|
|
|
|
| A |
B |
C |
D |
E |
F |
G |
H |
I |
J |
K |
L |
M |
N |
O |
P |
Q |
R |
S |
T |
U |
V |
W |
X |
Y |
Z |
0 |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
| Pain • Holist Nurs Pract. 2005 September/October;19(5):217-221. |
| |
September 1, 2005 |
| Author / Title |
Use of Acupuncture for Chronic Pain: Optimizing Clinical Practice. / Eshkevari L, Heath J. |
| Abstract |
Increasingly, individuals are turning to complementary therapies to reduce or cope with chronic pain. Acupuncture, one of the oldest complementary therapies, originated from China more than 2500 years ago. It has steadily gained popularity in the United States over the last few decades as a modality for pain relief among both practitioners and patients. A 1997 National Institutes of Health consensus conference concluded that acupuncture needling releases endorphins and other neurotransmitters in the brain and should be considered as an appropriate pain treatment option. This article will provide an overview about acupuncture principles, discuss current clinical evidence, and identify acupuncture resources to optimize practice for chronic pain management. |
| Conclusion |
This article will provide an overview about acupuncture principles, discuss current clinical evidence, and identify acupuncture resources to optimize practice for chronic pain management. |
| Local |
Department of Anesthesia Pain Services, Georgetown University Hospital, and the Nurse Anesthesia Program (Ms Eshkevari), and the Acute Care Nurse Practitioner and Critical Care Clinical Nurse Specialist Program (Ms Heath), Georgetown University, School of Nursing and Health Studies, Washington, DC. |
| Web |
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16145331&query_hl=21 |
| xo |
| Pain • Health Technol Assess. 2005 Aug;9(32):1-126. |
| |
August 1, 2005 |
| Author / Title |
Longer term clinical and economic benefits of offering acupuncture care to patients with chronic low back pain. / Thomas KJ, Macpherson H, Ratcliffe J, Thorpe L, Brazier J, Campbell M, Fitter M, Roman M, Walters S, Nicholl JP. |
| Abstract |
OBJECTIVES: To test whether patients with persistent non-specific low back pain, when offered access to traditional acupuncture care alongside conventional primary care, gained more long-term relief from pain than those offered conventional care only, for equal or less cost. Safety and acceptability of acupuncture care to patients, and the heterogeneity of outcomes were also tested. DESIGN: A pragmatic, two parallel group, randomised controlled trial. Patients in the experimental arm were offered the option of referral to the acupuncture service comprising six acupuncturists. The control group received usual care from their general practitioner (GP). Eligible patients were randomised in a ratio of 2:1 to the offer of acupuncture to allow between-acupuncturist effects to be tested. SETTING: Three non-NHS acupuncture clinics, with referrals from 39 GPs working in 16 practices in York, UK. PARTICIPANTS: Patients aged 18-65 years with non-specific low back pain of 4-52 weeks' duration, assessed as suitable for primary care management by their general practitioner. INTERVENTIONS: The trial protocol allowed up to ten individualised acupuncture treatments per patient. The acupuncturist determined the content and the number of treatments according to patient need. MAIN OUTCOME MEASURES: The Short Form 36 (SF-36) Bodily Pain dimension (range 0-100 points), assessed at baseline, and 3, 12 and 24 months. The study was powered to detect a 10-point difference between groups at 12 months post-randomisation. Cost--utility analysis was conducted at 24 months using the EuroQoL 5 Dimensions (EQ-5D) and a preference-based single index measure derived from the SF-36 (SF-6D). Secondary outcomes included the McGill Present Pain Index (PPI), Oswestry Pain Disability Index (ODI), all other SF-36 dimensions, medication use, pain-free months in the past year, worry about back pain, satisfaction with care received, and safety and acceptability of acupuncture care. RESULTS: A total of 159 patients were in the 'acupuncture offer' arm and 80 in the 'usual care' arm. All 159 patients randomised to the offer of acupuncture care chose to receive acupuncture treatment, and received an average of eight acupuncture treatments within the trial. Analysis of covariance, adjusting for baseline score, found an intervention effect of 5.6 points on the SF-36 Pain dimension [95% confidence interval (CI) -1.3 