Yael Lichter, A. Nini, Y. Szekely, Noam Goder, Reut Schvartz, Lilach Zac, Y. Topilsky, Jacob Vine, A. Gal-Oz
A 61-year-old woman, presented to the Emergency Department (ED) with respiratory failure and cardiogenic shock following a face lift surgery earlier that day. Her intraoperative course included highly labile blood pressure (BP) and heart rate (HR). Initial investigation revealed severe global left ventricular (LV) failure with sparing of the base, high levels of troponin-I and bilateral chest infiltrates, without electrocardiographic evidence of acute myocardial ischemia. Her condition quickly deteriorated to severe hypoxemia and refractory shock. Peripheral veno-arterial extracorporeal membrane oxygenation (VA-ECMO) was installed during resuscitation, resulting in rapid hemodynamic stabilization, normalization of lactate levels and restoration of normal urinary output. Laboratory investigation and computed tomography (CT) revealed a round lesion with a hypodense core in the left adrenal gland, and high blood levels of epinephrine and norepinephrine, supporting a diagnosis of pheochromocytoma. The patient gradually recovered and was weaned from ECMO support on day 5, but continued to experience repeated, life threatening, events of hemodynamic instability. Following a multidisciplinary discussion that included intensivists, endocrinologists, anesthetists and surgeons, urgent adrenalectomy was successfully performed. The patient made a full recovery and was discharged home. This case emphasizes the role of ECMO as a life-saving mean in cases of potentially reversible cardiogenic shock, and triggers the discussion as to the optimal timing and safety of adrenalectomy in cases of pheochromocytoma crisis.
{"title":"Pheochromocytoma crisis treated with veno-arterial extracorporeal membrane oxygenation and urgent adrenalectomy—case report","authors":"Yael Lichter, A. Nini, Y. Szekely, Noam Goder, Reut Schvartz, Lilach Zac, Y. Topilsky, Jacob Vine, A. Gal-Oz","doi":"10.21037/jeccm-21-32","DOIUrl":"https://doi.org/10.21037/jeccm-21-32","url":null,"abstract":"A 61-year-old woman, presented to the Emergency Department (ED) with respiratory failure and cardiogenic shock following a face lift surgery earlier that day. Her intraoperative course included highly labile blood pressure (BP) and heart rate (HR). Initial investigation revealed severe global left ventricular (LV) failure with sparing of the base, high levels of troponin-I and bilateral chest infiltrates, without electrocardiographic evidence of acute myocardial ischemia. Her condition quickly deteriorated to severe hypoxemia and refractory shock. Peripheral veno-arterial extracorporeal membrane oxygenation (VA-ECMO) was installed during resuscitation, resulting in rapid hemodynamic stabilization, normalization of lactate levels and restoration of normal urinary output. Laboratory investigation and computed tomography (CT) revealed a round lesion with a hypodense core in the left adrenal gland, and high blood levels of epinephrine and norepinephrine, supporting a diagnosis of pheochromocytoma. The patient gradually recovered and was weaned from ECMO support on day 5, but continued to experience repeated, life threatening, events of hemodynamic instability. Following a multidisciplinary discussion that included intensivists, endocrinologists, anesthetists and surgeons, urgent adrenalectomy was successfully performed. The patient made a full recovery and was discharged home. This case emphasizes the role of ECMO as a life-saving mean in cases of potentially reversible cardiogenic shock, and triggers the discussion as to the optimal timing and safety of adrenalectomy in cases of pheochromocytoma crisis.","PeriodicalId":73727,"journal":{"name":"Journal of emergency and critical care medicine (Hong Kong, China)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"46625338","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}
Robert Anderson, M. Pitlick, Armando Pérez, K. Kashani
