Case Reports in Gastroenterology最新文献

{"title":"Recurrent Upper Gastrointestinal Bleeding due to Radiation-Induced Hemorrhagic Gastroduodenal Ectasia: A Review of Current Treatment Options for Radiation-Induced Gastric Injury.","authors":"Simone A Jarrett, Rushi Kaushik Talati, Johann Hasbun, Wenqing Cao, Scott M Smukalla","doi":"10.1159/000538965","DOIUrl":"10.1159/000538965","url":null,"abstract":"<p><strong>Introduction: </strong>Acute upper gastrointestinal bleeding is one of the most common medical emergencies that present to the hospital, and delineating the underlying etiology is essential to provide adequate definitive treatment. The purpose of this case report was to review the diagnosis and treatment of a rare complication known as radiation-induced hemorrhagic gastritis (RIHG) that can occur in patients with prior radiation exposure. The motivation for this study arose from the identification of a case within our institution.</p><p><strong>Case presentation: </strong>The study involved a review of the diagnosis and management of a patient who presented with anemia and recurrent episodes of gastrointestinal bleeding at our institution after undergoing treatment for metastatic biliary adenocarcinoma. With the advent of new therapies, we aimed to investigate the various techniques utilized to manage these patients and highlight the importance of maintaining a high index of suspicion for RIHG as a potential etiology of gastrointestinal bleeding in patients with a relevant medical history of radiation exposure. Despite the literature review, we found that there is a lack of guidelines in the approach to the management of these patients.</p><p><strong>Conclusion: </strong>This case report underscores the rarity of radiation-induced gastritis and the complications that may arise from its diagnosis, including recurrent GI bleeding. Further investigation into identifying definitive treatment and creating guidelines for its management is desperately needed.</p>","PeriodicalId":9614,"journal":{"name":"Case Reports in Gastroenterology","volume":"18 1","pages":"306-312"},"PeriodicalIF":0.5,"publicationDate":"2024-06-07","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11249716/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141626099","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":"Hepatitis and Vasodilatory Shock due to an Unsuspected Culprit: A Rare Presentation of Multisystem Langerhans Cell Histiocytosis.","authors":"Shubhang K Bhatt, Nikita Ashcherkin, John Fanous, Rish K Pai, Janhavi Athale","doi":"10.1159/000538794","DOIUrl":"10.1159/000538794","url":null,"abstract":"<p><strong>Introduction: </strong>Langerhans cell histiocytosis (LCH) is a rare hematologic condition which can affect multiple organ systems and has variable presentation. LCH is more commonly seen as a malignancy of childhood. LCH in adulthood can have poor outcomes depending on the involvement of critical organs.</p><p><strong>Case presentation: </strong>We report a case of a 71-year-old female who presented with progressive weakness, weight loss, diarrhea, and jaundice, and had been undergoing outpatient workup for elevated liver enzymes for the last 2 years. She required admission to the intensive care unit for vasodilatory shock, requiring vasopressor and chronotropic support. Imaging showed an underlying multiorgan process involving the gastrointestinal tract, liver, spleen, and central nervous system. A repeat liver biopsy after a prior inconclusive one revealed the diagnosis of multisystem LCH presenting as secondary sclerosing cholangitis.</p><p><strong>Conclusion: </strong>The uniqueness of this multisystem LCH case lies not only in its rarity but also in the diagnostic journey that necessitated a repeat biopsy for a conclusive diagnosis. Early identification and targeted intervention can help in ensuring better patient outcomes, especially when the presentation can overlap with various other possible conditions.