to 12.5] in favour of the acupuncture group at 12 months, and 8 points (95% CI 0.7 to 15.3) at 24 months. No evidence of heterogeneity of effect was found for the different acupuncturists. Patients receiving acupuncture care did not report any serious or life-threatening events. No significant treatment effect was found for any of the SF-36 dimensions other than Pain, or for the PPI or the ODI. Patients receiving acupuncture care reported a significantly greater reduction in worry about their back pain at 12 and 24 months compared with the usual care group. At 24 months, the acupuncture care group was significantly more likely to report 12 months pain free and less likely to report the use of medication for pain relief. The acupuncture service was found to be cost-effective at 24 months; the estimated cost per quality-adjusted (QALY) was 4241 pounds sterling (95% CI 191 pounds sterling to 28,026 pounds sterling) using the SF-6D scoring algorithm based on responses to the SF-36, and 3598 pounds sterling (95% CI 189 pounds sterling to 22,035 pounds sterling) using the EQ-5D health status instrument. The NHS costs were greater in the acupuncture care group than in the usual care group. However, the additional resource use was less than the costs of the acupuncture treatment itself, suggesting that some usual care resource use was offset. CONCLUSIONS: Traditional acupuncture care delivered in a primary care setting was safe and acceptable to patients with non-specific low back pain. Acupuncture care and usual care were both associated with clinically significant improvement at 12- and 24-month follow-up. Acupuncture care was significantly more effective in reducing bodily pain than usual care at 24-month follow-up. No benefits relating to function or disability were identified. GP referral to a service providing traditional acupuncture care offers a cost-effective intervention for reducing low back pain over a 2-year period. Further research is needed to examine many aspects of this treatment including its impact compared with other possible short-term packages of care (such as massage, chiropractic or physiotherapy), various aspects of cost-effectiveness, value to patients and implementation protocols. |
| Conclusion |
Traditional acupuncture care delivered in a primary care setting was safe and acceptable to patients with non-specific low back pain. Acupuncture care and usual care were both associated with clinically significant improvement at 12- and 24-month follow-up. Acupuncture care was significantly more effective in reducing bodily pain than usual care at 24-month follow-up. No benefits relating to function or disability were identified. GP referral to a service providing traditional acupuncture care offers a cost-effective intervention for reducing low back pain over a 2-year period. Further research is needed to examine many aspects of this treatment including its impact compared with other possible short-term packages of care (such as massage, chiropractic or physiotherapy), various aspects of cost-effectiveness, value to patients and implementation protocols. |
| Local |
School of Health and Related Research (ScHARR), University of Sheffield, UK. |
| Web |
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16095547&query_hl=1 |
| xo |
| Pain • Eur J Pain. 2005 Aug 8 |
| |
August 1, 2005 |
| Author / Title |
Survey of chronic pain in Europe: Prevalence, impact on daily life, and treatment. / Breivik H, Collett B, Ventafridda V, Cohen R, Gallacher D. |
| Abstract |
This large scale computer-assisted telephone survey was undertaken to explore the prevalence, severity, treatment and impact of chronic pain in 15 European countries and Israel. Screening interviews identified respondents aged 18 years with chronic pain for in-depth interviews. 19% of 46,394 respondents willing to participate (refusal rate 46%) had suffered pain for 6 months, had experienced pain in the last month and several times during the last week. Their pain intensity was 5 on a 10-point Numeric Rating Scale (NRS) (1=no pain, 10=worst pain imaginable) during last episode of pain. In-depth interviews with 4839 respondents with chronic pain (about 300 per country) showed: 66% had moderate pain (NRS=5-7), 34% had severe pain (NRS=8-10), 46% had constant pain, 54% had intermittent pain. 59% had suffered with pain for two to 15 years, 21% had been diagnosed with depression because of their pain, 61% were less able or unable to work outside the home, 19% had