: This case study illustrates a clinically observed interaction between Smoflipid and the development of anaphylactic shock in a patient on long-term parenteral nutrition. This patient had a history of a well-differentiated retroperitoneal liposarcoma, now resected, which was complicated by duodenal perforation and intraperitoneal drain placement; due to significant gastrointestinal tract dysfunction the patient was maintained on continuous parenteral nutrition via a PICC line. Following a routine and drain exchange, the patient was admitted to the hospital. The patient subsequently developed anaphylactic-like shock symptomatology, necessitating admission to the critical care unit. Intermittent dual vasopressor use was required. There was also an intermittently visible rash that was noted. The etiology of the shock state was unclear. After review of the patient’s case and clinical course, a potential etiology of his shock state was the inpatient protocolized substitution of Smoflipid instead of Intralipid in the parenteral nutrition regimen. After consultation with Allergic Diseases, Nutrition, and Pharmacy the Smoflipid was discontinued and the patient’s regimen was reverted to the standing home regimen including Intralipid. Following discontinuation of Smoflipid and resumption of Intralipid, the shock physiology resolved. The patient was subsequently transferred from the critical care unit and discharged soon thereafter by the primary surgical service. A formal Allergic Disease evaluation was completed in the outpatient setting. Continuous parenteral nutrition therapy was maintained at home using the previous home Intralipid regimen without issue. This case illustrates a multidisciplinary approach including Surgery, Allergic Diseases, Nutrition, Pharmacy, and Critical Care to address the patient’s acute shock state. In addition, a review of different shock states is presented. A literature review evaluating side effects of Smoflipid and an association of shock to its use is presented.
{"title":"Sepsis versus anaphylaxis—differentiating shock etiology: a case report involving Smoflipid","authors":"Robert Anderson, M. Pitlick, Armando Pérez, K. Kashani","doi":"10.21037/jeccm-21-28","DOIUrl":"https://doi.org/10.21037/jeccm-21-28","url":null,"abstract":": This case study illustrates a clinically observed interaction between Smoflipid and the development of anaphylactic shock in a patient on long-term parenteral nutrition. This patient had a history of a well-differentiated retroperitoneal liposarcoma, now resected, which was complicated by duodenal perforation and intraperitoneal drain placement; due to significant gastrointestinal tract dysfunction the patient was maintained on continuous parenteral nutrition via a PICC line. Following a routine and drain exchange, the patient was admitted to the hospital. The patient subsequently developed anaphylactic-like shock symptomatology, necessitating admission to the critical care unit. Intermittent dual vasopressor use was required. There was also an intermittently visible rash that was noted. The etiology of the shock state was unclear. After review of the patient’s case and clinical course, a potential etiology of his shock state was the inpatient protocolized substitution of Smoflipid instead of Intralipid in the parenteral nutrition regimen. After consultation with Allergic Diseases, Nutrition, and Pharmacy the Smoflipid was discontinued and the patient’s regimen was reverted to the standing home regimen including Intralipid. Following discontinuation of Smoflipid and resumption of Intralipid, the shock physiology resolved. The patient was subsequently transferred from the critical care unit and discharged soon thereafter by the primary surgical service. A formal Allergic Disease evaluation was completed in the outpatient setting. Continuous parenteral nutrition therapy was maintained at home using the previous home Intralipid regimen without issue. This case illustrates a multidisciplinary approach including Surgery, Allergic Diseases, Nutrition, Pharmacy, and Critical Care to address the patient’s acute shock state. In addition, a review of different shock states is presented. A literature review evaluating side effects of Smoflipid and an association of shock to its use is presented.","PeriodicalId":73727,"journal":{"name":"Journal of emergency and critical care medicine (Hong Kong, China)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"44363074","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}
