Medical Acupuncture最新文献

{"title":"Effect of Spinal Cord Response on Changes in Pain Thresholds of Each Tissue Due to Electroacupuncture.","authors":"Miho Oba, Shingo Saito, Kazunori Itoh","doi":"10.1089/acu.2023.0108","DOIUrl":"10.1089/acu.2023.0108","url":null,"abstract":"<p><strong>Background: </strong>Acupuncture enhances the endogenous analgesic system and reduces pain. However, its effect is not constant, and it has been reported that it varies depending on the endogenous analgesic system and spinal cord response. Therefore, we investigated whether there was a difference in the changes in pain thresholds in muscle and skin tissue due to differences in the spinal cord response when electroacupuncture was applied to healthy participants whose endogenous analgesic system works normally.</p><p><strong>Methods: </strong>We included 29 healthy volunteers who gave consent to participate. The participants underwent psychological evaluations, pain thresholds assessment for muscle and skin tissue, temporal summation of pain (TSP), and conditioned pain modulation (CPM). The participants subsequently received 30 min of acupuncture (scalp + three limbs) as an intervention, and the pain thresholds of muscle and skin tissue were measured before, 30 and 60 min after intervention. Note that participants were grouped by TSP based on high and low spinal cord response.</p><p><strong>Results: </strong>Analysis of participants grouped by spinal cord response showed no difference in CPM between high and low groups prior to the intervention, indicating that the endogenous analgesic systems were the same for the two groups. However, electroacupuncture intervention affected changes in muscle pain threshold (<i>p</i> = 0.03). A significant difference in pain threshold was noted in the high group, 60 min after intervention (<i>p</i> = 0.04).</p><p><strong>Conclusion: </strong>When electroacupuncture is applied to healthy participants, those with higher spinal cord response may have higher muscle pain threshold.</p>","PeriodicalId":45511,"journal":{"name":"Medical Acupuncture","volume":"37 3","pages":"231-238"},"PeriodicalIF":1.1,"publicationDate":"2025-06-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12179354/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144477236","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":"Structure-Based Medical Acupuncture: New Perspective on an Ancient Technique.","authors":"Chi-Tsai Tang, Ling Guan","doi":"10.1089/acu.2024.0125","DOIUrl":"10.1089/acu.2024.0125","url":null,"abstract":"<p><p>With more recent research into the neuromyofascial system, one can begin to surmise how acupuncture may work through modulating nerves, muscles, and fascia. Pain relief from acupuncture is thought to involve the release of endogenous opioids and monoamines. Various different peripheral nerves are stimulated with acupuncture, and there are also specific effects on the brain that can be seen on functional magnetic resonance imaging. Acupuncture has long been used to treat muscular pain from trigger points, and there is now research that can objectively quantify these trigger points. Needling therapies have been shown to improve trigger point status and improve patients' pain and function. Fascia is an often overlooked structure that can contribute to pain and various other symptoms. Fascia is a multilayered structure that interpenetrates and surrounds muscles, bones, nerves, and blood vessels, binding all of these together, and acupuncture has been shown to have specific effects on the fascia. There is evidence for the existence of myofascial meridians that span the body where separate muscles are mechanically linked through the fascia. Structure-based medical acupuncture (SMA) is based on the idea that the targets for acupuncture treatment are actual structures. Some meridians are myofascial meridians such as the Bladder (BL) and Gallbladder (GB) meridian, whereas others may be blood vessels or nerves, such as the Lung (LU) and Pericardium (PC) meridians, respectively. SMA was developed in China but utilizes both ancient and modern, Chinese and Western medicine concepts and understandings of human structure. Principles include that anatomy is foundational, manual manipulation is essential, tools (the needle) are an extension of the hand, and exercise and rehabilitation are the ways to prevent recurrences and maintain efficacy. SMA differs from more traditional TCM acupuncture in that imaging and physical exams are used to guide treatment, immediate pain relief is expected after treatment, and fewer treatment sessions are typically needed.