Physicians who care for patients with dementia also must provide support for patient caregivers and family members. Caregiver burden requires attention from the health care team because most caregivers of patients with dementia report high levels of emotional stress. This burden is more severe when patients have comorbid conditions, behavioral and psychological symptoms of dementia, and more severe functional impairments. A functional assessment of activities of daily living can be done using standardized screening tools. Driving is a specific instrumental activity of daily living that can become dangerous in dementia; decisions about stopping driving often are complicated by patient resistance and loss of independence. Clinicians will be faced with questions regarding patient decision-making capacity, which is the ability to comprehend information and use reason to communicate an informed choice. As complex decision-making capacity is likely to diminish with dementia progression, discussing advance directives and designation of a surrogate decision-maker early in the disease course is paramount. Dementia remains an incurable progressive disease; therefore, management often is directed toward maintaining quality of life, managing symptoms, and palliating suffering. Patients with dementia may become eligible for hospice when they lose speech, locomotion, or consciousness.
{"title":"Dementia: Helping Caregivers and Family Members Cope.","authors":"Scott T Larson","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>Physicians who care for patients with dementia also must provide support for patient caregivers and family members. Caregiver burden requires attention from the health care team because most caregivers of patients with dementia report high levels of emotional stress. This burden is more severe when patients have comorbid conditions, behavioral and psychological symptoms of dementia, and more severe functional impairments. A functional assessment of activities of daily living can be done using standardized screening tools. Driving is a specific instrumental activity of daily living that can become dangerous in dementia; decisions about stopping driving often are complicated by patient resistance and loss of independence. Clinicians will be faced with questions regarding patient decision-making capacity, which is the ability to comprehend information and use reason to communicate an informed choice. As complex decision-making capacity is likely to diminish with dementia progression, discussing advance directives and designation of a surrogate decision-maker early in the disease course is paramount. Dementia remains an incurable progressive disease; therefore, management often is directed toward maintaining quality of life, managing symptoms, and palliating suffering. Patients with dementia may become eligible for hospice when they lose speech, locomotion, or consciousness.</p>","PeriodicalId":38325,"journal":{"name":"FP essentials","volume":"534 ","pages":"24-32"},"PeriodicalIF":0.0,"publicationDate":"2023-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"136399677","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}
Early and accurate diagnosis are crucial to appropriate care, ensuring timely intervention, and planning for future needs of patients with dementia. Dementia is a clinical diagnosis and should include comprehensive evaluation of patient cognitive and functional abilities, diagnostic laboratory evaluation, and brain imaging. A comprehensive evaluation for dementia includes a thorough medical history and physical examination, which may reveal important clues about the potential underlying causes of cognitive decline. A detailed medical history, physical examination, laboratory tests, and imaging studies can help identify any contributing factors. In addition, validated cognitive assessment tools can help clinicians identify the extent and nature of cognitive deficits, and track disease progression over time. Advances in the field of dementia research, such as serum biomarkers, are showing promise in facilitating an earlier and more accurate diagnosis. With the rise of telemedicine, new opportunities for virtual diagnosis have emerged, which can expand access to care for individuals in remote or underserved areas. The use of telemedicine for dementia diagnosis is still in its infancy, but research suggests that it has the potential to be an effective and convenient tool for evaluating patients with suspected dementia.
