Recent trends in acupuncture for chronic pain: A bibliometric analysis and review of the literature

BackgroundAcupuncture has been increasingly used in patients with chronic pain, yet no bibliometric analysis of acupuncture studies for chronic pain exists.ObjectivesTo investigate the characteristics, hotspots and frontiers of global scientific output in acupuncture research for chronic pain over the past decade.MethodsWe retrieved publications on acupuncture for chronic pain published from 2011 to 2022 from the Science Citation Index Expanded (SCI-expanded) of the Web of Science Core Collection (WoSCC). The co-occurrence relationships of journals/countries/institutions/authors/keywords were performed using VOSviewer V6.1.2, and CiteSpace V1.6.18 analyzed the clustering and burst analysis of keywords and co-cited references.ResultsA total of 1616 articles were retrieved. The results showed that the number of annual publications on acupuncture for chronic pain has increased over time, with the main types of literature being original articles (1091 articles, 67.5 %) and review articles (351 articles, 21.7 %). China had the most publications (598 articles, 37 %), with Beijing University of Traditional Chinese Medicine (93 articles, 5.8 %) and Evidence-based Complementary and Alternative Medicine ranked first (169 articles, 10.45 %) as the most prolific affiliate and journal, respectively. Liang FR was the most productive author (43 articles), and the article published by Vickers Andrew J in 2012 had the highest number of citations (625 citations). Recently, "acupuncture" and "pain" appeared most frequently. The hot topics in acupuncture for chronic pain based on keywords clustering analysis were experimental design, hot diseases, interventions, and mechanism studies. According to burst analysis, the main research frontiers were functional connectivity (FC), depression, and risk.ConclusionThis study provides an in-depth perspective on acupuncture for chronic painstudies, revealing pivotal points, research hotspots, and research trends. Valuable ideas are provided for future research activities.     

Neurobiological correlates of acupuncture: November 17-18, 2005

The "Neurobiological Correlates of Acupuncture" Conference was convened November 17-18, 2005 in Bethesda, Maryland. The conference was sponsored by the National Center for Complementary and Alternative Medicine (NCCAM) of the National Institutes of Health (NIH), U.S. Department of Health and Human Services (DHHS). Its goals were to encourage exchange of ideas regarding the direction of neuroimaging in acupuncture research as well as to discuss some of the challenges in this field. The use of neuroimaging, a relatively recent advance in the study of acupuncture, holds the promise of localizing and characterizing brain activity associated with acupuncture interventions in real time and in a minimally invasive way. Among the main challenges to research into the biological mechanisms of acupuncture are the multiple treatment variables and the difficulties of selecting appropriate experimental controls. Despite these challenges, numerous findings from acupuncture neuroimaging experiments were presented and discussed at the conference on topics related to possible signaling networks, sham acupuncture controls, acupoint specificity, acupuncture analgesia, acupuncture-associated brain response, and the potential for using neuroimaging in conjunction with translational and clinical acupuncture research. Future directions in acupuncture neuroimaging research, as recommended by conference participants, should focus on (1) continuing exploration of acupuncture signaling networks; (2) establishing standards and recommendations for performing and reporting acupuncture neuroimaging results; (3) enabling data sharing in the acupuncture neuroimaging community; (4) gaining a better understanding of placebo and control groups in acupuncture neuroimaging experiments; and (5) developing biomarkers that relate to physiologically and/or clinically relevant acupuncture responses to neuroimaging results.     

Analyzing the research in Integrative & Complementary Medicine by means of science mapping

ObjectivesThe research in the Complementary and Alternative Medicine (CAM) field is analyzed according to the journals indexed in ISI Web of Science. Science Mapping Analysis (SMA) is used to provide and overview of the conceptual evolution of the CAM field.MethodsThe software SciMAT is used to detect and visualize the hidden themes and their evolution over a consecutive span of years. It combines SMA and performance analysis. Twenty one journals related to CAM were analyzed, in four consecutive periods from 1974 to 2011.ResultsStrategic diagrams and the thematic evolution of CAM, together with performance indicators (h-index), were obtained. The results show that CAM research has focused on seven main thematic areas: MEDICINAL-PLANTS, CHIROPRACTIC-AND-LOW-BACK-PAIN, ACUPUNCTURE-AND-PAIN, CELL-PROCESSES-AND-DISEASES, LIPID-PEROXIDATION and DIABETES-AND-INSULIN.ConclusionThe research output could be used by the scientific community to identify thematic areas on which interest is focused.     