lost their job and 13% had changed jobs because of their pain. 60% visited their doctor about their pain 2-9 times in the last six months. Only 2% were currently treated by a pain management specialist. One-third of the chronic pain sufferers were currently not being treated. Two-thirds used non-medication treatments, e.g,. massage (30%), physical therapy (21%), acupuncture (13%). Almost half were taking non-prescription analgesics; 'over the counter' (OTC) NSAIDs (55%), paracetamol (43%), weak opioids (13%). Two-thirds were taking prescription medicines: NSAIDs (44%), weak opioids (23%), paracetamol (18%), COX-2 inhibitors (1-36%), and strong opioids (5%). Forty percent had inadequate management of their pain. Interesting differences between countries were observed, possibly reflecting differences in cultural background and local traditions in managing chronic pain. Conclusions: Chronic pain of moderate to severe intensity occurs in 19% of adult Europeans, seriously affecting the quality of their social and working lives. Very few were managed by pain specialists and nearly half received inadequate pain management. Although differences were observed between the 16 countries, we have documented that chronic pain is a major health care problem in Europe that needs to be taken more seriously. |
| Conclusion |
Chronic pain of moderate to severe intensity occurs in 19% of adult Europeans, seriously affecting the quality of their social and working lives. Very few were managed by pain specialists and nearly half received inadequate pain management. Although differences were observed between the 16 countries, we have documented that chronic pain is a major health care problem in Europe that needs to be taken more seriously. |
| Local |
University of Oslo, Faculty of Medicine, Faculty Division Rikshospitalet, Department of Anaesthesiology, Rikshospitalet University Hospital, NO-0027 Oslo, Norway. |
| Web |
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16095934&query_hl=1 |
| xo |
| Pain • J Fam Pract. 2005 Jul;54(7):599-603. |
| |
July 1, 2005 |
| Author / Title |
Complex regional pain syndrome: which treatments show promise? / Quisel A, Gill JM, Witherell P. |
| Abstract |
Treatments for CRPS type 1 supported by evidence of efficacy and little likelihood for harm are: topical DMSO cream (B), IV bisphosphonates (A) and limited courses of oral corticosteroids (B). Despite some contradictory evidence, physical therapy and calcitonin (intranasal or intramuscular) are likely to benefit patients with CRPS type 1 (B). Due to modest benefits and the invasiveness of the therapies, epidural clonidine injection, intravenous regional sympathetic block with bretylium and spinal cord stimulation should be offered only after careful counseling (B). Therapies to avoid due to lack of efficacy, lack of evidence, or a high likelihood of adverse outcomes are IV regional sympathetic blocks with anything but bretylium, sympathetic ganglion blocks with local anesthetics, systemic IV sympathetic inhibition, acupuncture, and sympathectomy (B). |
| Conclusion |
Therapies to avoid due to lack of efficacy, lack of evidence, or a high likelihood of adverse outcomes are IV regional sympathetic blocks with anything but bretylium, sympathetic ganglion blocks with local anesthetics, systemic IV sympathetic inhibition, acupuncture, and sympathectomy (B). |
| Local |
Family Medicine Center, 1401 Foulk Road, Wilmington, DE 19803, USA. |
| Web |
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16009087&query_hl=5 |
| xo |
| Pain • Taehan Kanho Hakhoe Chi. 2005 Jun;35(3):487-93. |
| |
June 1, 2005 |
| Author / Title |
The effects of hand-acupuncture therapy on intermittent abdominal pain in children / Hong YR. |
| Abstract |
PURPOSE: The purpose of this study was to identify the effects of hand acupuncture therapy on intermittent abdominal pain in children. METHOD: A quasi experimental pre-test and post (1,2)-test design was used. Data was collected from May, 2002 to February, 2003. Forty children were assigned to the experimental (20) or control group (20). The experimental group received Hand-Acupuncture therapy on the meridian point; A8, A9, A10, A11, A12, E22, E45 for 20 minutes, while the control group rested on the bed. Data was analyzed using the SAS program with Fisher's Exact chi (2) test, repeated measured ANOVA, and ANCOVA. RESULT: In the experimental group, pain intensity (f=63.26, p=0.00), A12(A)(F=60.40, p=0.00), and medication requirement (chi (2)=32.63, p=0.00) were significantly lower than that of the control group. CONCLUSION: These findings indicate that hand acupuncture therapy is effective for reduction of intermittent abdominal pain. Therefore, hand acupuncture therapy can be considered an independent nursing intervention for reducing intermittent abdominal pain. |