{"title":"Dementia: Diagnostic Evaluation.","authors":"Ellie Fishbein","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>Early and accurate diagnosis are crucial to appropriate care, ensuring timely intervention, and planning for future needs of patients with dementia. Dementia is a clinical diagnosis and should include comprehensive evaluation of patient cognitive and functional abilities, diagnostic laboratory evaluation, and brain imaging. A comprehensive evaluation for dementia includes a thorough medical history and physical examination, which may reveal important clues about the potential underlying causes of cognitive decline. A detailed medical history, physical examination, laboratory tests, and imaging studies can help identify any contributing factors. In addition, validated cognitive assessment tools can help clinicians identify the extent and nature of cognitive deficits, and track disease progression over time. Advances in the field of dementia research, such as serum biomarkers, are showing promise in facilitating an earlier and more accurate diagnosis. With the rise of telemedicine, new opportunities for virtual diagnosis have emerged, which can expand access to care for individuals in remote or underserved areas. The use of telemedicine for dementia diagnosis is still in its infancy, but research suggests that it has the potential to be an effective and convenient tool for evaluating patients with suspected dementia.</p>","PeriodicalId":38325,"journal":{"name":"FP essentials","volume":"534 ","pages":"12-17"},"PeriodicalIF":0.0,"publicationDate":"2023-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"136399675","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}
Dementia, also called major neurocognitive disorder, is characterized by a chronic progressive loss of cognitive function in the absence of fluctuating consciousness. It represents a primarily geriatric syndrome that may be caused by one of several underlying conditions. There is insufficient evidence to support universal screening for cognitive impairment in older adults; however, clinicians should be alert to patient and caregiver concerns about cognitive changes and investigate such concerns with validated cognitive assessment tools. Alzheimer disease is the leading cause and prototypical form of dementia, presenting insidiously and causing progressive cognitive impairment with increasing severity over a period of years. Vascular dementia is the second most common form of dementia and often co-occurs with other progressive cognitive disorders. Lewy body dementias encompass Parkinson disease dementia and dementia with Lewy bodies, which have similar features and are differentiated primarily by the order of motor and cognitive symptom onset. Frontotemporal dementias occur earlier than other forms of dementia, progress rapidly, and often have a genetic component. An understanding of the conditions that cause dementia will assist clinicians in making an accurate diagnosis and providing appropriate treatment recommendations and counseling regarding the diagnosis and prognosis.
{"title":"Dementia: Dementia Types.","authors":"Jason Wilbur","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>Dementia, also called major neurocognitive disorder, is characterized by a chronic progressive loss of cognitive function in the absence of fluctuating consciousness. It represents a primarily geriatric syndrome that may be caused by one of several underlying conditions. There is insufficient evidence to support universal screening for cognitive impairment in older adults; however, clinicians should be alert to patient and caregiver concerns about cognitive changes and investigate such concerns with validated cognitive assessment tools. Alzheimer disease is the leading cause and prototypical form of dementia, presenting insidiously and causing progressive cognitive impairment with increasing severity over a period of years. Vascular dementia is the second most common form of dementia and often co-occurs with other progressive cognitive disorders. Lewy body dementias encompass Parkinson disease dementia and dementia with Lewy bodies, which have similar features and are differentiated primarily by the order of motor and cognitive symptom onset. Frontotemporal dementias occur earlier than other forms of dementia, progress rapidly, and often have a genetic component. An understanding of the conditions that cause dementia will assist clinicians in making an accurate diagnosis and providing appropriate treatment recommendations and counseling regarding the diagnosis and prognosis.</p>","PeriodicalId":38325,"journal":{"name":"FP essentials","volume":"534 ","pages":"7-11"},"PeriodicalIF":0.0,"publicationDate":"2023-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"136399674","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}
Dementia management requires individualized patient encounters that focus on education and realistic expectations. Numerous vitamins and supplements are promoted for memory enhancement, but they lack evidence to support their use. Nonpharmacotherapy should be used through all stages of dementia. Common initial pharmacotherapy includes cholinesterase inhibitors and memantine, with use guided by dementia type, tolerability, patient goals, and disease stage. Assessment of benefit should incorporate caregiver input, functional improvements, behavioral symptoms, and tolerability. Management length is individualized. When a drug is discontinued, physicians should evaluate the patient for early worsening of cognitive or functional symptoms. Newer treatments, such as aducanumab, can reduce beta-amyloid plaques, but evidence for cognitive improvements is lacking; these treatments also are expensive and patient access is limited, resulting in barriers to widespread use. As dementia progresses, patients often develop behavioral and psychological symptoms, which are challenging for patients and caregivers. Nonpharmacotherapy is the first-line treatment for behavioral and psychological symptoms of dementia. Use of antipsychotics and benzodiazepines should be limited unless symptoms are placing the patient or others in imminent danger. Pharmacotherapy for these symptoms should be individualized, often requiring trials of various therapeutic options.
