{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,8]],"date-time":"2026-10-08T10:00:44Z","timestamp":1791453644836,"version":"4.3.3"},"reference-count":53,"publisher":"MDPI AG","issue":"7","license":[{"start":{"date-parts":[[2026,3,31]],"date-time":"2026-03-31T00:00:00Z","timestamp":1774915200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Background: Peripheral venous cannulation is one of the most common clinical procedures, yet it often causes significant pain, anxiety, and discomfort for patients. While pharmacological methods exist, non-pharmacological interventions offer a low-cost, low-risk alternative that eliminates waiting times for anesthetic onset. The aim of this review is to synthesize the various nonpharmacological interventions for procedural pain reduction during PIVC in adults, covering interventions ranging from psychological distraction to advanced procedural support technologies. Methods: A systematic review was conducted following PRISMA 2020 guidelines and the Joanna Briggs Institute (JBI) framework. Databases including PubMed, CINAHL, Web of Science, and Scopus were searched for studies published between 2015 and 2025. Inclusion criteria focused on randomized controlled trials (RCTs) and quasi-experimental studies involving adult patients undergoing PIVC. Results: Thirty studies (29 randomized controlled trials and one experimental study) were included in the final analysis. The interventions were categorized into three primary groups: distraction techniques, physical methods, and behavioral techniques. The application of virtual reality (VR), optical illusion cards, and music therapy significantly reduced pain scores and enhanced patient satisfaction. Similarly, physical methods, such as thermomechanical stimulation (e.g., the Buzzy\u00ae device), local heat application, and vibration, were found to be effective in lowering pain intensity compared to standard care. Behavioral techniques, including the \u201ccough trick,\u201d diaphragmatic breathing, and the Valsalva maneuver, consistently demonstrated efficacy in reducing both procedural pain and anxiety. Notably, while most interventions successfully reduced pain, certain methods\u2014such as near-infrared (NIR) vein visualization\u2014improved procedural success rates without significantly altering the subjective perception of pain. Conclusions: Findings from this review suggest that non-pharmacological interventions may serve as effective, safe, and feasible adjuncts for pain management during peripheral venous cannulation. Techniques such as the cough trick and vibration-based devices are particularly recommended due to their ease of integration into routine nursing practice, potentially improving patient comfort and clinical outcomes.<\/jats:p>","DOI":"10.3390\/jcm15072662","type":"journal-article","created":{"date-parts":[[2026,3,31]],"date-time":"2026-03-31T16:34:08Z","timestamp":1774974848000},"page":"2662","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Nonpharmacological Interventions for Pain Relief During Peripheral Venous Cannulation: Implications for Practice"],"prefix":"10.3390","volume":"15","author":[{"ORCID":"https:\/\/orcid.org\/0009-0003-9542-100X","authenticated-orcid":false,"given":"Damian","family":"Roma\u0144czuk","sequence":"first","affiliation":[{"name":"Department of Anesthesiology and Intensive Care, Medical University of Gda\u0144sk, 80-952 Gda\u0144sk, Poland"},{"name":"Department of Anesthesiology and Intensive Care, University Clinical Center, 80-952 Gda\u0144sk, Poland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Aleksandra","family":"Maruszak","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology and Intensive Care, University Clinical Center, 80-952 Gda\u0144sk, Poland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-9728-5011","authenticated-orcid":false,"given":"Sandra","family":"Lange","sequence":"additional","affiliation":[{"name":"Department of Internal and Pediatric Nursing, Medical University of Gda\u0144sk, 80-211 Gda\u0144sk, Poland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8377-4893","authenticated-orcid":false,"given":"Wioletta","family":"M\u0119drzycka-D\u0105browska","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology and Intensive Care, Medical University of Gda\u0144sk, 80-952 Gda\u0144sk, Poland"},{"name":"Department of Anesthesiology and Intensive Care, University Clinical Center, 80-952 