H. Umpleby, Ahilanandan Dushianthan, Timothy Catton, K. Saeed
{"title":"Antimicrobial stewardship programmes focused on de-escalation: a narrative review of efficacy and risks","authors":"H. Umpleby, Ahilanandan Dushianthan, Timothy Catton, K. Saeed","doi":"10.21037/jeccm-22-6","DOIUrl":"https://doi.org/10.21037/jeccm-22-6","url":null,"abstract":"","PeriodicalId":73727,"journal":{"name":"Journal of emergency and critical care medicine (Hong Kong, China)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"47351849","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}
: Heatstroke is a life-threatening condition with high morbidity and mortality. Prompt recognition and institution of cooling measures has been shown to greatly improve outcomes. This is a case report demonstrating the use of a novel cooling suit (CarbonCool ® suit) in a case of exertional heatstroke (EHS). The CarbonCool ® suit is a half-body suit with cooling pads (MPad TM ) that are filled with a graphite water solution found to be 15 times more thermally conductive than ice. In this case report, a previously well 31-year-old male presented to the Emergency Department (ED) with EHS, subsequently requiring intubation. The CarbonCool ® suit was used to reduce his core (rectal) temperature from 41 ℃ to 38.7 ℃ in two hours. Patient’s core temperature subsequently normalized to 37 ℃ and he was discharged well and neurologically intact. The case report demonstrates that the suit can be easily worn and secured in place, while resuscitative measures are ongoing. This reduces the need for constant monitoring and replacement of ice packs, hence serving as a convenient alternative to ice packs for initial management of patients with EHS. While alternative cooling methods such as powered cooling devices may be utilized, these devices are often only available in the intensive care unit, with significantly higher operative costs. Use of the CarbonCool ® suit as an adjunct to other cooling methods may be a simple solution for rapid initiation of cooling in the patient with heatstroke.
{"title":"Management of heatstroke using the novel, reusable, CarbonCool® suit: a case report","authors":"P. J. M. Tay, A. Ho, N. Shahidah, G. Nadarajan","doi":"10.21037/JECCM-20-107","DOIUrl":"https://doi.org/10.21037/JECCM-20-107","url":null,"abstract":": Heatstroke is a life-threatening condition with high morbidity and mortality. Prompt recognition and institution of cooling measures has been shown to greatly improve outcomes. This is a case report demonstrating the use of a novel cooling suit (CarbonCool ® suit) in a case of exertional heatstroke (EHS). The CarbonCool ® suit is a half-body suit with cooling pads (MPad TM ) that are filled with a graphite water solution found to be 15 times more thermally conductive than ice. In this case report, a previously well 31-year-old male presented to the Emergency Department (ED) with EHS, subsequently requiring intubation. The CarbonCool ® suit was used to reduce his core (rectal) temperature from 41 ℃ to 38.7 ℃ in two hours. Patient’s core temperature subsequently normalized to 37 ℃ and he was discharged well and neurologically intact. The case report demonstrates that the suit can be easily worn and secured in place, while resuscitative measures are ongoing. This reduces the need for constant monitoring and replacement of ice packs, hence serving as a convenient alternative to ice packs for initial management of patients with EHS. While alternative cooling methods such as powered cooling devices may be utilized, these devices are often only available in the intensive care unit, with significantly higher operative costs. Use of the CarbonCool ® suit as an adjunct to other cooling