</p>","PeriodicalId":9614,"journal":{"name":"Case Reports in Gastroenterology","volume":"18 1","pages":"286-292"},"PeriodicalIF":0.6,"publicationDate":"2024-05-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11167066/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141310138","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":"Two Cases of Increased Gastrointestinal Polyps in Familial Adenomatous Polyposis following Antiacid Agent Intake.","authors":"Yuji Urabe, Hideki Ishikawa, Akira Ishikawa, Shingo Ishiguro, Kazuki Ishibashi, Koji Arihiro, Michihiro Mutoh, Shiro Oka","doi":"10.1159/000538833","DOIUrl":"10.1159/000538833","url":null,"abstract":"<p><strong>Introduction: </strong>Familial adenomatous polyposis (FAP), a hereditary disorder of the gastrointestinal tract, is an autosomal dominant inherited condition caused by germline mutations in the adenomatous polyposis coli (<i>APC</i>) gene. It is characterized by the development of hundreds to thousands of colorectal adenomatous polyps, which, if left untreated, can eventually develop into colorectal carcinomas. Representative extracolonic tumors in FAP include multiple duodenal adenomas and desmoid tumors. Moreover, multiple fundic gland polyps are frequently identified in the stomachs of patients with FAP.</p><p><strong>Case presentation: </strong>Herein, we report the two cases. A 52-year-old woman who underwent total colectomy for FAP, and pancreatoduodenectomy was initiated on esomeprazole for the treatment of anastomotic erosion. Esophagogastroduodenoscopy performed 42 months later showed an increased number and size of gastric fundic gland polyps, which subsequently decreased after replacing esomeprazole with ranitidine. Similarly, a 39-year-old woman with FAP was initiated on vonoprazan for the treatment of reflux symptoms. Esophagogastroduodenoscopy and colonoscopy performed 14 months later indicated an increase in the number of gastric fundic gland polyps and colorectal polyps, which subsequently decreased after vonoprazan discontinuation. In these two cases, the increase and decrease in the number and size of fundic gland polyps and colon adenoma were associated with serum gastrin levels.</p><p><strong>Conclusion: </strong>Gastric fundic gland polyps and colon polyps may rapidly increase in number and size due to increased gastrin levels induced by proton pump inhibitor/potassium-competitive acid blocker use. Hence, these drugs should be prescribed with caution.</p>","PeriodicalId":9614,"journal":{"name":"Case Reports in Gastroenterology","volume":"18 1","pages":"293-298"},"PeriodicalIF":0.5,"publicationDate":"2024-05-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11250236/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141626101","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":"Peribiliary Gland Hyperplasia That Required Differentiation from Extrahepatic Bile Duct Cancer: A Case Report.","authors":"Kazuhiro Takami, Kuniharu Yamamoto, Hiroto Sakurai, Yoshihiro Sato, Noriko Kondo, Toru Nakano, Shingo Tsujinaka, Akinobu Koiwai, Morihisa Hirota, Keigo Murakami, Kazuhiro Murakami, Chikashi Shibata, Yu Katayose","doi":"10.1159/000538491","DOIUrl":"10.1159/000538491","url":null,"abstract":"<p><strong>Introduction: </strong>The peribiliary gland is an accessory bile duct gland. Hyperplasia of these tissues may lead to elevation of the mucosa in the bile ducts and bile duct stenosis. We herein report a case of peribiliary gland hyperplasia that required preoperative differentiation from bile duct cancer, with a discussion of the literature.</p><p><strong>Case presentation: </strong>The patient had an adenomatous lesion in the ascending colon that was difficult to treat endoscopically; therefore, surgery was planned. Preoperative abdominal ultrasonography revealed a bile duct tumor, and endoscopic ultrasonography revealed a mass lesion around the confluence of the cystic duct. Computed tomography revealed localized wall thickening in the middle bile duct, and the upstream bile ducts were slightly dilated. In addition, continuous thickening of the bile duct wall from the gallbladder to the confluence of the cystic duct was observed. No distant metastases, such as liver metastases, or nearby enlarged lymph nodes were observed. Endoscopic retrograde cholangiopancreatography and magnetic resonance cholangiopancreatography revealed a papillary-like elevated lesion in the bile duct near the confluence of the cystic duct, and a biopsy and bile cytology from the same area showed no malignant