| Conclusion |
These findings indicate that hand acupuncture therapy is effective for reduction of intermittent abdominal pain. Therefore, hand acupuncture therapy can be considered an independent nursing intervention for reducing intermittent abdominal pain. |
| Local |
Department of nursing, Chodang University, Korea. |
| Web |
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16027500&query_hl=1 |
| xo |
| Pain • Acupunct Med. 2005 Jun;23(2):83-5. |
| |
June 1, 2005 |
| Author / Title |
Acupuncture for acute postoperative pain relief in a patient with pregnancy-induced thrombocytopenia--a case report. / Oomman S, Liu D, Cummings M. |
| Abstract |
A 39 year old woman, scheduled for elective caesarean section in her second pregnancy, developed thrombocytopenia. Therefore, at the time of surgery, spinal anaesthesia and non-steroidal analgesic drugs were avoided and she was given a standard general anaesthetic procedure including fentanyl 100 microg and morphine 10 mg. In the early postoperative period she received tramadol 100 mg and a further 10 mg of morphine. These drugs did not control her pain, but caused side effects--in particular nausea and retching. Acupuncture to LI4 and PC6 on the right side produced dramatic pain relief within minutes. |
| Conclusion |
Acupuncture to LI4 and PC6 on the right side produced dramatic pain relief within minutes. |
| Local |
|
| Web |
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=16025789&query_hl=1 |
| xo |
| Pain • Acupunct Med. 2004 Dec;22(4):189-202. |
| |
December 1, 2004 |
| Author / Title |
Low back pain assessment for the medical acupuncturist. / Cummings M. |
| Abstract |
Low back pain frequently presents to medical acupuncturists, many of whom are general practitioners working in the public sector. Under these circumstances there is often limited time to devote to an initial assessment of a patient's presenting complaint. This paper presents an assessment process that is aimed at informing management decisions for medical acupuncturists, although much of the process may be useful to a wider range of practitioners. The assessment is divided into an initial screening procedure, and a further more detailed assessment. The initial screening procedure can usefully be applied in a brief consultation. Using this assessment tool, practitioners with medical acupuncture training will be able to select the cases most likely to be helped by their acupuncture skills. |
| Conclusion |
Using this assessment tool, practitioners with medical acupuncture training will be able to select the cases most likely to be helped by their acupuncture skills. |
| Local |
|
| Web |
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15628776&query_hl=5 |
| xo |
| Pain • Clin J Pain. 2003 Nov-Dec;19(6):364-70. |
| |
November 1, 2003 |
| Author / Title |
Acupuncture in the management of chronic low back pain: a blinded randomized controlled trial. / Kerr DP, Walsh DM, Baxter D. |
| Abstract |
OBJECTIVE: To assess the efficacy of acupuncture in the treatment of chronic low back pain. METHODS: Patients (n = 60) with chronic low back pain were recruited and randomly allocated to either Acupuncture therapy or Placebo transcutaneous electrical nerve stimulation (TENS) groups. Patients were treated weekly for 6 weeks, and blinded assessments were carried out pre- and post-treatment using the McGill Pain Questionnaire (MPQ) and visual analog scales (VAS) for pain, the Short-form 36 quality-of-life questionnaire, and a simple range of motion measurement. A total of 46 patients completed the trial and were followed up at 6 months. RESULTS: Analysis of results using t tests showed that in both groups there were significant pre-post improvements for all scores, except for MPQ scores in the Placebo-TENS group. There was no significant difference between the 2 groups for any of the outcome measures at the end of treatment. Results from the 6-month follow-up would suggest that the response was better in the acupuncture group. DISCUSSION: Further research is necessary to fully assess the efficacy of this treatment in combating chronic low back pain using larger sample sizes or alternative control groups. |