{"title":"Dementia: Management and Controversies in Management.","authors":"John Swegle","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>Dementia management requires individualized patient encounters that focus on education and realistic expectations. Numerous vitamins and supplements are promoted for memory enhancement, but they lack evidence to support their use. Nonpharmacotherapy should be used through all stages of dementia. Common initial pharmacotherapy includes cholinesterase inhibitors and memantine, with use guided by dementia type, tolerability, patient goals, and disease stage. Assessment of benefit should incorporate caregiver input, functional improvements, behavioral symptoms, and tolerability. Management length is individualized. When a drug is discontinued, physicians should evaluate the patient for early worsening of cognitive or functional symptoms. Newer treatments, such as aducanumab, can reduce beta-amyloid plaques, but evidence for cognitive improvements is lacking; these treatments also are expensive and patient access is limited, resulting in barriers to widespread use. As dementia progresses, patients often develop behavioral and psychological symptoms, which are challenging for patients and caregivers. Nonpharmacotherapy is the first-line treatment for behavioral and psychological symptoms of dementia. Use of antipsychotics and benzodiazepines should be limited unless symptoms are placing the patient or others in imminent danger. Pharmacotherapy for these symptoms should be individualized, often requiring trials of various therapeutic options.</p>","PeriodicalId":38325,"journal":{"name":"FP essentials","volume":"534 ","pages":"18-23"},"PeriodicalIF":0.0,"publicationDate":"2023-11-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"136399678","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}
Fibromyalgia is a chronic pain syndrome that is considered a pain processing disorder; its pathophysiology is not completely understood. The estimated prevalence in the general population varies from 0.5% to 12%, depending on the population studied and diagnostic criteria used. It is more common in females than males. There is no diagnostic laboratory test. The two currently used diagnostic methods are scoring criteria from the American College of Rheumatology (ACR) and the Analgesic, Anesthetic, and Addiction Clinical Trial Translations Innovations Opportunities and Networks (ACTTION)-American Pain Society (APS). These diagnostic criteria include chronic widespread pain of at least 3 months' duration plus poor sleep and/or fatigue and other somatic symptoms. Other pain syndromes also should be considered in the differential diagnosis. A multimodal, targeted symptom management approach that emphasizes self-management is recommended. Nonpharmacotherapies include patient education, exercise, and cognitive behavior therapy. Pharmacotherapy should be based on predominant symptoms. Amitriptyline and pregabalin are effective for management of pain, fatigue, and sleep issues. Milnacipran (Savella) is effective for pain and fatigue. Duloxetine is effective for management of pain and depression. There is no evidence of benefit of analgesics. Common comorbidities, such as regional pain conditions and mental disorders, should be addressed.
{"title":"Chronic Pain Syndromes: Fibromyalgia.","authors":"Diane Flynn","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>Fibromyalgia is a chronic pain syndrome that is considered a pain processing disorder; its pathophysiology is not completely understood. The estimated prevalence in the general population varies from 0.5% to 12%, depending on the population studied and diagnostic criteria used. It is more common in females than males. There is no diagnostic laboratory test. The two currently used diagnostic methods are scoring criteria from the American College of Rheumatology (ACR) and the Analgesic, Anesthetic, and Addiction Clinical Trial Translations Innovations Opportunities and Networks (ACTTION)-American Pain Society (APS). These diagnostic criteria include chronic widespread pain of at least 3 months' duration plus poor sleep and/or fatigue and other somatic symptoms. Other pain syndromes also should be considered in the differential diagnosis. A multimodal, targeted symptom management approach that emphasizes self-management is recommended. Nonpharmacotherapies include patient education, exercise, and cognitive behavior therapy. Pharmacotherapy should be based on predominant symptoms. Amitriptyline and pregabalin are effective for management of pain, fatigue, and sleep issues. Milnacipran (Savella) is effective for pain and fatigue. Duloxetine is effective for management of pain and depression. There is no evidence of benefit of analgesics. Common comorbidities, such as regional pain conditions and mental disorders, should be addressed.</p>","PeriodicalId":38325,"journal":{"name":"FP essentials","volume":"533 ","pages":"7-15"},"PeriodicalIF":0.0,"publicationDate":"2023-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41183825","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}
Myofascial pain syndrome (MPS) is a regional musculoskeletal pain disorder characterized by trigger points within the muscle or fascia. There are no universally accepted diagnostic criteria. Diagnosis currently is based on a physical examination finding of at least one localized trigger point that, when palpated, recreates the pain at the site or produces pain away from the site in a referral pattern. MPS is thought to be related to sustained muscle contraction from under- or overuse. This syndrome commonly coexists with other chronic pain conditions, including fibromyalgia. The difference between MPS and fibromyalgia is that MPS involves localized pain with discrete areas of tenderness, whereas fibromyalgia symptoms are more diffuse and widespread. Most management recommendations for MPS are based on low-quality clinical trials or expert opinion. A multimodal approach is recommended, involving patient education, exercise, behavior modification, pharmacotherapy, and procedural interventions. Commonly used drugs include topical analgesics, nonsteroidal anti-inflammatory drugs, and muscle relaxants. Procedural interventions include manual therapy (eg, deep tissue massage, spray and stretch technique, myofascial release), dry needling, trigger point injections, onabotulinumtoxinA injections, acupuncture, kinesiology tape, transcutaneous electrical nerve stimulation, extracorporeal shockwave therapy, and low-level laser therapy. Symptoms often resolve with these interventions if they are used early in the course of the condition. As MPS enters the chronic stage, it becomes increasingly refractory to treatment.