findings. As a result, the possibility that the patient had gallbladder or bile duct cancer could not be ruled out; therefore, a policy of surgery together with the ascending colon tumor was decided after receiving sufficient informed consent. During surgery, the patient underwent extrahepatic bile duct resection, reconstruction of the biliary tract using the Roux-en-Y method, and right hemicolectomy. Both duodenal and hilar bile duct transects were subjected to a fast frozen section analysis during surgery, and the results were negative for cancer. A histopathological examination of the resected specimen revealed no malignant findings in the bile duct lesions, and a diagnosis of peribiliary gland hyperplasia with chronic inflammatory cell infiltration and fibrosis of the extrahepatic bile duct wall was made.</p><p><strong>Conclusions: </strong>We encountered a case of peribiliary gland hyperplasia that was difficult to distinguish from bile duct cancer.</p>","PeriodicalId":9614,"journal":{"name":"Case Reports in Gastroenterology","volume":"18 1","pages":"279-285"},"PeriodicalIF":0.5,"publicationDate":"2024-05-23","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11249448/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141626098","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":"Side Effects of Stem Cell Transplant Mimicking Symptoms of Known Amyloidosis.","authors":"Gabriel Heering, Zilan Lin, Michael Rosman, Nao Hara, Fouzia Shakil, Dimitrios Georgostathis","doi":"10.1159/000538947","DOIUrl":"10.1159/000538947","url":null,"abstract":"<p><strong>Introduction: </strong>AL amyloidosis can involve the gastrointestinal (GI) tract in a sporadic manner, affecting certain anatomical areas while sparing others.</p><p><strong>Case presentation: </strong>Our patient with AL amyloidosis and confirmed colonic involvement was found to have new odynophagia, GI bleeding, and imaging findings that might suggest AL amyloidosis. However, negative pathology results from esophageal biopsies suggested the patient's new ulcerations were more likely a side effect of her autologous stem cell transplant (SCT) and chemotherapy meant to target amyloidosis, as opposed to an effect of amyloid infiltration itself.</p><p><strong>Conclusion: </strong>GI involvement of amyloidosis requires a high degree of clinical suspicion and should be considered in patients with systemic diseases affecting the kidney, heart, and GI tract; however, when satisfactory biopsies obtained from endoscopy results are negative, other causes should be considered.</p>","PeriodicalId":9614,"journal":{"name":"Case Reports in Gastroenterology","volume":"18 1","pages":"273-278"},"PeriodicalIF":0.6,"publicationDate":"2024-05-21","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11175601/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141316800","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":"Oesophageal Lichen Planus Successfully Treated with Budesonide Orodispersible Tablets: A Case Report.","authors":"Harald Bagger-Jörgensen, Mohammed Abdulrasak, Kevin Sandeman, Mohammed Binsalman, Klas Sjöberg","doi":"10.1159/000538894","DOIUrl":"10.1159/000538894","url":null,"abstract":"<p><strong>Introduction: </strong>Lichen planus is a relatively common inflammatory condition of the nails, skin, and mucosal surfaces. Oesophageal involvement of lichen planus is thought to be very rare, mainly described in case reports, but is associated with a high risk of oesophageal stenosis as well as squamous cell carcinoma. No evidence-based treatment recommendations exist, with the majority of described treatment regimens involving systemic immunosuppression.</p><p><strong>Case report: </strong>In this case report, we describe a novel approach in treating oesophageal lichen planus in a patient with budesonide orodispersible tablets, a treatment normally reserved for eosinophilic oesophagitis. The patient achieved complete relief of dysphagia, with a follow-up oesophagogastroduodenoscopy 2 months after treatment commencement being macroscopically and microscopically free of inflammatory activity. This case report is to our knowledge the first to report this treatment regimen in oesophageal lichen planus.