| Conclusion |
Further research is necessary to fully assess the efficacy of this treatment in combating chronic low back pain using larger sample sizes or alternative control groups. |
| Local |
Rehabilatation Sciences Research Group, School of Rehabilitation Sciences, University of Ulser at Jordanstown, County Antrim, Northern Ireland. |
| Web |
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14600536&query_hl=7 |
| xo |
| Pain • Spine J. 2003 Nov-Dec;3(6):442-50. |
| |
November 1, 2003 |
| Author / Title |
Compliance with clinical practice guidelines in family physicians managing worker's compensation board patients with acute lower back pain. / Bishop PB, Wing PC. |
| Abstract |
BACKGROUND CONTEXT: Family physician compliance with acute lower back pain clinical practice guidelines remains uncertain. PURPOSE: To determine the degree of guideline compliance of family physicians managing patients with workers' compensation claims and acute mechanical lower back pain. STUDY DESIGN: Observational study. PATIENT SAMPLE: One hundred thirty-nine family physicians in British Columbia. OUTCOME MEASURES: Compliance with guideline recommendations for history, examination procedures, diagnostic testing and treatments. METHODS: Physician workers' compensation board patient reports for acute lower back pain without leg symptoms and not greater than 2 to 3 weeks duration were scored for guideline adherence up until 12 weeks after onset. RESULTS: Physicians demonstrated a high degree of compliance with the guideline-recommended history, examination procedures and medications, but low compliance with recommended imaging and many treatment recommendations. CONCLUSIONS: Recently published clinical practice guidelines regarding the management of patients with acute mechanical lower back pain have not been fully implemented into the patterns of practice of the family physicians. |
| Conclusion |
Recently published clinical practice guidelines regarding the management of patients with acute mechanical lower back pain have not been fully implemented into the patterns of practice of the family physicians. |
| Local |
Combined Neurosurgical and Orthopaedic Spine Program, Heather Pavilion, Vancouver General Hospital, Vancouver, BC, Canada. |
| Web |
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14609688&query_hl=1 |
| xo |
| Pain • Lakartidningen. 2002 Nov 7;99(45):4484-9. |
| |
November 1, 2002 |
| Author / Title |
Physical activity can influence the course of early arthritis. Both strength training and aerobic exercise provide pain relief and functional improvement / Roos E. |
| Abstract |
There is no causal treatment for osteoarthritis. Instead treatment is aimed at decreasing pain and improving function. The base of osteoarthritis treatment is education and exercise. Exercise, both aerobic exercise and muscular strength training, have positive effects on pain and function. The minimum recommendations of exercise are equivalent to the recommendations of physical activity to obtain or maintain a good general health. Acupuncture is a safe and effective treatment for osteoarthritis pain. However, function is not automatically improved when pain is relieved. |
| Conclusion |
Acupuncture is a safe and effective treatment for osteoarthritis pain. However, function is not automatically improved when pain is relieved. |
| Local |
Avdelningen for ortopedi, institutionen for rorelseorganens sjukdomar, Universitetssjukhuset, Lund. |
| Web |
cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12469527&query_hl=1 |
| xo |
| Pain • Pain. 2000 May;86(1-2):119-32. |
| |
May 1, 2000 |
| Author / Title |
Teasing apart quality and validity in systematic reviews: an example from acupuncture trials in chronic neck and back pain. / Smith LA, Oldman AD, McQuay HJ, Moore RA. |
| Abstract |
