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| Les deux révisions précédentes Révision précédente Prochaine révision | Révision précédente | ||
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acupuncture:evaluation:oncologie:03. douleur en oncologie [29 Dec 2023 08:08] Nguyen Johan [2.2. Zhang 2023] |
acupuncture:evaluation:oncologie:03. douleur en oncologie [28 Aug 2025 18:57] (Version actuelle) Nguyen Johan [1.1.1. Li 2025] |
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| ===== Systematic Reviews and Meta-Analysis ===== | ===== Systematic Reviews and Meta-Analysis ===== | ||
| - | ** GRADE certainty of evidence** \\ | ||
| - | |⊕⊕⊕⊕|High|The authors have a lot of confidence that the true effect is similar to the estimated effect | | ||
| - | |⊕⊕⊕⊖|Moderate |The authors believe that the true effect is probably close to the estimated effect| | ||
| - | |⊕⊕⊖⊖|Low|The true effect might be markedly different from the estimated effect| | ||
| - | |⊕⊖⊖⊖|Very low| The true effect is probably markedly different from the estimated effect| | ||
| - | If no GRADE, GERA indicative score | ||
| - | | ☆☆☆ | Evidence for effectiveness and a specific effect of acupuncture | | ||
| - | | ☆☆ | Evidence for effectiveness of acupuncture | | ||
| - | | ☆ |Limited evidence for effectiveness of acupuncture | | ||
| - | | Ø |No evidence or insufficient evidence | | ||
| ==== Generic Acupuncture ==== | ==== Generic Acupuncture ==== | ||
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| + | === Li 2025 === | ||
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| + | Li Y, Li B, Cui Y, Yang X, Wang S, Wang X, Li M, Tu Y, Jing A, Zhou Y, Luo M. Acupuncture for chronic cancer pain: a systematic review and meta-analysis. Eur J Integr Med. 2025;77:102493. https://doi.org/10.1016/j.eujim.2025.102493 | ||
| + | ^Introduction|Pain is highly prevalent among cancer patients. Cancer pain is classified as chronic cancer pain (MG30.10) and chronic post-cancer treatment pain (MG30.11) in the International Classification of Diseases, 11th Revision (ICD-11). This research aims to ascertain the efficacy and safety of acupuncture in treating chronic cancer pain (MG30.10). | | ||
| + | ^Methods|Eight Chinese and English databases were systematically searched from their inception to December 31, 2024, to identify randomized controlled trials (RCTs) that examined the efficacy of acupuncture in combination with active treatments versus active treatment alone (identical to the treatment group), no treatment, or sham acupuncture for cancer pain management. The risk of bias was assessed using the version 2 of the Cochrane risk-of-bias tool (ROB 2.0), and data analysis was conducted utilizing RevMan 5.4 and Stata 17.0. Additionally, the quality of evidence was evaluated using the grading of recommendations assessment, development, and evaluation (GRADE) approach. | | ||
| + | ^Results|A total of** 21 RCTs** were included in the meta-analysis, involving **1432 patients**. The meta-analysis revealed that compared to the control group, the treatment group exhibited significantly reduced Numeric Rating Scales (NRS) scores (mean difference (MD) = -0.93, 95 % confidence interval (CI) [-1.21, -0.64], P<0.00001, low certainty), fewer burst pain events (MD = -2.13, 95 % CI [-2.86, -1.39], P < 0.00001, low certainty), reduced analgesic consumption (standard mean difference (SMD) =-0.60, 95 % CI [-0.84, -0.37], P<0.00001, moderate certainty), improved quality of life (MD =6.37, 95 % CI [3.21, 9.54], P<0.0001, low certainty), and diminished side effects of taking analgesics, with no serious adverse effects of acupuncture treatment. | | ||
| + | ^Conclusion|The integration of acupuncture with analgesic drugs has demonstrated considerable potential to significantly mitigate pain and ameliorate adverse effects of analgesics in patients with chronic cancer pain (MG30.11). However, further high-quality RCTs are required to elucidate the efficacy of acupuncture in cancer pain management and optimize treatment protocols. | | ||
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| + | === Yan 2025 === | ||
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| + | Yan S, Yan F, Liangyu P, Fei X. Assessment of non-pharmacological nursing strategies for pain management in tumor patients: a systematic review and meta-analysis. Front Pain Res (Lausanne). 2025 Apr 15;6:1447075. https://doi.org/10.3389/fpain.2025.1447075 | ||