Quantitative analysis of the scientific literature on acetaminophen in medicine and biology: a 2003–2005 study†

This study quantifies the utilization of acetaminophen in life sciences and clinical medicine using bibliometric indicators. A total of 1626 documents involving acetaminophen published by 74 countries during 2003–2005 in the Thompson‐Scientific Life sciences and Clinical Medicine collections were identified and analyzed. The USA leads in the number of publications followed by the UK, and industrialized countries, including France, Japan and Germany; the presence of countries such as China, India and Turkey among the top 15 countries deserves to be noticed. The European Union stands as a comparable contributor to the USA, both in terms of number of publications and in terms of profile of papers distributed among subcategories of Life Sciences and Clinical Medicine disciplines. All documents were published in 539 different journals. The most prolific journals were related to pharmacology and/or pharmaceutics. All aspects of acetaminophen (chemistry, pharmacokinetics, metabolism, etc.) were studied with primary interest for therapeutic use (42%) and adverse effects (28%) comprising a large part of publications focusing on acetaminophen hepatotoxicity. This quantitative overview provides as to the interest of the scientific community in this analgesic and completes the various review documents that regularly appear in the scientific literature.     

Protocol for the development of consensus-based clinical case reporting guideline extension: CARE for acupuncture

BackgroundHealth research reporting guidelines for case reports (CARE - CAse REport) published in 2013 and 2017 have become a generally accepted standard for publishing case reports. The CARE guidelines represent an architectural framework for writing an evidence-based case report that can be customized as need for a specialty (or disease) if needed. We aim to develop a CARE guideline extension for acupuncture following the EQUATOR Network (Enhancing the QUAlity and Transparency Of health Research) and the 2010″Guidance for Developers of Health Research Reporting". We have established a group of international experts including; clinicians, researchers and methodologists. We performed a needs assessment based on a review of acupuncture case reports published in the indexed medical literature. The needs assessment will be followed by (1) a series of expert interviews to establish a draft, (2) a modified Delphi process, and (3) a consensus meeting. Following the consensus meeting we will pilot test the CARE draft before publishing the CARE extension for acupuncture.MethodsWe will develop the CARE extensions for acupuncture following recommendations of the EQUATOR Network and the 2010 "Guidance for Developers of Health Research Reporting". We will establish an international multidisciplinary group including clinical practitioners, acupuncturists, researchers of reporting guidelines on acupuncture, clinical epidemiologists and statisticians.We performed a needs assessment, reviewing published case reports using acupuncture as a therapeutic intervention from indexed medical journals (PubMed-PMC and Medline, Scopus, Embase, the Allied and Complementary Medicine Database (AMED), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Wan Fang database, Chinese BioMedicine database (CBM), China National Knowledge Infrastructure (CNKI), and VIP). In consultations with advisors we will develop a draft of potential items to be included in the CARE extension for acupuncture. Then we will conduct a modified Delphi process of at least three rounds, hold a face-to-face consensus meeting, pilot test and submit the CARE extension for acupuncture for publication.ConclusionThe development of a widely accepted CARE extension for acupuncture for case reports published in indexed medical journals. These guidelines will follow the EQUATOR Network recommendations and the 2010 "Guidance for Developers of Health Research Reporting".     

Fifty-year of Global Research in Calendula Officinalis L. (1971−2021): A Bibliometric Study

BackgroundCalendula officinalis L. (Compositae) is a Mediterranean annual plant widely used for its versatile biological activities.ObjectiveA bibliometric study of research data conducted from 1971 to 2021 was conducted.MethodsBibliographic data was retrieved from the Scopus database and analyzed using VOSviewer and MS Excel. Polynomial regression was used to assess the annual production of research documents related to C. officinalis.ResultsA total of 1,252 journal articles and conference papers were published by 4,452 authors, originated from 98 countries and disseminated in 706 sources. Iran (n = 131), Brazil (n = 119), India (n = 113), Poland (n = 112), and Italy (n = 72) are the top-publishing countries. Journal of Ethnopharmacology is the top-cited journal, while Italy is the top-cited country. Steady growth was observed in the last fifty years, from 1971 to 2021. The anti-inflammatory, wound-healing, and anti-microbial properties are among the most prolific studies that have been conducted on this plant. Extensive research has been carried out on antioxidant compounds, terpenes, and volatile oils. Skin care and wound healing are the most common clinical applications. Co-citation analysis, keywords co-occurrence, and bibliographic coupling revealed diverse knowledge structures and intellectual dynamics.ConclusionThis comprehensive bibliometric study indicates that Calendula officinalis received significant research. The structured information may help understand research trends and locate this plant's research hot spots and gaps.     