</p><p><strong>Conclusion: </strong>We consider a trial of budesonide orodispersible tablets a reasonable initial management as it's a local therapy specific to the oesophagus with a more benign side effect profile than systemic immunosuppression, but further studies need to be undertaken to corroborate our findings. Also, based on the severity and malignant potential of oesophageal lichen planus, we suggest that physicians be liberal in ordering oesophagogastroduodenoscopy with biopsy taking as part of the workup of dysphagia in a patient with known lichen planus.</p>","PeriodicalId":9614,"journal":{"name":"Case Reports in Gastroenterology","volume":"18 1","pages":"266-272"},"PeriodicalIF":0.6,"publicationDate":"2024-05-15","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11095609/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140944038","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":"Biliary Cast Syndrome and Secondary Sclerosing Cholangitis in Critically Ill Patient after Long-Term Treatment in the Intensive Care Unit.","authors":"Adnan Alkurdi, Johannes Herrmann, Damir Bikmukhametov, Rebecca Tschöpe","doi":"10.1159/000537957","DOIUrl":"10.1159/000537957","url":null,"abstract":"<p><strong>Introduction: </strong>Secondary sclerosing cholangitis in critically ill patients (SSC-CIP) is a rare but underdiagnosed entity that occurs after life-threatening events and treatment in the intensive care unit (ICU). The etiology of SSC-CIP is not fully understood but may be caused by ischemic bile duct injury. SSC-CIP is a cholestatic liver disease that rapidly progresses to liver cirrhosis, with a high mortality rate in the first year of 50%. Endoscopic retrograde cholangiopancreatography (ERCP), which is the gold standard for diagnosing SSC-CIP, shows primary SC-like changes, usually in the intrahepatic bile ducts. Biliary cast formation is pathognomonic for SSC-CIP. No proven effective conservative treatment is available for SSC-CIP, and liver transplantation is the only curative therapy when liver cirrhosis or recurrent cholangitis occurs.</p><p><strong>Case presentation: </strong>We report the case of a 47-year-old male patient who developed cholestasis after a long treatment in the ICU for severe pneumonia. ERCP showed characteristic findings with rarefication and multiple segmental stenosis in the intrahepatic bile ducts. We removed multiple biliary casts from the bile ducts.</p><p><strong>Conclusion: </strong>SSC-CIP should be considered for ICU patients with unclear cholestasis, especially when the cholestasis persists after recovery from the underlying disease. Early diagnosis is important to achieve better outcomes; without liver transplantation, the prognosis is generally poor.</p>","PeriodicalId":9614,"journal":{"name":"Case Reports in Gastroenterology","volume":"18 1","pages":"260-265"},"PeriodicalIF":0.6,"publicationDate":"2024-05-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11087035/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140911502","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 Fatal Outcome after Cessation of Nucleotide Analogue Therapy in a Patient with Chronic Hepatitis B: A Case Report.","authors":"Sylvia M Brakenhoff, Heng Chi, Pieter Friederich, Michail Doukas, Caroline den Hoed, Hajo J Flink, Robert J de Knegt, Robert A de Man","doi":"10.1159/000538342","DOIUrl":"https://doi.org/10.1159/000538342","url":null,"abstract":"<p><strong>Introduction: </strong>Emerging evidence suggests that long-term nucleos(t)ide analogue (NA) therapy can be ceased in a selective group of chronic hepatitis B (CHB). This is being gradually implemented in clinical practice.</p><p><strong>Case presentation: </strong>A 68-year-old man known with a chronic hepatitis B e antigen-positive hepatitis B infection without signs of advanced liver fibrosis or cirrhosis was admitted with acute liver failure. Two months prior to his admission, he ceased his NA therapy. During the admission, NA therapy was restarted, but the liver function worsened. The patient was put on the high-urgency liver transplantation waiting list, and the next day, he was successfully transplanted. However, the patient died 17 days later due to hemorrhagic shock that resulted from intra-abdominal bleeding and acute pancreatitis.