| + | ^Summary background|Cancer is a multifactorial disease associated with intense pain and fatigue. Pain is the main discomfort experienced during cancer treatment, particularly as a major side effect of chemotherapy.| | ||
| + | ^Objective| This study has aimed to investigate the effectiveness of non-pharmacological nursing strategies, including reflexology, aromatherapy, acupressure, massage therapy and acupuncture, in the management of cancer-associated pain. Moreover, it provides evidence-based recommendations for integrating these interventions into standard pain management protocols.| | ||
| + | ^Search methodology| We gathered data from three major online databases; PubMed, the Cochrane Library and Embase. For the analysis, we exclusively targeted randomized controlled trials (RCTs) assessing the effectiveness of non-pharmacological interventions in managing cancer-related pain. No language restrictions were applied, and pain was considered the primary outcome measure.| | ||
| + | ^Results| Seventeen RCTs (n = 1,070) were included in this meta-analysis from 166 eligible studies. The pooled effect size demonstrated that all evaluated non-pharmacological nursing strategies, including aromatherapy, massage, reflexology, **acupressure and acupuncture** significantly reduced cancer-related pain compared to usual care (p < 0.001). Moreover, the reflexology and massage showed negligible heterogeneity among other interventions.| | ||
| + | ^Conclusion| This meta-analysis found the significant effectiveness of non-pharmacological nursing strategies, particularly reflexology and massage in reducing cancer-related pain. The findings support their integration into clinical practice, providing evidence-based recommendations for enhancing standard pain management protocols.| | ||
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| + | === Faria 2024 === | ||
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| + | Faria M, Teixeira M, Pinto MJ, Sargento P. Efficacy of acupuncture on cancer pain: A systematic review and meta-analysis. J Integr Med. 2024 May;22(3):235-244. https://doi.org/10.1016/j.joim.2024.03.002 | ||
| + | ^Backgound| Pain associated with cancer is one of the greatest causes of reduced quality of life in patients. Acupuncture is one of the treatments used to address this issue, with the great advantage of having little or no side effects, especially when compared with pharmacological pain-killers.| | ||
| + | ^Objective| The aim of this systematic review and meta-analysis was to evaluate the current evidence regarding the efficacy of acupuncture for cancer pain.| | ||
| + | ^Methods|Search strategy: Six electronic databases (PubMed, EBSCO, Cochrane Library, Scielo, b-On and Scopus) were searched for relevant articles about pain relief in cancer patients from their beginning until 2022 using MeSH terms such as "acupuncture," "electroacupuncture," "ear acupuncture," "acupuncture analgesia," ''oncological pain," and "cancer pain." Inclusion criteria: Studies included were randomized controlled trials (RCTs) where acupuncture was compared with no treatment, placebo acupuncture or usual care. Data extraction and analysis: Three independent reviewers participated in data extraction and evaluation of risk of bias, and a meta-analysis was conducted. The primary outcome was pain intensity, measured with the visual analog scale, numeric rating scale, or brief pain inventory. Secondary outcomes also assessed were quality of life, functionality, xerostomia, pain interference, and analgesic consumption. Results were expressed as standardized mean difference (SMD) with 95% confidence interval (CI).| | ||
| + | ^Results| **Sixteen RCTs with a total of 1124 participants** were included in the meta-analysis, with the majority of the studies presenting a low or unclear risk of bias. Acupuncture was more effective in reducing pain than no treatment (SMD = -0.90, 95 % CI [-1.68, -0.12]), sham acupuncture (SMD = -1.10, 95 % CI [-1.59, -0.61]) or usual care (SMD = -1.16, 95 % CI [-1.38, -0.93]).| | ||
| + | ^Conclusion| The results of this study suggest that acupuncture may be an effective intervention to reduce pain associated with cancer. Despite some limitations due to the low quality and small sample size of some included studies, as well as the different types and stages of cancer, acupuncture might provide an effective and safe treatment to reduce cancer pain. | | ||
| === Abe 2022 === | === Abe 2022 === | ||
| - | |⊕⊕⊖⊖|Low| | ||