The effectiveness and safety of acupuncture treatment on sciatica: A systematic review and meta-analysis

BackgroundSciatica results from primary or secondary damage to the sciatic nerve in the lumbar or gluteal region. The first option for sciatica is analgesics, but their therapeutic effect and safety in long-term use are questionable. On the other hand, acupuncture has recently been recognized as a complementary and alternative medicine (CAM) to conventional medicine, and studies on its effectiveness and safety have been actively conducted.ObjectiveTo systematically compare acupuncture with analgesics in terms of effect, safety, and durability in the treatment of sciaticaMethodsThis review was performed in accordance with Cochrane Handbook for Systematic Reviews of Interventions Version 6.2. Four databases were searched for this review: Wangfang, the Korean Traditional Knowledge Portal (KTKP), PubMed, and EBSCOhost. The primary outcome measures in the review were total effective rate (TER), visual analog scale (VAS) score and pain threshold, and the secondary ones were adverse effects (AEs) and relapse rates. Risk ratio (RR) for TER and mean difference (MD) for VAS score and pain threshold were used as statistics for the meta-analysis of effectiveness, along with associated 95 % confidence intervals (CIs) and P-values. AEs and relapse rates were used for the safety and durability of the interventions. Version 2 of the Cochrane risk-of-bias assessment tool for randomized trials (RoB 2) was used for the methodological quality of randomized controlled trials (RCTs) included in the review.ResultsThe synthesized TER of 28 RCTs involving 2707 participants was significantly higher in the acupuncture group compared to the analgesic group (RR [95 % CI] = 1.20 [1.16, 1.24], P < 0.001). The synthesized VAS score of 7 RCTs involving 589 participants was significantly reduced in the acupuncture group compared to the analgesic group (MD [95 % CI] = − 1.78 [− 2.44, − 1.12], P < 0.001). In 5 RCTs involving 311 participants, the synthesized pain threshold was significantly elevated in the acupuncture group compared to the analgesic group (MD [95 % CI] = 0.93 [0.64, 1.22], P < 0.001). Additionally, adverse effects (AEs) and relapse rates of RCTs in the review were lower in the acupuncture group compared to the analgesic group.ConclusionIn this systematic review, acupuncture treatment was significantly effective and safe compared to analgesics in sciatica. In the future, studies with a rigorous study design are required to increase the validity of the effectiveness and safety of acupuncture treatment for sciatica.     

基于CiteSpace软件的国内近15年慢性稳定性心绞痛研究的文献计量及可视化分析

目的对国内近15年的慢性稳定性心绞痛相关研究进行文献计量、共现分析、聚类分析及可视化分析,探索研究现状、热点及趋势。方法以CNKI为文献来源,检索2004~2018年慢性稳定性心绞痛的相关研究。运用CiteSpace软件以作者、机构、关键词作为节点进行共现分析,并对关键词进行聚类分析、时间演化分析和Burst分析,绘制对应的可视化图谱并进行解析。结果共检索到相关文献4 329篇。分析结果显示,近年来慢性稳定性心绞痛的研究热度稳步发展,贡献较为突出的是以杨关林为代表的辽宁中医药大学及其附属医院。研究热点与前沿主要集中在心绞痛、冠心病、曲美他嗪、临床研究等方面。结论运用CiteSpace软件对国内慢性稳定性心绞痛近15年的研究进行分析,较直观地展现了慢性稳定性心绞痛的研究概况,初步揭示了可合作的研究者及机构,对其研究热点、前沿及研究趋势形成了大致认识,为本病以后的研究发展方向提供了参考。     

Acupoint Stimulation With Diluted Bee Venom (Apipuncture) Potentiates the Analgesic Effect of Intrathecal Clonidine in the Rodent Formalin Test and in a Neuropathic Pain Model