</p>","PeriodicalId":45511,"journal":{"name":"Medical Acupuncture","volume":"37 3","pages":"176-181"},"PeriodicalIF":1.1,"publicationDate":"2025-06-11","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12179381/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144477241","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":"Observational Cross-Sectional Study with Guatemalan Lay Midwives About Acupressure Use for Preeclampsia.","authors":"Lisa J Taylor-Swanson, Cheryl Armstrong, Jill Johnson, Eli Iacob, Claudia Citkovitz, Zena Kocher, Kayla Madsen, Emily Flynn, Ashlee Taft Nelson, Wen Tu, Caroline Howell, Kimberly Garcia","doi":"10.1089/acu.2024.0190","DOIUrl":"10.1089/acu.2024.0190","url":null,"abstract":"<p><strong>Introduction: </strong>Preeclampsia is the second leading cause of maternal death in Guatemala, where the maternal mortality rate (MMR) is second highest in Central America. Lay midwives (LMs), who attend most births in their country at home, are forbidden from providing biomedicine to treat disorders, such as preeclampsia. Acupressure, which has been shown to decrease blood pressure, is a promising treatment LMs could offer while transferring hypertensive patients to hospitals, particularly in the remote Peten Department where this study took place.</p><p><strong>Materials and methods: </strong>Educational sessions regarding preeclampsia were held in 11 locations. A total of 179 LMs who participated in the educational sessions were taught six acupressure points to address preeclampsia and given laminated Reminder Cards with culturally appropriate drawings of the acupressure points to reinforce knowledge retention.</p><p><strong>Results: </strong>Participants experienced a significant increase in knowledge (possible 0-6) from pre-test (M = 0, SD = 0) to post-test (M = 4.29, SD = 1.722), paired <i>t</i>-test <i>p</i> < 0.001. No participants were aware of any acupressure sites on the pre-test (0%) compared with >71% who identified at least one site on the post-test.</p><p><strong>Discussion: </strong>Given no participants knew acupressure sites to address preeclampsia before the educational sessions, a change in knowledge is not surprising, yet significant. Providing these well-respected community leaders with tools, such as acupressure, to address preeclampsia could help reduce Guatemala's MMR. Educating LMs about acupressure points to treat other pregnancy-related issues, such as encouraging and discouraging labor, turning breech babies, treating back and labor pain, and nausea and vomiting, would expand the care pregnant patients receive, particularly in remote areas.</p>","PeriodicalId":45511,"journal":{"name":"Medical Acupuncture","volume":"38 3","pages":"211-218"},"PeriodicalIF":1.1,"publicationDate":"2025-05-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13158480/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"147934311","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":"Pines and Needles: Experience of an Acupuncture Practice at an Academic Medical Center in Rural New England.","authors":"James E Stahl","doi":"10.1089/acu.2025.0009","DOIUrl":"10.1089/acu.2025.0009","url":null,"abstract":"<p><strong>Objective: </strong>To report on our experience treating patients in an academic medical acupuncture practice in a rural setting and set the stage for future research.</p><p><strong>Methods: </strong>Our healthcare systems electronic medical record was queried for all patients seen in the general internal medicine clinic for acupuncture since the service was first offered. Data on demographics, medical diagnoses were extracted and anonymized. Diagnoses were grouped by their ICD-10 codes. Zip code was collected to help ask the question whether distance or socioeconomic and education status had an impact on use of this service. Data was analyzed using standard descriptive and analytics methods.</p><p><strong>Results: </strong>A total of 200 patients over a 7 year period for a total of 1534 visits. Average number of visits was 7.75, age 66 yrs old and were 63.8 % female. The majority of patients terminal degree was High School, had a median income of $82 K and the and a median distance travel of 34 miles. The lower the terminal degree the greater distance travelled. The top three diagnostic categories were musculoskeletal, mental health and neurologic. Pain was the secondary complaint in 27.4% of cases.</p><p><strong>Conclusions: </strong>Acupuncture appears to be an acceptable therapeutic option for rural patients. This is evidenced by the willingness-to-travel, the broad range of problems being addressed and the wide socioeconomic profile taking advantage of the service.