| Abe H, Inoue R, Tsuchida R, Ando M, Saita K, Konishi M, Edamura T, Ogawa A, Matsuoka Y, Sumitani M. Efficacy of treatments for pain and numbness in cancer survivors: a systematic review and meta-analysis. Ann Palliat Med. 2022 Dec;11(12):3674-3696. https://doi.org/10.21037/apm-22-420 | Abe H, Inoue R, Tsuchida R, Ando M, Saita K, Konishi M, Edamura T, Ogawa A, Matsuoka Y, Sumitani M. Efficacy of treatments for pain and numbness in cancer survivors: a systematic review and meta-analysis. Ann Palliat Med. 2022 Dec;11(12):3674-3696. https://doi.org/10.21037/apm-22-420 | ||
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| === Yan 2022 (Bone Pain) === | === Yan 2022 (Bone Pain) === | ||
| - | |⊕⊖⊖⊖|Very low| | + | |
| Yan Z, MuRong Z, Huo B, Zhong H, Yi C, Liu M, Liu M. Acupuncture as a Complementary Therapy for Cancer-Induced Bone Pain: A Systematic Review and Meta-Analysis. Front Pain Res (Lausanne). 2022 Aug 1;3:925013. https://doi.org/10.3389/fpain.2022.925013. | Yan Z, MuRong Z, Huo B, Zhong H, Yi C, Liu M, Liu M. Acupuncture as a Complementary Therapy for Cancer-Induced Bone Pain: A Systematic Review and Meta-Analysis. Front Pain Res (Lausanne). 2022 Aug 1;3:925013. https://doi.org/10.3389/fpain.2022.925013. | ||
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| === Lung Cancer === | === Lung Cancer === | ||
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| + | == Jia 2024 == | ||
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| + | Jia L, Wang K, Chen S. Acupuncture combined with opioid for treatment of lung cancer-related pain: A systematic review and meta-analysis. Medicine (Baltimore). 2024 Oct 18;103(42):e40158. https://doi.org/10.1097/MD.0000000000040158. | ||
| + | ^Backgound| Many individuals diagnosed with lung cancer suffer from tremendous pain, and it is crucial to implement more effective measures to assist these patients in alleviating their pain. The present study utilizes a meta-analysis to evaluate the safety and efficacy of acupuncture combined with opioids for treating lung cancer-related pain in patients.| | ||
| + | ^Methods| We have searched 8 electronic databases: The Cochrane Library, PubMed, Embase, Web of Science, China National Knowledge Infrastructure, China Science and Technology Journal Database, Wanfang Database, and SinoMed. We included all randomized controlled trials of acupuncture combined with opioids for lung cancer-related pain in adults. We observed the main outcome indicators, including pain relief rates, numeric rating scale scores, and adverse events. Two researchers independently conducted literature screening, literature data extraction, and assessment of bias risk in the literature quality. Any disagreements were resolved through discussions between the 2 researchers or consultations with a third researcher. The risk of bias in the included studies was assessed using the revised risk of bias assessment tool. The overall quality of evidence for each outcome was evaluated using Grading of Recommendations, Assessment, Development and Evaluations.| | ||
| + | ^Results| We retrieved **812 lung cancer patients from 11 trials**. The study showed that compared to opioids alone, the combination of acupuncture and opioids significantly reduced numeric rating scale scores, increased pain relief rates, and decreased the occurrence of side effects.| | ||
| + | ^Conclusion| The current evidence indicates that combining acupuncture with opioid analgesics is superior to using opioid analgesics alone for managing lung cancer-related pain. Additionally, this combination therapy has fewer adverse reactions.| | ||
| == Bian 2020 == | == Bian 2020 == | ||
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| ^Results|**Five studies (n=189)** were included in this systematic review. Results indicated a favourable effect of acupuncture on pain relief in palliative care for patients with cancer. According to OCEBM 2011 Levels of Evidence, they were level 2 in one case (20%), level 3 in two cases (40%) and level 4 in the remaining (40%). Low-level evidence adversely affects the reliability of findings. | | ^Results|**Five studies (n=189)** were included in this systematic review. Results indicated a favourable effect of acupuncture on pain relief in palliative care for patients with cancer. According to OCEBM 2011 Levels of Evidence, they were level 2 in one case (20%), level 3 in two cases (40%) and level 4 in the remaining (40%). Low-level evidence adversely affects the reliability of findings. | | ||