methods may be a simple solution for rapid initiation of cooling in the patient with heatstroke.","PeriodicalId":73727,"journal":{"name":"Journal of emergency and critical care medicine (Hong Kong, China)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"42957905","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":"Theophylline toxicity: a case report of an unusual mimicker of septic shock","authors":"Rehman Jinah, Jerrold L Perrott, V. Dhingra","doi":"10.21037/jeccm-22-10","DOIUrl":"https://doi.org/10.21037/jeccm-22-10","url":null,"abstract":"","PeriodicalId":73727,"journal":{"name":"Journal of emergency and critical care medicine (Hong Kong, China)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"45208115","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":"Rescue veno-arterial extracorporeal membrane oxygenation in venlafaxine overdose: a case report","authors":"A. Felix, D. Campbell, M. Neavyn, P. Hackett","doi":"10.21037/jeccm-22-2","DOIUrl":"https://doi.org/10.21037/jeccm-22-2","url":null,"abstract":"","PeriodicalId":73727,"journal":{"name":"Journal of emergency and critical care medicine (Hong Kong, China)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"44083531","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}
Jenessa Lemon, Quinn Bohn, S. N. Sloan, Greg Stahl, Kerry Johnson, S. Goade, R. Arnce
{"title":"Sepsis and acute kidney failure outcomes investigated in a rural, Midwestern population","authors":"Jenessa Lemon, Quinn Bohn, S. N. Sloan, Greg Stahl, Kerry Johnson, S. Goade, R. Arnce","doi":"10.21037/jeccm-21-117","DOIUrl":"https://doi.org/10.21037/jeccm-21-117","url":null,"abstract":"","PeriodicalId":73727,"journal":{"name":"Journal of emergency and critical care medicine (Hong Kong, China)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41808870","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}
M. Dettmer, Michael D. Miller, Z. Jerusalem, Vase Bari, Gretchen L. Sacha, Alyssa Y. Chen, A. Duggal
{"title":"Delays in subsequent antibiotic dosing for septic patients undergoing early interhospital transfer","authors":"M. Dettmer, Michael D. Miller, Z. Jerusalem, Vase Bari, Gretchen L. Sacha, Alyssa Y. Chen, A. Duggal","doi":"10.21037/jeccm-21-100","DOIUrl":"https://doi.org/10.21037/jeccm-21-100","url":null,"abstract":"","PeriodicalId":73727,"journal":{"name":"Journal of emergency and critical care medicine (Hong Kong, China)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41525612","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}
Narindra N. M. Raza manjato, Andriamanantsialonina Andrianony, A. Rabemazava, H. Rakotovao
: Mediastinal impalement by a sharp object is both an extraordinary and fortunately exceptional situation. The cases are infrequently encountered and rarely report in literature because the majority of these patients die in pre-hospital care. In the literature, only a few cases have been published to date. A review of the literature reveals that most patients with mediastinal impalement do not survive or have an unpredictable injury pattern. In this presentation, the authors report a strange case of attempted homicide in the context of family vindictiveness with a sharp knife of a 58-year-old woman was reported. The surgical exploration was chosen, allowing good exposure of the object but no visceral or vascular lesions were observed. The marking hazard we encountered with this observation was that the innominate artery passed through the hole in the tail of the knife, which was already broken at the lower edge without causing any damage to the vessel. Perioperative management may involve multiple surgeons performing simultaneous surgical procedures. The removal of the intra-mediastinal knife is a delicate process that requires a careful etiopathogenic analysis of the victim and the intrathoracic impaled object to prevent other damages to the patient. The authors describe an unexpected non-fatal of penetrating intra-mediastinal injury and via a literature review, the tricks and tips of surgical management are discussed in a stable patient.