Gda\u0144sk, Poland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6339-6135","authenticated-orcid":false,"given":"Grzegorz","family":"Cichowlas","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology and Intensive Care Education, Medical University of Warsaw, 02-097 Warsaw, Poland"},{"name":"Department of Anesthesiology and Intensive Care, Czerniakowski Hospital sp. z.o.o., 00-739 Warsaw, Poland"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0005-8002-5682","authenticated-orcid":false,"given":"Anna","family":"G\u0105sior","sequence":"additional","affiliation":[{"name":"Department of Anesthesiology and Intensive Care, Czerniakowski Hospital sp. z.o.o., 00-739 Warsaw, Poland"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,3,31]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"7","DOI":"10.4103\/aer.AER_172_17","article-title":"The Role of Nonpharmacological Methods in Attenuation of Pain Due to Peripheral Venous Cannulation: A Randomized Controlled Study","volume":"12","author":"Shivashankar","year":"2018","journal-title":"Anesth. Essays Res."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"531","DOI":"10.1016\/j.jopan.2024.06.108","article-title":"Comparison of analgesic effect of local anesthetic injection for pain relief during peripheral venous insertion in adult surgical patients: A prospective observational study","volume":"40","author":"Yoshida","year":"2025","journal-title":"J. Perianesthesia Nurs."},{"key":"ref_3","unstructured":"Beecham, G.B., Agarwal, A., and Tackling, G. (2026, February 24). Peripheral Line Placement, StatPearls, Available online: https:\/\/www.ncbi.nlm.nih.gov\/books\/NBK539795\/."},{"key":"ref_4","doi-asserted-by":"crossref","unstructured":"Pedersen, J.B., Martensen, A., Funder, P., Bakke, S.A., Bhavsar, R.P., and Str\u00f8m, T. (2024). Cryospray reduces pain during venous cannulation in elective surgery patients: A randomized placebo-controlled study. BMC Anesthesiol., 24.","DOI":"10.1186\/s12871-024-02858-2"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"105123","DOI":"10.1016\/j.ijnurstu.2025.105123","article-title":"Comparative analysis of the effectiveness of pharmacological and non-pharmacological interventions on arteriovenous fistula cannulation-related pain in patients receiving hemodialysis: A systematic review and network meta-analysis","volume":"169","author":"Sharifnia","year":"2025","journal-title":"Int. J. Nurs. Stud."},{"key":"ref_6","first-page":"605","article-title":"Pain During Venous Cannulation","volume":"114","author":"Koch","year":"2017","journal-title":"Dtsch. Arztebl. Int."},{"key":"ref_7","doi-asserted-by":"crossref","unstructured":"Rodriguez-Calero, M.A., de Pedro-Gomez, J.E., Molero-Ballester, L.J., Fernandez-Fernandez, I., Matamalas-Massanet, C., Moreno-Mejias, L., Blanco-Mavillard, I., Moya-Suarez, A.B., Personat-Labrador, C., and Morales-Asencio, J.M. (2020). Risk Factors for Difficult Peripheral Intravenous Cannulation. The PIVV2 Multicentre Case-Control Study. J. Clin. Med., 9.","DOI":"10.3390\/jcm9030799"},{"key":"ref_8","doi-asserted-by":"crossref","unstructured":"Kaplan, F., \u00c7elik, H., Aslan, H., and Aktura, S.\u00c7. (2025). Comparison of peripheral intravenous catheterization applied to different anatomical sites in terms of pain, phlebitis and infiltration. BMC Nurs., 24.","DOI":"10.1186\/s12912-025-02979-0"},{"key":"ref_9","unstructured":"Tufanaru, C., Munn, Z., Aromataris, E., Campbell, J., and Hopp, L. (2017). Checklist for Randomized Controlled Trials, Joanna Briggs Institute."},{"key":"ref_10","unstructured":"Tufanaru, C., Munn, Z., Aromataris, E., Campbell, J., and Hopp, L. (2017). Checklist for Quasi-Experimental Studies, Joanna Briggs Institute."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"n71","DOI":"10.1136\/bmj.n71","article-title":"The PRISMA 2020 statement: An updated guideline for reporting systematic reviews","volume":"372","author":"Page","year":"2021","journal-title":"BMJ"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"190","DOI":"10.1097\/NAN.0000000000000542","article-title":"Ultrasound-Guided Peripheral Venipuncture Decreases the Procedure\u2019s Pain and Positively Impacts Patient\u2019s Experience: The PRECISE Randomized Clinical Trial","volume":"47","author":"Junges","year":"2024","journal-title":"J. Infus. Nurs."},{"key":"ref_13","first-page":"571","article-title":"Effects of Vibration and Cold Application on Pain and Anxiety During Intravenous Catheterization","volume":"34","year":"2019","journal-title":"J. PeriAnesthesia Nurs."