| ^Conclusions|Acupuncture may be an effective and safe treatment associated with pain reduction in the palliative care of patients with cancer. Further high-quality, adequately powered studies are needed in the future.| | ^Conclusions|Acupuncture may be an effective and safe treatment associated with pain reduction in the palliative care of patients with cancer. Further high-quality, adequately powered studies are needed in the future.| | ||
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| + | === Stomach cancer === | ||
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| + | == Zhou 2024 == | ||
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| + | Zhou X, Zhang J, Jiang L, Zhang S, Gu Y, Tang J, Pu T, Quan X, Chi H, Huang S. Therapeutic efficacy of acupuncture point stimulation for stomach cancer pain: a systematic review and meta-analysis. Front Neurol. 2024 Apr 4;15:1334657. https://doi.org/10.3389/fneur.2024.1334657 | ||
| + | ^Purpose|In recent years, traditional Chinese medicine has received widespread attention in the field of cancer pain treatment. This meta-analysis is the first to evaluate the effectiveness and safety of acupuncture point stimulation in the treatment of stomach cancer pain.| | ||
| + | ^Methods| For this systematic review and meta-analysis, we searched PubMed, Web of Science, Cochrane Library, Embase, WANFANG, China National Knowledge Infrastructure (CNKI), and Chinese Journal of Science and Technology (VIP) databases as well as forward and backward citations to studies published between database creation to July 27, 2023. All randomized controlled trials (RCTs) on acupuncture point stimulation for the treatment of patients with stomach cancer pain were included without language restrictions. We assessed all outcome indicators of the included trials. The evidence from the randomized controlled trials was synthesized as the standardized mean difference (SMD) of symptom change. The quality of the evidence was assessed using the Cochrane Risk of Bias tool. This study is registered on PROSPERO under the number CRD42023457341.| | ||
| + | ^Results| **Eleven RCTs** were included. The study included 768 patients, split into 2 groups: acupuncture point stimulation treatment group (n = 406), medication control group (n = 372). The results showed that treatment was more effective in the acupuncture point stimulation treatment group than in the medication control group (efficacy rate, RR = 1.63, 95% CI 1.37 to 1.94, p < 0.00001), decreasing in NRS score was greater in acupuncture point stimulation treatment group than in the medication control group (SMD = -1.30, 95% CI -1.96 to -0.63, p < 0.001).| | ||
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| ==== Special Acupuncture Techniques ==== | ==== Special Acupuncture Techniques ==== | ||
| === Comparison of Acupuncture techniques === | === Comparison of Acupuncture techniques === | ||
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| + | == Xie 2025 == | ||
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| + | Xie T, Liu C, Wu Y, Li X, Yang Q, Tan J. Efficacy and Safety of Different Acupuncture Treatments for Cancer-Related Pain: A Systematic Review and Network Meta-Analysis. Integr Cancer Ther. 2025 Jan-Dec;24:15347354251314500. https://doi.org/10.1177/15347354251314500 | ||
| + | ^Backgound| Cancer pain is a prevalent and persistent issue, and while there have been some observations of the possible benefits of acupuncture in managing cancer pain, there is still debate regarding its safety and effectiveness. This study aims to compare the efficacy and safety of different acupuncture modalities in the treatment of cancer pain through a network meta-analysis.| | ||
| + | ^Methods| Between the time each database was created and June 3, 2024, eight databases were queried: PubMed, Cochrane, Embase, Web of Science, CNKI, Wanfang, VIP, and China Biomedicine. Randomized controlled trials investigating the use of various acupuncture and moxibustion techniques in the treatment of cancer pain were identified. Publication bias and quality of randomized controlled trials were assessed using the Cochrane Risk of Bias tool and the Jadad scale, and network meta-analyses were performed using Stata 15 and R 4.3.2.| | ||