{"title":"A case report of rescue in extremis of mediastinal impalement: more fear than harm","authors":"Narindra N. M. Raza manjato, Andriamanantsialonina Andrianony, A. Rabemazava, H. Rakotovao","doi":"10.21037/JECCM-20-116","DOIUrl":"https://doi.org/10.21037/JECCM-20-116","url":null,"abstract":": Mediastinal impalement by a sharp object is both an extraordinary and fortunately exceptional situation. The cases are infrequently encountered and rarely report in literature because the majority of these patients die in pre-hospital care. In the literature, only a few cases have been published to date. A review of the literature reveals that most patients with mediastinal impalement do not survive or have an unpredictable injury pattern. In this presentation, the authors report a strange case of attempted homicide in the context of family vindictiveness with a sharp knife of a 58-year-old woman was reported. The surgical exploration was chosen, allowing good exposure of the object but no visceral or vascular lesions were observed. The marking hazard we encountered with this observation was that the innominate artery passed through the hole in the tail of the knife, which was already broken at the lower edge without causing any damage to the vessel. Perioperative management may involve multiple surgeons performing simultaneous surgical procedures. The removal of the intra-mediastinal knife is a delicate process that requires a careful etiopathogenic analysis of the victim and the intrathoracic impaled object to prevent other damages to the patient. The authors describe an unexpected non-fatal of penetrating intra-mediastinal injury and via a literature review, the tricks and tips of surgical management are discussed in a stable patient.","PeriodicalId":73727,"journal":{"name":"Journal of emergency and critical care medicine (Hong Kong, China)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"42397027","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}
Background: There is growing evidence that thiamine alone or in combination with vitamin C and steroids may have benefits in patients with sepsis. The purpose of this study is to evaluate the effects of intravenous thiamine following creation of an institutional thiamine guideline for sepsis. Methods: In this biphasic IRB-approved study, the pre-intervention group consisted of patients 18 years or older admitted to a critical care unit with sepsis/septic shock who received intravenous thiamine plus standard care (n=26). In the retrospective phase, they were matched with patients with the same diagnosis who served as a control group (n=26). The primary endpoint was hospital mortality. Secondary endpoints were time to death, critical care length of stay, time to lactate level <2 mmol/L, vasopressor use and duration, renal replacement therapy (RRT) requirement, and PaO 2 /FiO 2 ratio. An evidence-based thiamine guideline for sepsis, standardizing the dose, duration, and time of initiation, was developed and implemented. In the prospective phase, the post-intervention thiamine group was compared with both the pre-intervention thiamine and control groups measuring the same endpoints. Results: In the pre- and post-intervention phase, there was no difference in hospital mortality. However, more patients in the control group required RRT as compared to pre-intervention thiamine group (65.4% vs. 42.3%, P=0.013). The post-intervention thiamine group also showed decreased RRT requirement compared to the control group (36.8% vs. 65.4%, P=0.02). Conclusions: Thiamine did not show hospital mortality benefit. However, it may be considered for use in patients with renal dysfunction. Future studies should further explore renally-protective effects of thiamine.
{"title":"The effects of thiamine on patients with sepsis and septic shock","authors":"Yelena Sahakian, D. Dyakov","doi":"10.21037/jeccm-21-74","DOIUrl":"https://doi.org/10.21037/jeccm-21-74","url":null,"abstract":"Background: There is growing evidence that thiamine alone or in combination with vitamin C and steroids may have benefits in patients with sepsis. The purpose of this study is to evaluate the effects of intravenous thiamine following creation of an institutional thiamine guideline for sepsis. Methods: In this biphasic IRB-approved study, the pre-intervention group consisted of patients 18 years or older admitted to a critical care unit with sepsis/septic shock who received intravenous thiamine plus standard care (n=26). In the retrospective phase, they were matched with patients with the same diagnosis who served as a control group (n=26). The primary endpoint was hospital mortality. Secondary endpoints were time to death, critical care length of stay, time to lactate level <2 mmol/L, vasopressor use and duration, renal replacement therapy (RRT) requirement, and PaO 2 /FiO 2 ratio. An evidence-based thiamine guideline for sepsis, standardizing the dose, duration, and time of initiation, was developed and implemented. In the prospective phase, the post-intervention thiamine group was compared with both the pre-intervention thiamine and control groups measuring the same endpoints. Results: In the pre- and post-intervention phase, there was no difference in hospital mortality. However, more patients in the control group required RRT as compared to pre-intervention thiamine group (65.4% vs. 42.3%, P=0.013). The post-intervention thiamine group also showed decreased RRT requirement compared to the control group (36.8% vs. 65.4%, P=0.02). Conclusions: Thiamine did not show hospital mortality benefit. However, it may be considered for use in patients with renal dysfunction. Future studies should further explore renally-protective effects of thiamine.","PeriodicalId":73727,"journal":{"name":"Journal of emergency and critical care medicine (Hong Kong, China)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2021-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"45647877","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}
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