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"770","DOI":"10.1111\/jocn.15131","article-title":"Distraction-based relief of pain associated with peripheral intravenous catheterisation in adults: A randomised controlled trial","volume":"29","author":"Basak","year":"2020","journal-title":"J. Clin. Nurs."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"630","DOI":"10.1016\/j.jopan.2023.11.006","article-title":"Effect of breathing exercise during peripheral venous catheterization on pain, anxiety, and patient satisfaction: A randomized controlled trial","volume":"39","author":"Korkut","year":"2024","journal-title":"J. PeriAnesth Nurs."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"294","DOI":"10.1097\/NAN.0000000000000294","article-title":"Effects of thermomechanical stimulation during intravenous catheter insertion in adults: A prospective randomized study","volume":"41","author":"Redfern","year":"2018","journal-title":"J. Infus. Nurs."},{"key":"ref_17","first-page":"1572","article-title":"The effect on pain of three different nonpharmacological methods in peripheral intravenous catheterization in adults","volume":"26","year":"2017","journal-title":"J. Clin. Nurs."},{"key":"ref_18","doi-asserted-by":"crossref","unstructured":"Y\u0131lmaz, E., and Y\u0131lmaz, D. (2024). The effect of three different nonpharmacological methods on cannulation success during peripheral intravenous catheter placement in the emergency unit: A randomized controlled trial. BMC Anesthesiol., 24.","DOI":"10.1186\/s12871-024-02723-2"},{"key":"ref_19","first-page":"1371","article-title":"The impact of two methods on pain and anxiety during short peripheral cannula placement: A randomized controlled trial","volume":"26","author":"Su","year":"2024","journal-title":"J. Vasc. Access"},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"103460","DOI":"10.1016\/j.gerinurse.2025.103460","article-title":"The impact of the cough trick, spirometer blowing, and stress ball methods on older adults\u2019 pain, anxiety, and comfort during peripheral intravenous catheter practice: A randomized controlled study","volume":"65","author":"Turan","year":"2025","journal-title":"Geriatr. Nurs."},{"key":"ref_21","first-page":"1533","article-title":"Benefits of the application of heat and pressure on peripheral venous cannulation in adults: A randomized controlled trial","volume":"77","year":"2020","journal-title":"J. Adv. Nurs."},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"925","DOI":"10.1016\/j.jen.2025.04.005","article-title":"The effect of using thermomechanical stimulation and virtual reality glasses during peripheral intravenous catheterization on pain and patient satisfaction: A randomized controlled trial","volume":"51","author":"Serin","year":"2025","journal-title":"J. Emerg. Nurs."},{"key":"ref_23","first-page":"1123","article-title":"The effect of using vein visualization devices to facilitate peripheral intravenous cannulation on pain, fear, and patient satisfaction in adult oncology patients: A randomized controlled trial","volume":"33","author":"Karacan","year":"2025","journal-title":"Support. Care Cancer"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"292","DOI":"10.1016\/j.bja.2019.11.020","article-title":"Hypnosis and communication reduce pain and anxiety in peripheral intravenous cannulation: A multicentre randomised trial","volume":"124","author":"Fusco","year":"2020","journal-title":"Br. J. Anaesth."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"356","DOI":"10.1016\/j.pmn.2020.12.005","article-title":"Effect of hand massage on pain, anxiety, and vital signs in patients before venipuncture procedure: A randomized controlled trial","volume":"22","year":"2021","journal-title":"Pain. Manag. Nurs."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"1853","DOI":"10.1177\/11297298231190250","article-title":"Comparison of procedure-related pain and patient satisfaction according to catheter size and insertion site in peripheral intravenous catheterization","volume":"25","author":"Kaplan","year":"2024","journal-title":"J. Vasc. Access"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"1936","DOI":"10.1177\/11297298251314217","article-title":"Comparison Valsalva maneuver and auriculotherapy on pain intensity of peripheral intravenous cannulation in adults: A randomized clinical trial","volume":"26","author":"Hosseini","year":"2025","journal-title":"J. Vasc. Access"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"104988","DOI":"10.1016\/j.ijnurstu.2024.104988","article-title":"Efficacy of a vein visualisation device for facilitating peripheral venous line placement in adult patients with sickle cell disease: A randomised clinical trial","volume":"163","author":"Corbasson","year":"2025","journal-title":"Int. J. Nurs. Stud."