</p>","PeriodicalId":45511,"journal":{"name":"Medical Acupuncture","volume":"38 4","pages":"277-283"},"PeriodicalIF":1.1,"publicationDate":"2025-05-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC13329023/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"148392083","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":"Integrating Medical and Traditional Acupuncture Education in the United States: Enhancing Patient Care Through Combined Expertise.","authors":"Weidong Lu","doi":"10.1089/acu.2024.0140","DOIUrl":"10.1089/acu.2024.0140","url":null,"abstract":"<p><strong>Background: </strong>In the United States, acupuncture education is divided into two primary pathways: medical acupuncture for licensed physicians and traditional acupuncture rooted in Traditional Chinese Medicine (TCM) for nonphysician practitioners. These pathways reflect the distinct educational needs and historical development of acupuncture in the United States.</p><p><strong>Objective: </strong>To compare medical and traditional acupuncture educational systems, highlighting their strengths, weaknesses, and the potential for integration to enhance patient care.</p><p><strong>Methods: </strong>This narrative review utilized comprehensive literature searches, analyzing peer-reviewed articles, institutional reports, and accreditation documents. The study focused on programs approved by the American Academy of Medical Acupuncture and accredited by the Accreditation Commission for Acupuncture and Herbal Medicine.</p><p><strong>Results: </strong>Medical acupuncture programs are shorter and emphasize evidence-based practice, allowing physicians to integrate acupuncture into conventional medical treatment. These programs focus on Western medical terminology and concepts but may lack depth in TCM principles. Traditional acupuncture programs offer extensive training in TCM principles and practices, including herbal medicine, with comprehensive clinical training but may lack emphasis on modern medical science and research-based evidence. There is a significant workforce disparity between licensed traditional acupuncturists and the much smaller number of medical acupuncturists in practice.</p><p><strong>Conclusions: </strong>Integrating both educational pathways can enhance patient care through comprehensive treatment approaches. Successful integration examples demonstrate improved patient outcomes. Future efforts should focus on developing joint training programs, promoting research collaboration, and increasing hospital-based internships to foster interdisciplinary learning and practice.</p>","PeriodicalId":45511,"journal":{"name":"Medical Acupuncture","volume":"37 2","pages":"112-123"},"PeriodicalIF":1.1,"publicationDate":"2025-04-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12038309/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"143986979","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":"TCM Academy-Online Platform for Acupuncture and Traditional Chinese Medicine Education: Advancing Global Standards.","authors":"Yair Maimon, Guy Traiber","doi":"10.1089/acu.2024.0122","DOIUrl":"10.1089/acu.2024.0122","url":null,"abstract":"<p><strong>Objective: </strong>This article presents the educational strategies and global impact of the TCM Academy (TCMA), an online platform established to advance global standards in Acupuncture and Traditional Chinese Medicine (TCM) education.</p><p><strong>Methods: </strong>TCMA integrates evidence-based pedagogy, a multidisciplinary teaching team, and innovative e-learning techniques-including video chunking, interactive quizzes, and worksheets. The curriculum is built upon three pillars: Western medicine, Chinese medicine, and evidence-based research. Specialized certificate programs, such as Oncology and Pediatric Acupuncture, are delivered via recorded lectures, live webinars, and real-time assessments. The platform utilizes technology to track learner progress and enhance engagement and retention.</p><p><strong>Results: </strong>Since its launch, TCMA has collaborated with over 100 international experts, offering more than 1200 hours of online content. Its Oncology Acupuncture program has graduated over 700 students worldwide, including medical doctors and TCM practitioners. The annual international oncology symposium draws more than 1,300 participants. Feedback indicates improved practitioner confidence, knowledge retention, and clinical application. Tools to support motivation, time management, and accessibility have mitigated common challenges in online education, fostering an inclusive learning environment across six continents.