatment adherence was similar; 93 .5% versus 98.3% of CT versus non-CT participants completed the assigned treatment duration. Cure rates (sustained virologic response) were comparable, ranging from 94.9% to 98.1%. All reinfections were among CT participants, with a rate of 13.8/100 person-years (95% CI 9.2-20.8) with mean time to reinfection of 24.6 (SD 0.6) months.</p><p><strong>Conclusions: </strong>CT and non-CT participants respond equally well to DAA treatment; however, with some reinfections among CT participants. Innovative multidisciplinary programs must be developed to mitigate this risk in this key population.</p>","PeriodicalId":9527,"journal":{"name":"Canadian liver journal","volume":" ","pages":"346-359"},"PeriodicalIF":0.0,"publicationDate":"2021-11-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9235128/pdf/canlivj-2021-0005.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"40712711","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":"Cost-effectiveness of obeticholic acid for the treatment of non-alcoholic steatohepatitis: An early economic evaluation.","authors":"Chanh-Phong Tran, John J Kim, Jordan J Feld, William Wl Wong","doi":"10.3138/canlivj-2021-0011","DOIUrl":"10.3138/canlivj-2021-0011","url":null,"abstract":"<p><strong>Background: </strong>Currently, there are no pharmacological options available for the treatment of non-alcoholic steatohepatitis (NASH). In the 18-month interim analysis of an ongoing randomized, placebo-controlled phase 3 trial (REGENERATE), early results demonstrated that obeticholic acid (OCA) 25 mg significantly improved fibrosis with no worsening of NASH among patients with NASH and fibrosis compared with placebo (PBO). This study aimed to assess the potential cost-effectiveness of OCA compared with PBO in NASH patients.</p><p><strong>Methods: </strong>A state-transition model was developed to perform a cost-utility analysis comparing two treatment strategies, PBO and OCA 25 mg, from a Canadian public payer perspective. The model time horizon was lifetime with annual cycle lengths. Cost and utility parameters were discounted at 1.5% annually. The efficacy data were obtained from the REGENERATE trial, and costs and utilities were derived from other published literature. Probabilistic and deterministic sensitivity analyses were performed to test the robustness of the model.</p><p><strong>Results: </strong>Treatment with OCA led to reductions of 3.58% in decompensated cirrhosis cases, 3.95% in hepatocellular carcinoma, 7.88% in liver transplant, and 6.01% in liver-related death. However, at an annual price of CAD $36,000, OCA failed to be cost-effective compared with PBO at an incremental cost-effectiveness ratio of $815,514 per quality-adjusted life year (QALY). An 88% reduction in drug price to an annual cost of $4,300 would make OCA cost-effective at a willingness-to-pay threshold of $50,000/QALY.</p><p><strong>Conclusions: </strong>OCA failed to be cost-effective compared with PBO, despite demonstrating clinical benefits due to a high drug cost. A significant price reduction would be needed to make the drug cost-effective.</p>","PeriodicalId":9527,"journal":{"name":"Canadian liver journal","volume":" ","pages":"360-369"},"PeriodicalIF":0.0,"publicationDate":"2021-11-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9235126/pdf/canlivj-2021-0011.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"40712715","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"A national paucity of hepatologists: An unprecedented opportunity for interdisciplinary collaboration.","authors":"Sydney McLean,&nbsp;Eric M Yoshida,&nbsp;Sanjeev Sirpal,&nbsp;Natasha Chandok","doi":"10.3138/canlivj-2021-0921","DOIUrl":"https://doi.org/10.3138/canlivj-2021-0921","url":null,"abstract":"The national supply of hepatologists unfortunately mismatches the burgeoning growth of liver disease and thus demand for liver specialists. However, the unmet need for the management of complex liver disease pathology presents a unique opportunity to foster cross-disciplinary collaborations to ultimately improve patient care. All of us would like to think we are indispensable. As a subspecialty of gastroenterology, it is easy to surmise that the depth and breadth of hepatology itself is vast enough that one can easily focus their career exclusively on the management of liver disease. However, many find hepatology an ever-evolving field for which our collective unmet need to serve our communities lies further and further from our grasp. If we conservatively estimate that perhaps 1 in 5 adults in Canada has a chronic liver disease— that is, non-alcoholic fatty liver disease (NAFLD), alcoholic fatty liver disease, viral hepatitis, hemochromatosis, or any of the many other less common conditions we treat—the inadequacy of the hepatology workforce to unilaterally address the public health burden of liver disease becomes all too apparent. Therefore, it is imperative to seek innovative solutions that leverage the strengths of an interdisciplinary approach to optimize the liver health of Canadians. The supply-demand gap is expected to widen in the future, due in part to changing demographics. Indeed, the public health burden of chronic liver disease is projected to increase substantially, much as it has over the past two decades (1,2). As the sizeable baby boomer population ages, rates of cirrhosis will undoubtedly increase from the current twelfth leading cause of death overall and the fifth leading cause of death for patients aged 45–54 years (3). Furthermore, owing to the oft-insidious onset and progression of liver disease, it is telling A national paucity of hepatologists","PeriodicalId":9527,"journal":{"name":"Canadian liver journal","volume":" ","pages":"343-345"},"PeriodicalIF":0.0,"publicationDate":"2021-10-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9235121/pdf/canlivj-2021-0921.