</p><p><strong>Conclusion: </strong>Current guidelines suggest that NA therapy can be discontinued in a selective group of CHB patients. However, these guidelines suggest different stopping and follow-up criteria. This case illustrates that NA withdrawal is not without risks and that these differences in recommendations may lead to inadequate management and eventually a fatal outcome.</p>","PeriodicalId":9614,"journal":{"name":"Case Reports in Gastroenterology","volume":"18 1","pages":"252-259"},"PeriodicalIF":0.6,"publicationDate":"2024-04-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11052559/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140849401","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":"Primary Malignant Melanoma of the Esophagus Treated with Surgical Resection at an Early Stage.","authors":"Akira Yoneda, Ryosuke Ogata, Shintaro Ryu, Kyohei Yoshino, Saeko Fukui, Takahiro Ikeda, Amane Kitasato, Nozomu Sugiyama, Hiroaki Takeshita, Shigeki Minami, Masahiro Ito, Tamotsu Kuroki","doi":"10.1159/000538161","DOIUrl":"10.1159/000538161","url":null,"abstract":"<p><strong>Introduction: </strong>Primary malignant melanoma of the esophagus is a very rare disease with a poor prognosis. We herein report a patient with primary malignant melanoma of the esophagus who underwent surgical resection.</p><p><strong>Case presentation: </strong>A 73-year-old female underwent an upper gastrointestinal endoscopy during follow-up for colonic diverticulitis. An endoscopic examination and constructed radiography revealed a slightly elevated black pigmented lesion in the upper esophagus and a black pigmented area in the esophagogastric junction. Through a preoperative endoscopic biopsy, she was diagnosed with malignant melanoma of the esophagus. We performed thoracoscopy-assisted and laparoscopy-assisted subtotal esophagectomy with lymphadenectomy. The surgical specimens were subjected to immunohistochemical analysis, resulting in a diagnosis of malignant melanoma. The tumor cells were positive for Melan-A and HMB-45 diffusely, supporting that diagnosis. We performed surgical resection in a case of primary malignant melanoma of the esophagus, and the patient has remained disease free for 2 years since the surgery.</p><p><strong>Conclusion: </strong>Early diagnosis and radical resection may be essential for long-term survival in patients with malignant melanoma of the esophagus.</p>","PeriodicalId":9614,"journal":{"name":"Case Reports in Gastroenterology","volume":"18 1","pages":"189-194"},"PeriodicalIF":0.6,"publicationDate":"2024-03-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10978042/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140317796","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 Case Report of Pulmonary Edema Secondary to Large Volume Bowel Preparation in a High-Risk Patient with Multiple Cardiopulmonary Co-Morbidities.","authors":"Kush Fansiwala, Preeti Prakash, Christopher L Coe, Guy A Weiss","doi":"10.1159/000538158","DOIUrl":"10.1159/000538158","url":null,"abstract":"<p><strong>Introduction: </strong>Polyethylene glycol 3,350 and electrolytes is a commonly prescribed bowel regimen for colonoscopy preparation with an overall excellent safety profile, though prior reports have demonstrated risk of volume overload.</p><p><strong>Case presentation: </strong>A 55-year-old man with significant cardiopulmonary co-morbidities was admitted for acute hypoxic respiratory failure and subsequent evaluation for lung transplant. As part of his pretransplant evaluation, colon cancer screening was advised. Despite multiple days of bowel preparation, his stools contained sediment. Unfortunately, he developed pulmonary edema due to prolonged bowel preparation.</p><p><strong>Conclusion: </strong>While bowel preparation is considered generally safe, our case report highlights the importance of judicious use with monitoring in high-risk individuals.</p>","PeriodicalId":9614,"journal":{"name":"Case Reports in Gastroenterology","volume":"18 1","pages":"176-180"},"PeriodicalIF":0.6,"publicationDate":"2024-03-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10972573/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"140305002","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}