| + | ^Results| We incorporated **111 studies encompassing 9549 individuals** diagnosed with cancer, examining 29 distinct therapies. Network meta-analysis showed that, compared to Usual Medicine, Acupuncture + Usual Medicine + Traditional Chinese medicine (MD = -1.83, 95% CI: -2.86 to -0.80) could reduce NRS scores, Acupuncture + Traditional Chinese medicine (OR = 30.86, 95% CI: 3.75-254.20) could improve cancer pain relief, Moxibustion + Usual Medicine (MD = 2.12, 95% CI: 0.43-3.80) could effectively improve KPS score, Acupuncture + Application of Chinese medicine (OR = 0.16, 95% CI: 0.04-0.66) is associated with a lower incidence of constipation, Electro-Acupuncture + Usual Medicine (OR = 0.11, 95% CI: 0.03-0.45) shows a lower incidence of nausea and vomiting, Acupuncture + Moxibustion + Usual Medicine (OR = 0.29, 95% CI: 0.09-0.90) is associated with a lower incidence of dizziness.| | ||
| + | ^Conclusion| Acupuncture + Traditional Chinese medicine is the best intervention for different acupuncture methods in the treatment of cancer pain, and Moxibustion + Usual Medicine is the best intervention to improve the quality of life of patients.| | ||
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| + | == Jin 2024 == | ||
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| + | Jin H, Liang J, Zhang S, Ma S, Qin H, Zhang D, Pang X, Zhang M. External treatment of traditional Chinese medicine for cancer pain: A systematic review and network meta-analysis. Medicine (Baltimore). 2024 Feb 23;103(8):e37024. https://doi.org/10.1097/MD.0000000000037024. PMID: 38394488. | ||
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| + | ^Backgound| Cancer pain is one of the most intolerable and frightening symptoms of cancer patients. However, the clinical effect of the three-step analgesic ladder method (TSAL) is not satisfactory. The combination of external treatment of traditional Chinese medicine (TCM) can improve the clinical effect.| | ||
| + | ^Objective| This study used network meta-analysis to compare the effects of different external treatment methods of TCM combined with TSAL on cancer pain.| | ||
| + | ^Methods| Databases searched by our team included Google Scholar, Web of Science, Scopus, Embase, PubMed, and Cochrane Library. Randomized controlled trials related to the external treatment of TCM combined with TSAL for cancer pain were screened from the establishment of the database till now. The above literature extracted clinical efficacy, NRS score, KPS score, analgesic onset time, and duration as the main results after the screening. The 95% confidence interval (95% CI) of OR value and SMD value was used as the effect index to compare the difference in efficacy of different interventions, and the ranking was conducted. STATA 17.0 software was used for the statistical analysis of the above data.| | ||
| + | ^Results| A total of 78 studies were included, including 8 interventions and 5742 participants. Based on ranking probability, the clinical effective rate of manual acupuncture combined with TSAL was the best when the intervention time was set at 4 weeks [OR = 5.42, 95% CI (1.99,14.81)], and the improvement effect on KPS score was also the best [SMD = 0.97, 95% CI (0.61, 1.33)]. Acupoint external application was the best intervention in reducing NRS score [SMD = -1.14, 95% CI (-1.90, -0.93)]. Acupoint moxibustion combined with TSAL was considered to be the most effective intervention to prolong the duration of analgesia [SMD = 1.69, 95% CI (0.84, 2.54)] and shortening the onset time of analgesia [SMD = -3.00, 95% CI (-4.54, -1.47)].| | ||
| + | ^Conclusions| TSAL combined with manual acupuncture is the best in terms of clinical efficacy and improvement of patients' functional activity status. With the extension of treatment time, the intervention of this kind of treatment on the clinical effect is more pronounced. Acupoint external application also has a unique advantage in reducing the pain level of patients. From the point of view of analgesic duration and duration of analgesia, combined acupoint moxibustion has the best effect.| | ||
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| == Zhang 2023 == | == Zhang 2023 == | ||
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| ^Results| We included **48 RCTs, which consisted of 4,026 patients**, and investigated nine interventions. A network meta-analysis showed that a combination of APS and opioids was superior in relieving moderate to severe cancer pain and reducing the incidence of adverse reactions such as nausea, vomiting, and constipation compared to opioids alone. The ranking of total pain relief rates was as follows: fire needle (surface under the cumulative ranking curve (SUCRA) = 91.1%), body acupuncture (SUCRA = 85.0%), point embedding (SUCRA = 67.7%), auricular acupuncture (SUCRA = 53.8%), moxibustion (SUCRA = 41.9%), transcutaneous electrical acupoint stimulation (TEAS) (SUCRA = 39.0%), electroacupuncture (SUCRA = 37.4%), and wrist-ankle acupuncture (SUCRA = 34.1%). The ranking of total incidence of adverse reactions was as follows: auricular acupuncture (SUCRA = 23.3%), electroacupuncture (SUCRA = 25.1%), fire needle (SUCRA = 27.2%), point embedding (SUCRA = 42.6%), moxibustion (SUCRA = 48.2%), body acupuncture (SUCRA = 49.8%), wrist-ankle acupuncture (SUCRA = 57.8%), TEAS (SUCRA = 76.3%), and opioids alone (SUCRA = 99.7%).