{"title":"Chronic Pain Syndromes: Myofascial Pain Syndrome.","authors":"Julie Henson","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>Myofascial pain syndrome (MPS) is a regional musculoskeletal pain disorder characterized by trigger points within the muscle or fascia. There are no universally accepted diagnostic criteria. Diagnosis currently is based on a physical examination finding of at least one localized trigger point that, when palpated, recreates the pain at the site or produces pain away from the site in a referral pattern. MPS is thought to be related to sustained muscle contraction from under- or overuse. This syndrome commonly coexists with other chronic pain conditions, including fibromyalgia. The difference between MPS and fibromyalgia is that MPS involves localized pain with discrete areas of tenderness, whereas fibromyalgia symptoms are more diffuse and widespread. Most management recommendations for MPS are based on low-quality clinical trials or expert opinion. A multimodal approach is recommended, involving patient education, exercise, behavior modification, pharmacotherapy, and procedural interventions. Commonly used drugs include topical analgesics, nonsteroidal anti-inflammatory drugs, and muscle relaxants. Procedural interventions include manual therapy (eg, deep tissue massage, spray and stretch technique, myofascial release), dry needling, trigger point injections, onabotulinumtoxinA injections, acupuncture, kinesiology tape, transcutaneous electrical nerve stimulation, extracorporeal shockwave therapy, and low-level laser therapy. Symptoms often resolve with these interventions if they are used early in the course of the condition. As MPS enters the chronic stage, it becomes increasingly refractory to treatment.</p>","PeriodicalId":38325,"journal":{"name":"FP essentials","volume":"533 ","pages":"16-20"},"PeriodicalIF":0.0,"publicationDate":"2023-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41183827","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}
Neuropathic pain affects 7% to 10% of the population and has major effects on quality of life. It is defined as pain caused by a lesion or disease of the somatosensory nervous system and may be central or peripheral. Diagnostic testing may yield inconclusive or inconsistent results, so physicians often rely on clinical judgment based on the history and physical examination findings. Questionnaires and scoring systems can aid in diagnosis. Neuropathic pain is differentiated from other types of chronic pain by abnormal sensory symptoms, such as shooting pain, burning pain, or numbness. It is difficult to manage and can be accompanied by mood and sleep disturbances. Referral for psychotherapy may be useful for these patients. Nonpharmacotherapy options include mindfulness training, transcutaneous electrical nerve stimulation, and massage. Acupuncture also may be effective, but the data are mixed. Topical drugs (eg, lidocaine, capsaicin), gabapentinoids, tricyclic antidepressants, and serotonin-norepinephrine reuptake inhibitors are considered first-line drugs. Tramadol is considered a second-line drug, but may considered first-line for certain patients. For persistent pain, physicians can consider referring patients to a pain specialist for nerve blocks or other procedural interventions. Opioids may be considered for refractory pain, but their additional benefit has been shown to be modest compared with those of other treatments.