Although intrathecal (i.t.) administration of the α₂-adrenoceptor agonist clonidine has a pronounced analgesic effect, the clinical use of clonidine is limited by its side effects. Previously, our laboratory has demonstrated that the subcutaneous injection of diluted bee venom (DBV) into an acupoint (termed apipuncture) produces significant analgesic effect in various pain animal models. The present study was designed to examine whether DBV injection into the Zusanli acupoint (ST-36) could enhance lower-dose clonidine-induced analgesic effects without the development of hypotension, bradycardia, or sedation. In the mouse formalin test, DBV injection produced a dramatic leftward shift in the dose-response curve for clonidine-induced analgesia. In a rat neuropathic pain model i.t. clonidine dose dependently suppressed chronic constriction injury (CCI)-induced mechanical allodynia and thermal hyperalgesia, and this clonidine-induced analgesic effect was significantly potentiated by apipuncture pretreatment. DBV apipuncture alone or in combination with a low dose of i.t. clonidine produced an analgesic effect similar to that of the high dose of clonidine, but without significant side effects. The analgesic effect produced by the combination of i.t. clonidine and apipuncture was completely blocked by pretreatment with an α₂-adrenoceptor antagonist. These data show that DBV-apipuncture significantly enhances clonidine-induced analgesia and suggest that a combination of low dose clonidine with acupuncture therapy represents a novel strategy for pain management that could eliminates clonidine's side effects.PerspectiveThis study demonstrated that intrathecal clonidine-induced analgesia is significantly enhanced when it is combined with chemical acupuncture treatment. The administration of low-dose clonidine in combination with acupuncture produced a potent analgesic effect without significant side effects and thus represents a potential novel strategy for the management of chronic pain.     

European participation in major intensive care journals

To evaluate the recent evolution of the European contribution to the international literature in intensive care medicine, we reviewed the source of all original articles and case reports published from 1989 to 1993 in 5 major journals:Critical Care Medicine, Intensive Care Medicine, Chest, The American Review of Respiratory Disease andCirculatory Shock. There was an overall decline in the US contributions and a corresponding increase in the European participations toChest andthe American Review of Respiratory Disease, but not toCritical Care Medicine orCirculatory Shock. The European participation toIntensive Care Medicine remained largely predominant. The evaluation of the contributions of major European countries to these 5 journals revealed a progressive increase in the French, Italian and Spanish contributions, whilst the German contribution remained stable and the UK contributions decreased. The UK contribution, which was the first in 1989, became second in 1993, after France.     

The Use of Acupuncture in the Management of Patients With Humeral Fractures: A Systematic Review and Meta-analysis

ObjectiveThe purpose of this study was to conduct a systematic review and meta-analysis of the effects of acupuncture on humeral fractures.MethodsRandomized controlled trials were searched systematically from inception to January 2020 using the Cochrane Central Register of Controlled Trials, Embase, PubMed, Web of Science, China National Knowledge Infrastructure, and 7 Korean databases. Pain scale and Japanese Orthopaedic Association scores were the primary and secondary measurements. A risk-of-bias assessment and meta-analysis were conducted.ResultsSeven randomized controlled trials were included in the systematic review; the quality of the studies was ambiguous. The meta-analysis showed that acupuncture improved the pain severity score compared with conventional therapies (standard mean difference = ?4.55, 95% confidence interval, ?7.48 to ?1.61, I² = 98%, P < .00001) but did not improve the Japanese Orthopaedic Association score (standard mean difference = 4.99, 95% confidence interval, ?0.31 to 10.30, I² = 99%, P < .00001).ConclusionOur meta-analysis shows that acupuncture reduced pain after proximal humeral fracture, in addition to common rehabilitative modalities. However, the conclusion of this review should be cautiously applied in clinical practice owing to the low quality of the included studies.     