| | ^Results| We included **48 RCTs, which consisted of 4,026 patients**, and investigated nine interventions. A network meta-analysis showed that a combination of APS and opioids was superior in relieving moderate to severe cancer pain and reducing the incidence of adverse reactions such as nausea, vomiting, and constipation compared to opioids alone. The ranking of total pain relief rates was as follows: fire needle (surface under the cumulative ranking curve (SUCRA) = 91.1%), body acupuncture (SUCRA = 85.0%), point embedding (SUCRA = 67.7%), auricular acupuncture (SUCRA = 53.8%), moxibustion (SUCRA = 41.9%), transcutaneous electrical acupoint stimulation (TEAS) (SUCRA = 39.0%), electroacupuncture (SUCRA = 37.4%), and wrist-ankle acupuncture (SUCRA = 34.1%). The ranking of total incidence of adverse reactions was as follows: auricular acupuncture (SUCRA = 23.3%), electroacupuncture (SUCRA = 25.1%), fire needle (SUCRA = 27.2%), point embedding (SUCRA = 42.6%), moxibustion (SUCRA = 48.2%), body acupuncture (SUCRA = 49.8%), wrist-ankle acupuncture (SUCRA = 57.8%), TEAS (SUCRA = 76.3%), and opioids alone (SUCRA = 99.7%).| | ||
| ^Conclusions| APS seemed to be effective in relieving cancer pain and reducing opioid-related adverse reactions. Fire needle combined with opioids may be a promising intervention to reduce moderate to severe cancer pain as well as reduce opioid-related adverse reactions. However, the evidence was not conclusive. More high-quality trials investigating the stability of evidence levels of different interventions on cancer pain must be conducted. | | ^Conclusions| APS seemed to be effective in relieving cancer pain and reducing opioid-related adverse reactions. Fire needle combined with opioids may be a promising intervention to reduce moderate to severe cancer pain as well as reduce opioid-related adverse reactions. However, the evidence was not conclusive. More high-quality trials investigating the stability of evidence levels of different interventions on cancer pain must be conducted. | | ||
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| + | === Sham acupuncture === | ||
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| + | == Lee 2023 == | ||
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| + | Lee B, Kwon CY, Lee HW, Nielsen A, Wieland LS, Kim TH, Birch S, Alraek T, Lee MS. Different Outcomes According to Needling Point Location Used in Sham Acupuncture for Cancer-Related Pain: A Systematic Review and Network Meta-Analysis. Cancers (Basel). 2023 Dec 17;15(24):5875. https://doi.org/10.3390/cancers15245875 | ||
| + | ^Backgound| Numerous acupuncture studies have been conducted on cancer-related pain; however, its efficacy compared to sham acupuncture remains controversial. We confirmed whether the outcome of acupuncture differs according to the needling points of sham acupuncture for cancer-related pain. | | ||
| + | ^Methods| We searched 10 databases on 23 May 2023 to screen acupuncture trials using sham acupuncture or waiting list as controls for cancer-related pain. Sham acupuncture was classified into two types, depending on whether the needling was applied at the same locations as verum acupuncture (SATV) or not (SATS). A network meta-analysis (NMA) was performed on the basis of a frequentist approach to assess pain severity. | | ||
| + | ^Results|Eight studies (n = 574 participants) were included in the review, seven of which (n = 527 participants) were included in the NMA. The pain severity was not significantly different between SATV and verum acupuncture, but verum acupuncture significantly improved pain severity compared to SATS. The risk of bias affecting the comparisons between the verum and sham acupuncture was generally low. Previous acupuncture trials for cancer-related pain showed differing outcomes of sham and verum acupuncture, depending on the needling points of sham acupuncture. | | ||
| + | ^Conclusions| The application of SATV cannot be considered a true placebo, which leads to an underestimation of the efficacy of verum acupuncture.| | ||
| === Moxibustion === | === Moxibustion === | ||