The objectives of the study were (1) to carry out a systematic review to assess the analgesic efficacy and the adverse effects of acupuncture compared with placebo for back and neck pain and (2) to develop a new tool, the Oxford Pain Validity Scale (OPVS), to measure validity of findings from randomized controlled trials (RCTs), and to enable ranking of trial findings according to validity within qualitative reviews. Published RCTs (of acupuncture at both traditional and non-traditional points) were identified from systematic searching of bibliographic databases (e.g. MEDLINE) and reference lists of retrieved reports. Pain outcome data were extracted with preference given to standardized outcomes such as pain intensity. Information on adverse effects was also extracted. All included trials were scored using a five-item 0-16 point validity scale (OPVS). The individual RCTs were ranked according to their OPVS score to enable more weight to be placed on the trials of greater validity when drawing an overall conclusion about the efficacy of acupuncture for relieving neck and back pain. Statistical analyses were carried out on the OPVS scores to assess the relationship between trial finding (positive or negative) and validity. Thirteen RCTs met the inclusion criteria. Five trials concluded that acupuncture was effective, and eight concluded that it was not effective for relieving back or neck pain. There was no obvious difference between the findings of trials using traditional and non-traditional points. Using the new OPVS scale, the validity scores of the included trials ranged from 4 to 14. There was no significant relationship between OPVS score and trial finding (positive versus negative). Authors' conclusions did not always agree with their data. We drew our own conclusions (positive/negative) based on the data presented in the reports. Re-analysis using our conclusions showed a significant relationship between OPVS score and trial finding, with higher validity scores associated with negative findings. OPVS is a useful tool for assessing the validity of trials in qualitative reviews. With acupuncture for chronic back and neck pain, we found that the most valid trials tended to be negative. There is no convincing evidence for the analgesic efficacy of acupuncture for back or neck pain. |
| Conclusion |
With acupuncture for chronic back and neck pain, we found that the most valid trials tended to be negative. There is no convincing evidence for the analgesic efficacy of acupuncture for back or neck pain. |
| Local |
Pain Research, Nuffield Department of Anaesthetics, University of Oxford, The Churchill, Oxford Radcliffe Hospital, Headington, UK. |
| Web |
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=10779669&query_hl=7 |
| xo |
| Pain • Neurol Res. 2004 Oct;26(7):797-800. |
| |
|
| Author / Title |
Objectivation of cerebral effects with a new continuous electrical auricular stimulation technique for pain management. / Szeles JC, Litscher G. |
| Abstract |
AIMS: The electrical point stimulation system (P-STIM) reflects a new, miniaturized system for pain therapy through ear acupuncture. For this reason, ultrathin needles were applied at the ear. The needles stimulate the acupuncture areas at the ear using electrical impulses, which come from a little generator applied behind the acupunctured ear. METHODS: This study describes continuous, non-invasive measurements of near infrared spectroscopy (NIRS) and multidirectional transcranial Doppler sonography in two healthy females (aged 23 and 27 years) during stimulation with P-STIM, for the first time. RESULTS: The results of the pilot measurements have shown that electrical point stimulation using the new electrical stimulation system on eye acupuncture points is able to modulate the mean blood flow velocity (vm) of the supratrochlear artery. These effects were present using a stimulation frequency of 100 Hz. A lower increase in vm was found in the middle cerebral artery. In addition, stimulus induced, quantifiable and reproducible alterations of the regional cerebral NIRS parameters were be detected. CONCLUSION: For the first time, P-Stim allows intermittent ear acupuncture stimulation for up to several days in combination with complete mobility for the patient. |
| Conclusion |
The results of the pilot measurements have shown that electrical point stimulation using the new electrical stimulation system on eye acupuncture points is able to modulate the mean blood flow velocity (vm) of the supratrochlear artery. These effects were present using a stimulation frequency of 100 Hz. A lower increase in vm was found in the middle cerebral artery. In addition, stimulus induced, quantifiable and reproducible alterations of the regional cerebral NIRS parameters were be detected. CONCLUSION: For the first time, P-Stim allows intermittent ear acupuncture stimulation for up to several days in combination with complete mobility for the patient. |
| Local |
Department of Vascular Surgery, Medical University of Vienna, Austria |
| Web |
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15494125&query_hl=28 |
| xo |
|
| |
|