{"title":"Chronic Pain Syndromes: Chronic Neuropathic Pain.","authors":"Tyler J Raymond","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>Neuropathic pain affects 7% to 10% of the population and has major effects on quality of life. It is defined as pain caused by a lesion or disease of the somatosensory nervous system and may be central or peripheral. Diagnostic testing may yield inconclusive or inconsistent results, so physicians often rely on clinical judgment based on the history and physical examination findings. Questionnaires and scoring systems can aid in diagnosis. Neuropathic pain is differentiated from other types of chronic pain by abnormal sensory symptoms, such as shooting pain, burning pain, or numbness. It is difficult to manage and can be accompanied by mood and sleep disturbances. Referral for psychotherapy may be useful for these patients. Nonpharmacotherapy options include mindfulness training, transcutaneous electrical nerve stimulation, and massage. Acupuncture also may be effective, but the data are mixed. Topical drugs (eg, lidocaine, capsaicin), gabapentinoids, tricyclic antidepressants, and serotonin-norepinephrine reuptake inhibitors are considered first-line drugs. Tramadol is considered a second-line drug, but may considered first-line for certain patients. For persistent pain, physicians can consider referring patients to a pain specialist for nerve blocks or other procedural interventions. Opioids may be considered for refractory pain, but their additional benefit has been shown to be modest compared with those of other treatments.</p>","PeriodicalId":38325,"journal":{"name":"FP essentials","volume":"533 ","pages":"27-40"},"PeriodicalIF":0.0,"publicationDate":"2023-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41183823","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}
Complex regional pain syndrome (CRPS) is a chronic pain condition characterized by intense pain, usually in a body region that has experienced trauma, and autonomic and inflammatory features. It most commonly develops after an arm or leg injury. Patients typically present with extreme hyperalgesia and/or allodynia. The Budapest Criteria are used to make this clinical diagnosis. Prompt diagnosis and aggressive management are critical because long-term outcomes are improved when treatment is initiated soon after symptom onset. The primary management options are rehabilitation and physical therapy, including such approaches as progressive tactile stimulation, normalization of movement to prevent limited range of motion, and others. No drugs are approved by the Food and Drug Administration (FDA) for CRPS management, but some evidence supports the use of drugs used to manage other types of neuropathic pain (eg, gabapentin, tricyclic antidepressants, serotonin-norepinephrine reuptake inhibitors). Nonsteroidal anti-inflammatory drugs also are used, and corticosteroids, bisphosphonates, ketamine, and other drugs can be helpful, particularly for early-stage CRPS. When pain severity prevents patients from participating in rehabilitation, referral to a pain specialist is warranted for consideration of procedural interventions, including sympathetic nerve blockade and spinal cord stimulation.
{"title":"Chronic Pain Syndromes: Complex Regional Pain Syndrome.","authors":"Ghena Grinshpun","doi":"","DOIUrl":"","url":null,"abstract":"<p><p>Complex regional pain syndrome (CRPS) is a chronic pain condition characterized by intense pain, usually in a body region that has experienced trauma, and autonomic and inflammatory features. It most commonly develops after an arm or leg injury. Patients typically present with extreme hyperalgesia and/or allodynia. The Budapest Criteria are used to make this clinical diagnosis. Prompt diagnosis and aggressive management are critical because long-term outcomes are improved when treatment is initiated soon after symptom onset. The primary management options are rehabilitation and physical therapy, including such approaches as progressive tactile stimulation, normalization of movement to prevent limited range of motion, and others. No drugs are approved by the Food and Drug Administration (FDA) for CRPS management, but some evidence supports the use of drugs used to manage other types of neuropathic pain (eg, gabapentin, tricyclic antidepressants, serotonin-norepinephrine reuptake inhibitors). Nonsteroidal anti-inflammatory drugs also are used, and corticosteroids, bisphosphonates, ketamine, and other drugs can be helpful, particularly for early-stage CRPS. When pain severity prevents patients from participating in rehabilitation, referral to a pain specialist is warranted for consideration of procedural interventions, including sympathetic nerve blockade and spinal cord stimulation.</p>","PeriodicalId":38325,"journal":{"name":"FP essentials","volume":"533 ","pages":"21-26"},"PeriodicalIF":0.0,"publicationDate":"2023-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41183824","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}