</p><p><strong>Conclusion: </strong>TCMA demonstrates that high-quality, scalable online education in TCM is achievable and impactful. Its model supports and advances global standardization of acupuncture training, enhances clinical practice, and fosters a collaborative international community. The platform serves as a benchmark for future online integrative medical education, combining technological innovation with clinical depth to shape the future of TCM and integrative healthcare.</p>","PeriodicalId":45511,"journal":{"name":"Medical Acupuncture","volume":"37 2","pages":"96-99"},"PeriodicalIF":1.1,"publicationDate":"2025-04-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12038351/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144045141","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":"Clinical Training in Acupuncture Schools-From Virginia University of Integrative Medicine to International Perspectives.","authors":"Lixing Lao, Yaron Cohen, John Yoo","doi":"10.1089/acu.2024.0104","DOIUrl":"10.1089/acu.2024.0104","url":null,"abstract":"<p><strong>Background: </strong>Acupuncture is widely practiced globally, with significant variations in the length and quality of clinical training across different countries and regions.</p><p><strong>Methods: </strong>This article examines the acupuncture program at the Virginia University of Integrative Medicine to illustrate typical training in the United States. It also compares acupuncture training in mainland China and Hong Kong.</p><p><strong>Results: </strong>By identifying the strengths and weaknesses of these programs, this study aims to propose strategies to enhance the quality of acupuncture education.</p><p><strong>Conclusion: </strong>It is essential for US acupuncture schools to collaborate closely with hospitals and medical schools to improve acupuncture education and training.</p>","PeriodicalId":45511,"journal":{"name":"Medical Acupuncture","volume":"37 2","pages":"92-95"},"PeriodicalIF":0.9,"publicationDate":"2025-04-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12038354/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144023865","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":"Education of Acupuncture-Moxibustion and Tuina in Nanjing University of Chinese Medicine.","authors":"Jinhong Yuan, Yunchuan Wu","doi":"10.1089/acu.2024.0121","DOIUrl":"10.1089/acu.2024.0121","url":null,"abstract":"<p><strong>Background: </strong>In contemporary China, acupuncture and moxibustion education is a part of higher education. A complete system of acupuncture education has been established.</p><p><strong>Methods: </strong>This article provides a detailed account of the curriculum system, teaching mode, practical requirements, the path to obtaining the qualification of a practicing physician, employment situation, and the challenges faced by acupuncture education in the Acupuncture and Moxibustion and Tuina major at Nanjing University of Chinese Medicine.</p><p><strong>Result: </strong>The Acupuncture and Moxibustion and Tuina major at Nanjing University of Chinese Medicine covers both university degree education (including international education) and non-degree education. The teaching mode includes both online and offline teaching. The majority of acupuncture and moxibustion practitioners have undergone rigorous and systematic university training, obtained a university diploma, and passed the examination for practicing Chinese medicine physicians to become licensed acupuncturists. Academic groups of acupuncture regularly hold various forms of continuing education and exchanges in acupuncture. Participation in continuing education is a necessary condition for practitioners to renew their licenses and also provides learning opportunities for non-degree education enthusiasts of acupuncture.</p><p><strong>Conclusions: </strong>Taking Nanjing University of Chinese Medicine as an example, the acupuncture education system in China ensures the educational quality and high-level development trend of the acupuncture profession and is also an important participant in the global exchange of acupuncture.</p>","PeriodicalId":45511,"journal":{"name":"Medical Acupuncture","volume":"37 2","pages":"132-138"},"PeriodicalIF":1.1,"publicationDate":"2025-04-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12038305/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144057359","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":"Challenges and Issues in Acupuncture Education in Malaysia.","authors":"Yun Jin Kim","doi":"10.1089/acu.2024.0096","DOIUrl":"10.1089/acu.2024.0096","url":null,"abstract":"<p><strong>Background: </strong>Acupuncture, a traditional Chinese medicine (TCM) practice, has become globally recognized as a complementary therapeutic approach for various health conditions. In Malaysia, acupuncture occupies a significant role in the country's diverse healthcare system, reflecting its cultural heritage. However, the education and training of acupuncture practitioners face numerous challenges, including variability in educational approaches, accreditation, and integration with conventional medical practices.