Effect of complementary and alternative medicine interventions on cancer related pain among breast cancer patients: A systematic review

ObjectiveThis systematic review aimed to evaluate the efficacy of CAM interventions for cancer-related pain in breast cancer patients.MethodsDatabases (PubMed, Scopus, Web of Science, and EMBASE) were searched from January 1, 2000, up to April 31, 2019, using the keywords: Complementary and alternative medicine therapies and cancer related pain. Standard tools were used to evaluate the quality of the studies included.ResultsOf the 3742 articles found, 46 articles comprising 3685 participants entered the final phase. Our results indicate that interventions including acupuncture/acupressure, tai chi/qi gong, hypnosis, meditation, music therapy, yoga, massage, reflexology, and Reiki improve cancer-related pain in breast cancer patients. However, aromatherapy had no effect on the same.ConclusionsDespite the positive effect of various CAM interventions in reducing cancer-related pain, necessary precautions should be adopted to use them alongside other treatments to control cancer pain in the clinical setting.     

Scientific publication trends of emergency department of International Federation for Emergency Medicine members, 2009 to 2018

BackgroundEmergency medicine (EM) is a rapidly developing specialty worldwide. The scientific publications trend is one of the parameters to evaluate national EM developmental milestones. This study was performed to analyze the publication trends from emergency departments (EDs) of International Federation for Emergency Medicine (IFEM) full member countries from 2009 to 2018.MethodsAll data were retrieved from the SciVerse Scopus database. IFEM full member countries where EM was recognized as a specialty before 2009 and annual publication numbers exceeded 12 in 2018 were included. The EM journals list was adopted from the 2017 Journal Citation Reports. Publications with the first author affiliated with EDs were divided into EM or non-EM journal groups according to the publishing journal. The slope (β) of the linear regression was used to assess the trends of publication numbers. The correlation between the 2009 publication number and the trend of publication between 2009 and 2018 was measured by Pearson's correlation coefficient (r). The correlation between funding numbers and publication numbers was analyzed by Spearman's rank correlation coefficient (r_s).ResultsWe identified 30,130 publications with first authors from EDs in 19 countries. The numbers of publications in both EM and non-EM journals showed an increasing trend in 12 countries. Fifteen of the 19 countries had a greater increasing trend in non-EM journals than in EM journals. The 2009 publication numbers were positively correlated with the publication increasing trend between 2009 and 2018 in both EM and non-EM journals (r = 0.854 and 0.947, respectively, both p < 0.001). The funded publication number was positively correlated with the total national publication amount (r_s = 0.748, p < 0.001).ConclusionsThe research capacity of EDs has been increasingly recognized by other medical specialties. The national publication numbers from EDs may predict the academic publication increasing trends in the subsequent 10 years.     

Funding and Publishing Trends of Original Research by Emergency Medicine Investigators over the Past Decade

Objectives: To update the profile of author‐reported funding of reports of original research published since 1994 in the four U.S. peer‐reviewed general emergency medicine (EM) journals. Methods: For the primary analysis, articles published in Academic Emergency Medicine, American Journal of Emergency Medicine, Annals of Emergency Medicine, and Journal of Emergency Medicine between 1994 and 2003 were reviewed by two emergency physicians trained in abstracting from the literature. Original research was identified; case reports, case series, abstracts, and meta‐analysis were excluded. Articles were classified by author report of extramural funding as government (public), private nonprofit (foundation), for profit (industry), or multiple. Data are reported as percent per year per journal. A secondary analysis of MEDLINE was performed to identify publishing trends by EM investigators outside of these four journals over the same period. Results: The primary analysis identified 5,728 articles; 3,278 (57%) were considered original research, with 32% of these reporting extramural funding. In 1994, there were 292 articles with 28% funded (28% public, 43% foundation, 17% industry, and 12% multiple). By 2003, there were 358 articles with 36% funded (42% public, 30% foundation, 18% industry, and 10% multiple). There was a trend toward increased extramural funding in all four journals (p = 0.007), with an estimated growth of 3.6% (95% confidence interval = 1.0% to 6.3%) per year over the past decade. The primary review identified 48% of all articles published by EM investigators. Conclusions: Author‐reported extramural funding rates for original research have increased in the EM literature over the past decade. Foundations have funded the largest number of studies, with public (government) sources increasing in 2003.     