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"179","DOI":"10.7586\/jkbns.25.018","article-title":"Effects of a thermoelectric element tourniquet on venipuncture pain and stress relief in Korea: A randomized controlled trial","volume":"27","author":"Lee","year":"2025","journal-title":"J. Korean Biol. Nurs. Sci."},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"64","DOI":"10.1016\/j.ctcp.2016.03.008","article-title":"Evaluating the efficacy of lavender aromatherapy on peripheral venous cannulation pain and anxiety: A prospective, randomized study","volume":"23","author":"Karaman","year":"2016","journal-title":"Complement. Ther. Clin. Pract."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"364","DOI":"10.47857\/irjms.2024.v05i01.0224","article-title":"Impact of Local Heat Application on Peripheral Intravenous Cannulation Among Patients","volume":"5","author":"Sharma","year":"2024","journal-title":"Int. Res. J. Multidiscip. Scope"},{"key":"ref_32","doi-asserted-by":"crossref","unstructured":"Ak\u00e7oban, S., and Tosun, B. (Pain Manag. Nurs., 2025). Breathing Exercises, Valsalva Maneuver Reduce Pain in Peripheral Intravenous Catheterization: Randomized Trial, Pain Manag. Nurs., in press.","DOI":"10.1016\/j.pmn.2025.10.010"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"337","DOI":"10.1016\/j.anr.2021.12.003","article-title":"Effects of a Thermoelectric Element Band on Venipuncture-associated Pain and Anxiety: A Randomized Controlled Trial","volume":"15","author":"Hur","year":"2021","journal-title":"Asian Nurs. Res."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"772","DOI":"10.1097\/PSY.0000000000001246","article-title":"Is Positive Communication Sufficient to Modulate Procedural Pain and Anxiety in the Emergency Department? A Randomized Controlled Trial","volume":"85","author":"Berna","year":"2023","journal-title":"Psychosom. Med."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"397","DOI":"10.1097\/NAN.0000000000000065","article-title":"The Effect of Acupressure on Pain and Anxiety Caused by Venipuncture","volume":"38","author":"Hosseinabadi","year":"2015","journal-title":"J. Infus. Nurs."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"62","DOI":"10.1016\/j.explore.2023.06.002","article-title":"The effect of rose oil aromatherapy and hand-holding on pain due to peripheral intravenous catheter insertion","volume":"20","author":"Basak","year":"2024","journal-title":"Explore"},{"key":"ref_37","first-page":"21","article-title":"A comparative study on impact of dry versus moist heat application on feasibility of peripheral intravenous cannulation among the patients of a selected hospital at Mangalore","volume":"7","author":"Jisha","year":"2017","journal-title":"Nitte Univ. J. Health Sci."},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"335","DOI":"10.1007\/s40520-016-0547-0","article-title":"Effects of a new device to guide venous puncture in elderly critically ill patients: Results of a pilot randomized study","volume":"29","author":"Fumagalli","year":"2017","journal-title":"Aging Clin. Exp. Res."},{"key":"ref_39","first-page":"219","article-title":"Evaluating the efficacy of Valsalva\u2019s maneuver and music therapy on peripheral venous cannulation: A prospective study","volume":"22","author":"Tapar","year":"2018","journal-title":"Anaesth. Pain. Intensive Care"},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"21","DOI":"10.1111\/hae.12513","article-title":"Prospective evaluation of venous access difficulty and a near-infrared vein visualizer at four French haemophilia treatment centres","volume":"21","author":"Guillon","year":"2015","journal-title":"Haemophilia"},{"key":"ref_41","doi-asserted-by":"crossref","unstructured":"Rodr\u00edguez-Herrera, \u00c1., Solaz-Garc\u00eda, \u00c1., Moll\u00e1-Olmos, E., Ferrer-Puchol, D., Esteve-Claramunt, F., Trujillo-Barber\u00e1, S., Garc\u00eda-Bermejo, P., and Casa\u00f1a-Mohedo, J. (2022). Use of the Ultrasound Technique as Compared to the Standard Technique for the Improvement of Venous Cannulation in Patients with Difficult Access. Healthcare, 10.","DOI":"10.3390\/healthcare10020261"},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"9459103","DOI":"10.1155\/2019\/9459103","article-title":"Mechanisms of \u201ccough-trick\u201d for pain relief during venipuncture: An experimental crossover investigation in healthy volunteers","volume":"2019","author":"Usichenko","year":"2019","journal-title":"Pain. Res. Manag."