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"40413620","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":"Albumin infusions and decompensated cirrhosis: No longer the elixir of life?","authors":"Vladimir Marquez","doi":"10.3138/canlivj-2021-0009","DOIUrl":"https://doi.org/10.3138/canlivj-2021-0009","url":null,"abstract":"","PeriodicalId":9527,"journal":{"name":"Canadian liver journal","volume":" ","pages":"338-339"},"PeriodicalIF":0.0,"publicationDate":"2021-08-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9202766/pdf/canlivj-2021-0009.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"40630207","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":"Liver enzymes and fibrosis markers in patients with non-alcoholic fatty liver disease and concomitant chronic viral hepatitis.","authors":"Micah Grubert Van Iderstine,&nbsp;J Uhanova,&nbsp;Gerald Y Minuk","doi":"10.3138/canlivj-2020-0030","DOIUrl":"https://doi.org/10.3138/canlivj-2020-0030","url":null,"abstract":"<p><p>The impact of non-alcoholic fatty liver disease (NAFLD) on patients with chronic hepatitis B virus (HBV) and hepatitis C virus (HCV) infections has yet to be determined. In this retrospective, cross-sectional analysis, untreated chronic HBV, hepatitis B e-antigen (HBeAg)-positive patients with NAFLD had similar liver biochemistry and FIB-4 values as age-, gender-, and viral-load-matched HBeAg-positive patients without NAFLD. Among HBeAg-negative patients with NAFLD, although liver biochemistry findings were similar, mean FIB-4 values were significantly lower (0.98, SD 1.46, versus 1.51, SD 4.04, respectively; <i>p</i> < 0.05) and the percentage of patients with FIB-4 values in keeping with advanced fibrosis or cirrhosis was less (0.3% versus 3.9%, <i>p</i> < 0.015) than that of matched HBeAg-negative patients without NAFLD. Chronic HCV-infected patients with NAFLD had higher mean serum aminotransferase values than those without NAFLD (123 U/L, SD 247, versus 90 U/L, SD 128, respectively; <i>p</i> < 0.05). These results suggest that NAFLD adversely affects chronic HCV infections but not HBV infections.</p>","PeriodicalId":9527,"journal":{"name":"Canadian liver journal","volume":" ","pages":"317-321"},"PeriodicalIF":0.0,"publicationDate":"2021-08-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9202770/pdf/canlivj-2020-0030.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"40630160","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":"Congenital absence of the portal vein: Define the portosystemic shunt, avoid liver transplantation.","authors":"Noémie Laverdure,&nbsp;Michel Lallier,&nbsp;Josée Dubois,&nbsp;Massimiliano Paganelli","doi":"10.3138/canlivj-2020-0011","DOIUrl":"https://doi.org/10.3138/canlivj-2020-0011","url":null,"abstract":"<p><p>Liver transplantation has been historically recommended for patients with congenital absence of the portal vein associated with extrahepatic congenital portosystemic shunts. Here, based on a case report of a 2-year-old girl and a thorough review of all published cases from 1974 to 2020, we show that such a diagnosis most often conceals a hypoplastic portal vein, which can be successfully re-permeabilized through the closure of the shunt in order to re-establish a physiological vascular anatomy. This highlights the importance of achieving a detailed anatomical description of extrahepatic congenital portosystemic shunts with a balloon occlusion test in order to plan the best surgical approach and avoid unnecessary liver transplantation.</p>","PeriodicalId":9527,"journal":{"name":"Canadian liver journal","volume":" ","pages":"322-327"},"PeriodicalIF":0.0,"publicationDate":"2021-08-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9202773/pdf/canlivj-2020-0011.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"40630162","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":"Direct-acting antiviral treatment uptake and sustained virological response outcomes are not affected by alcohol use: A CANUHC analysis.","authors":"Matt Driedger,&nbsp;Marie-Louise Vachon,&nbsp;Alexander Wong,&nbsp;Brian Conway,&nbsp;Alnoor Ramji,&nbsp;Sergio Borgia,&nbsp;Ed Tam,&nbsp;Lisa Barrett,&nbsp;Dan Smyth,&nbsp;Jordan J Feld,&nbsp;Sam S Lee,&nbsp;Curtis Cooper","doi":"10.3138/canlivj-2021-0003","DOIUrl":"https://doi.org/10.3138/canlivj-2021-0003","url":null,"abstract":"<p><strong>Background: </strong>Alcohol use and hepatitis C virus (HCV) are two leading causes of liver disease. Alcohol use is prevalent among the HCV-infected population and accelerates the progression of HCV-related liver disease. Despite barriers to care faced by HCV-infected patients who use alcohol, few studies have analyzed uptake of direct-acting antiviral (DAA) treatment.