When Patients' Assessments of Treatment for Subjective Symptoms are At Odds with Authoritative Assessments in the Biomedical Literature: The Case of Patients Treated with Acupuncture for Low Back Pain in a Traditional Chinese Medicine Clinic in China (and Story of a Bewildered Chicken)

Assessments of treatments for ‘subjective symptoms’ are problematic and potentially contentious. These are symptoms without ascertainable pathophysiology, also referred to as ‘medically unexplained.’ Treatments of them may be assessed from different perspectives, and an assessment as seen from one perspective may be discrepant with an assessment as seen from another perspective. The observational study described in the paper represents one perspective. Patients in the study were treated with acupuncture for the subjective symptom of low back pain in a Traditional Chinese Medicine Clinic in China; acupuncture is a form of TCM, which is indigenous to China. Shortly after treatment began and six months afterward, patients reported ‘clinically important improvements’ on a variety of standard, cross-culturally validated outcome measures, including pain intensity, physical functioning, and emotional functioning; this assessment is consistent with numerous assessments of acupuncture in China and other Southeastern Asian countries. On the other hand, clinical trials represent another perspective from which to assess acupuncture. Although assessments based on trials are not uniform, several assessments based on them, including those published in journals such as Lancet and New England Journal of Medicine, conclude that acupuncture is not effective. These trials, however, were mainly situated in the U.S., western European countries, and other WEIRD (W estern, E ducated, I ndustrialized, R ich, D emocratic) countries. This is notable, because the population of China, the indigenous context of acupuncture, is greater than populations of WEIRD countries combined. Patients' expectations of a treatment such as acupuncture and their prior familiarity with it vary among contexts, and patients' experiences of treatment outcomes may vary accordingly. In short, although clinical trials constitute a test of truth in biomedicine and inform authoritative assessments in WEIRD countries, they do not necessarily represent the truth from the perspective of those experiencing outcomes of especially indigenous treatments for subjective symptoms in non-WEIRD contexts.     

Clinical evidence of Chinese medicine therapies for depression in women during perimenopause and menopause

BackgroundDepression is common in women during perimenopause and menopause. Complementary therapies such as acupuncture and Chinese herbal medicine (CHM) are often utilized by these women. However, the efficacy and safety of these treatments have not been systematically evaluated.MethodsWe conducted a systematic review and meta-analysis of randomized controlled trials (RCTs). Nine English and Chinese databases were searched and search terms included perimenopause, menopause, depression, Chinese herbal medicine, acupuncture, RCTs, and their synonyms. Methodological quality was assessed using the Cochrane Risk of Bias Tool.ResultsA total of 18 RCTs were identified (6 CHM, 11 acupuncture related therapies, 1 combination of CHM and acupuncture). For Hamilton Rating Scale of Depression (HRSD) and Kuppermans Index of Menopause, tuina-massage, combined therapy of CHM plus acupuncture showed significant benefits at end of treatment compared to antidepressants. Either CHM and acupuncture reduced HRSD scores, indicating less severe depression, showing comparable effects to antidepressants.ConclusionCHM and acupuncture treatment in perimenopause and menopausal women resulted in reduced severity of depression. Results should be interpreted with caution given the small number of studies included in this review and further RCTs are warranted to validate findings from this review.     

Author and journal self-citation in Emergency Medicine original research articles

ObjectiveTo determine author and journal self-citation rates in a sample of original emergency medicine (EM) research articles.MethodsWe undertook a retrospective observational study of original research articles published in 2019 in the top six English language general EM journals. Data comprised the total numbers of articles, citations, authors and self-citations for each author (author self-citations) as well as the number of articles in the reference list that had been previously published in the same journal (journal self-citations).Results3213 individual authors and 581 articles were examined. Most authors did not self-cite at all although 62 self-cited five or more times in a single article. The mean (SD) and median (IQR) numbers of individual author self-citations/article/year were 0.6 (1.3) and 0 (0–1), respectively. Overall, author self-citations accounted for 2.4% of all cited articles. There was a weak positive but significant correlation between the number of individual author self-citations/article/year and the number of articles published by the author (r = 0.38, p < 0.001). There was no correlation between the journal impact factor (IF) and the author self-citation rate (r = 0.14, p = 0.79). The journals differed significantly in their author self-citation rates (p < 0.001). Annals of Emergency Medicine had the highest journal self-citation rate at 8.1% (95%CI 7.0%–9.2%) self-citations/100 citations/year, almost twice that of some other journals. There was a large but non-significant positive correlation between the journal IF and journal self-citation rates (r = 0.78, p = 0.07).ConclusionBoth author and journal self-citation rates in the articles examined are relatively low compared to other medical and scientific disciplines.