},{"key":"ref_43","doi-asserted-by":"crossref","unstructured":"Cooke, M., Ullman, A.J., Ray-Barruel, G., Wallis, M., Corley, A., and Rickard, C.M. (2018). Not \u201cjust\u201d an intravenous line: Consumer perspectives on peripheral intravenous cannulation (PIVC). An international cross-sectional survey of 25 countries. PLoS ONE, 13.","DOI":"10.1371\/journal.pone.0193436"},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"467","DOI":"10.5847\/wjem.j.1920-8642.2022.104","article-title":"Management of difficult intravenous access: A qualitative review","volume":"13","author":"Ng","year":"2022","journal-title":"World J. Emerg. Med."},{"key":"ref_45","doi-asserted-by":"crossref","unstructured":"Bond, M., Crathorne, L., Peters, J., Coelho, H., Haasova, M., Cooper, C., Milner, Q., Shawyer, V., Hyde, C., and Powell, R. (2016). First do no harm: Pain relief for the peripheral venous cannulation of adults, a systematic review and network meta-analysis. BMC Anesthesiol., 16.","DOI":"10.1186\/s12871-016-0252-8"},{"key":"ref_46","first-page":"155","article-title":"The effect of slow deep breathing relaxation exercise on pain levels during and post chest tube removal after coronary artery bypass graft surgery","volume":"9","author":"Jarrah","year":"2022","journal-title":"Int. J. Nurs. Sci."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"857","DOI":"10.1016\/j.jemermed.2020.03.027","article-title":"Reducing pain during emergency arterial sampling using three anesthetic methods: A randomized controlled clinical trial","volume":"58","author":"Pagnucci","year":"2020","journal-title":"J. Emerg. Med."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"107580","DOI":"10.1016\/j.burns.2025.107580","article-title":"The effect of virtual reality and music on pain, anxiety, and pain-related anxiety in burn patient care","volume":"51","author":"Filinte","year":"2025","journal-title":"Burns"},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"2582444","DOI":"10.1080\/20565623.2025.2582444","article-title":"Patient\u2019s satisfaction, acceptability, and feasibility of virtual reality for pain and anxiety management during bone marrow biopsy","volume":"11","author":"Amara","year":"2025","journal-title":"Future Sci. OA"},{"key":"ref_50","doi-asserted-by":"crossref","unstructured":"Maruszak, A., Roma\u0144czuk, D., Lange, S., M\u0119drzycka-D\u0105browska, W., Cichowlas, G., and G\u0105sior, A. (2026). Local pharmacological interventions for pain relief during peripheral venous cannulation: A systematic review and implications for clinical nursing practice. J. Clin. Med., 15.","DOI":"10.3390\/jcm15031262"},{"key":"ref_51","doi-asserted-by":"crossref","first-page":"147","DOI":"10.9740\/mhc.2017.07.147","article-title":"Essential oil of lavender in anxiety disorders: Ready for prime time?","volume":"7","author":"Malcolm","year":"2018","journal-title":"Ment. Health Clin."},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"e70001","DOI":"10.1111\/jorc.70001","article-title":"The effect of music on fistula needle insertion-related pain intensity and pain distress: A single-centre, single-blind, randomised controlled trial","volume":"51","author":"Baykan","year":"2025","journal-title":"J. Ren. Care"},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"1","DOI":"10.5114\/ait.2023.126309","article-title":"Heart rate variability in anaesthesiology\u2014Narrative review","volume":"55","author":"Wujtewicz","year":"2023","journal-title":"Anaesthesiol. Intensive Ther."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/7\/2662\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,3,31]],"date-time":"2026-03-31T16:52:39Z","timestamp":1774975959000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/7\/2662"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,3,31]]},"references-count":53,"journal-issue":{"issue":"7","published-online":{"date-parts":[[2026,4]]}},"alternative-id":["jcm15072662"],"URL":"https:\/\/doi.org\/10.3390\/jcm15072662","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,3,31]]}}}