</p><p><strong>Objective: </strong>This article aims to explore the complexities of acupuncture education in Malaysia, providing an overview of the current landscape. It addresses the regulatory frameworks, educational challenges, and the implications these have on professional standards and patient care. The article also highlights potential solutions for improving acupuncture education in the country.</p><p><strong>Methods: </strong>A comprehensive review of existing literature, regulatory frameworks, and educational practices related to acupuncture in Malaysia is presented. The article examines the variability in training programs, accreditation standards, and the integration of acupuncture with conventional healthcare models.</p><p><strong>Results: </strong>The education and training of acupuncture practitioners in Malaysia are hindered by inconsistent curricula, lack of standardized guidelines, and differing levels of accreditation. These challenges contribute to variations in educational quality across institutions, complicating efforts to ensure competent practitioners. Furthermore, acupuncture's integration with mainstream medical practices remains unclear, affecting its overall acceptance and effectiveness within the broader healthcare system.</p><p><strong>Conclusion: </strong>Addressing the challenges in acupuncture education is crucial for enhancing the competence of practitioners and ensuring quality patient care. Key areas for improvement include the standardization of curricula, strengthening accreditation processes, promoting interdisciplinary collaboration, and increasing public awareness. Proactive efforts in these areas can enhance the quality of acupuncture education in Malaysia and foster better integration of acupuncture into the national healthcare framework.</p>","PeriodicalId":45511,"journal":{"name":"Medical Acupuncture","volume":"37 2","pages":"127-131"},"PeriodicalIF":1.1,"publicationDate":"2025-04-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12038326/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144041233","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":"Acupuncture Education for Nonphysician Practitioners in the UK: An Overview.","authors":"Vivien Shaw, Nina Paterson, Felicity Moir","doi":"10.1089/acu.2024.0133","DOIUrl":"10.1089/acu.2024.0133","url":null,"abstract":"<p><strong>Background: </strong>Acupuncture is not regulated in the United Kingdom, and in this review article, we look at how voluntary regulation, predicated on accredited degree-level acupuncture courses, is structured for professional nonphysician acupuncturists. These are practitioners for whom acupuncture is their primary mode of treatment, and who do not have an additional medical qualification.</p><p><strong>Overview of education: </strong>We describe how acupuncture education is set up and accredited, at the common syllabus shared by accredited acupuncture colleges, and how best teaching practices are employed.</p><p><strong>Regulation: </strong>Patient safety is an essential component of any healthcare training program, and we explore how professional acupuncturists meet the same standards required of other healthcare professionals through registration with the UK government Professional Standards Authority. There are also a number of nonaccredited courses available within the United Kingdom that do not meet this standard, and we explain how a patient can ensure that they find an appropriately qualified practitioner.</p><p><strong>Impact beyond the uk: </strong>The voluntary accreditation system that underpins the high-level college education available in the United Kingdom also makes it possible for there to be reciprocal agreements with organisations globally, such as the National Certification Commission for Acupuncture and Oriental Medicine in the United States. These reciprocal agreements allow students from around the world to come to the United Kingdom to train, knowing that their qualifications will be recognized in their home country.</p>","PeriodicalId":45511,"journal":{"name":"Medical Acupuncture","volume":"37 2","pages":"100-105"},"PeriodicalIF":1.1,"publicationDate":"2025-04-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC12038304/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"144029604","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}