</p><p><strong>Objective: </strong>We compared rates of treatment uptake and sustained virological response (SVR) between patients with and without alcohol use.</p><p><strong>Methods: </strong>Prospective data were obtained from the Canadian Network Undertaking against Hepatitis C (CANUHC) cohort. Consenting patients assessed for DAA treatment between January 2016 and December 2019 were included. Demographic and clinical characteristics were compared between patients with and without alcohol use by means of <i>t</i>-tests, χ² tests, and Fisher's Exact Tests. Univariate and multivariate analyses were used to determine predictors of SVR and treatment initiation.</p><p><strong>Results: </strong>Current alcohol use was reported for 217 of 725 (30%) patients. The proportion of patients initiating DAA treatment did not vary by alcohol use status (82% versus 83%; <i>p</i> = 0.99). SVR rate was similar between patients with alcohol use and patients without alcohol use (92% versus 94%; <i>p</i> = 0.45). Univariate and multivariate analysis found no association between alcohol use and SVR or treatment initiation.</p><p><strong>Conclusion: </strong>Patients engaged in HCV treatment have highly favourable treatment uptake and outcomes regardless of alcohol use. Public health interventions should be directed toward facilitating access to care for all patients irrespective of alcohol use. Research into high-level alcohol use and DAA outcomes is needed.</p>","PeriodicalId":9527,"journal":{"name":"Canadian liver journal","volume":" ","pages":"283-291"},"PeriodicalIF":0.0,"publicationDate":"2021-08-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9202771/pdf/canlivj-2021-0003.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"40630158","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":"Hepatic adenomatosis in a young woman with non-familial maturity-onset diabetes of the young type 3.","authors":"David A Miles,&nbsp;Signy Holmes,&nbsp;Gerald Y Minuk","doi":"10.3138/canlivj-2020-0010","DOIUrl":"https://doi.org/10.3138/canlivj-2020-0010","url":null,"abstract":"<p><p>Hepatic adenomatosis (HA) is a rare condition in which multiple adenomas exist in an otherwise healthy liver. The most common subtype (H-HA) is associated with bi-allelic, somatic hepatic nuclear factor 1-alpha (HNF1A) mutations. Maturity-onset diabetes of the young type 3 (MODY3) is most often seen in young individuals with heterozygous, germline mutations in HNF1A. In this report, we describe a 17-year-old woman with H-HA and non-familial MODY3.</p>","PeriodicalId":9527,"journal":{"name":"Canadian liver journal","volume":" ","pages":"328-331"},"PeriodicalIF":0.0,"publicationDate":"2021-08-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9202775/pdf/canlivj-2020-0010.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"40630157","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":"Disparities in hepatitis C care across Canadian provincial prisons: Implications for hepatitis C micro-elimination.","authors":"Nadine Kronfli, Camille Dussault, Sofia Bartlett, Dennaye Fuchs, Kelly Kaita, Kate Harland, Brandi Martin, Cindy Whitten-Nagle, Joseph Cox","doi":"10.3138/canlivj-2020-0035","DOIUrl":"10.3138/canlivj-2020-0035","url":null,"abstract":"<p><strong>Background: </strong>Delivery of hepatitis C virus (HCV) care to people in prison is essential to HCV elimination. We aimed to describe current HCV care practices across Canada's adult provincial prisons.</p><p><strong>Methods: </strong>One representative per provincial prison health care team (except Ontario) was invited to participate in a web-based survey from January to June 2020. The outcomes of interest were HCV screening and treatment, treatment restrictions, and harm reduction services. The government ministry responsible for health care was determined. Non-nominal data were aggregated by province and ministry; descriptive statistical analyses were used to report outcomes.</p><p><strong>Results: </strong>The survey was completed by 59/65 (91%) prisons. On-demand, risk-based, opt-in, and opt-out screening are offered by 19 (32%), 10 (17%), 18 (31%), and 9 (15%) prisons, respectively; 3 prisons offer no HCV screening. Liver fibrosis assessments are rare (8 prisons access transient elastography, and 15 use aspartate aminotransferase to platelet ratio or Fibrosis-4); 20 (34%) prisons lack linkage to care programs. Only 32 (54%) prisons have ever initiated HCV treatment on site. Incarceration length and a fibrosis staging of ≥F2 are the most common eligibility restrictions for treatment. Opioid agonist therapy is available in 83% of prisons; needle and syringe programs are not available anywhere. Systematic screening and greater access to treatment and harm reduction services are more common where the Ministry of Health is responsible.</p><p><strong>Conclusions: </strong>Tremendous variability exists in HCV screening and care practices across Canada's provincial prisons. To advance HCV care, adopting opt-out screening and removing eligibility restrictions may be important initial strategies.</p>","PeriodicalId":9527,"journal":{"name":"Canadian liver journal","volume":" ","pages":"292-310"},"PeriodicalIF":0.0,"publicationDate":"2021-08-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9202774/pdf/canlivj-2020-0035.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"40630206","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}