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The rotation of a star and the revolutions of its planets are not necessarily aligned. This article reviews the measurement techniques, key findings, and theoretical interpretations related to the obliquities (spin–orbit angles) of planet-hosting stars. The best measurements are for stars with short-period giant planets, which have been found on prograde, polar, and retrograde orbits. It seems likely that dynamical processes such as planet–planet scattering and secular perturbations are responsible for tilting the orbits of close-in giant planets, just as those processes are implicated in exciting orbital eccentricities. The observed dependence of the obliquity on orbital separation, planet mass, and stellar structure suggests that in some cases, tidal dissipation damps a star’s obliquity within its mainsequence lifetime. The situation is not as clear for stars with smaller or wider-orbiting planets. Although the earliest measurements of such systems tended to find low obliquities, some glaring exceptions are now known in which the star’s rotation is misaligned with respect to the coplanar orbits of multiple planets. In addition, statistical analyses based on projected rotation velocities and photometric variability have found a broad range of obliquities for F-type stars hosting compact multiple-planet systems. The results suggest it is unsafe to assume that stars and their protoplanetary disks are aligned. Primordial misalignments might be produced by neighboring stars or more complex events that occur during the epoch of planet formation.

We review the use of young low mass stars and protostars, or young stellar objects (YSOs), as tracers of star formation. Observations of molecular clouds at visible, infrared, radio and X-ray wavelengths can identify and characterize the YSOs populating these clouds, with the ability to detect deeply embedded objects at all evolutionary stages. Surveys with the Spitzer, Herschel, XMM-Newton and Chandra space telescopes have measured the spatial distribution of YSOs within a number of nearby (<2.5 kpc) molecular clouds, showing surface densities varying by more than three orders of magnitude. These surveys have been used to measure the spatially varying star formation rates and efficiencies within clouds, and when combined with maps of the molecular gas, have led to the discovery of star-forming relations within clouds. YSO surveys can also characterize the structures, ages, and star formation histories of embedded clusters, and they illuminate the relationship of the clusters to the networks of filaments, hubs and ridges in the molecular clouds from which they form. Measurements of the proper motions and radial velocities of YSOs trace the evolving kinematics of clusters from the deeply embedded phases through gas dispersal, providing insights into the factors that shape the formation of bound clusters. On 100 pc scales that encompass entire star-forming complexes, Gaia is mapping the young associations of stars that have dispersed their natal gas and exist alongside molecular clouds. These surveys reveal the complex structures and motions in associations, and show evidence for supernova driven expansions. Remnants of these associations have now been identified by Gaia, showing that traces of star-forming structures can persist for a few hundred million years.

In this review/tutorial we explore planetary nebulae as a stage in the evolution of low-to-intermediate-mass stars, as major contributors to the mass and chemical enrichment of the interstellar medium, and as astrophysical laboratories. We discuss many observed properties of planetary nebulae, placing particular emphasis on element abundance determinations and comparisons with theoretical predictions. Dust and molecules associated with planetary nebulae are considered as well. We then examine distances, binarity, and planetary nebula morphology and evolution. We end with mention of some of the advances that will be enabled by future observing capabilities.

Magnetohydrodynamic (MHD) turbulence is a crucial component of the current paradigms of star formation, dynamo theory, particle transport, magnetic reconnection, and evolution of structure in the interstellar medium (ISM) of galaxies. Despite the importance of turbulence to astrophysical fluids, a full theoretical framework based on solutions to the Navier–Stokes equations remains intractable. Observations provide only limited line-of-sight information on densities, temperatures, velocities, and magnetic field strengths, and therefore directly measuring turbulence in the ISM is challenging. A statistical approach has been of great utility in allowing comparisons of observations, simulations, and analytic predictions. In this review article, we address the growing importance of MHD turbulence in many fields of astrophysics and review statistical diagnostics for studying interstellar and interplanetary turbulence. In particular, we will review statistical diagnostics and machine learning algorithms that have been developed for observational data sets in order to obtain information about the turbulence cascade, fluid compressibility (sonic Mach number), and magnetization of fluid (Alfvénic Mach number). These techniques have often been tested on numerical simulations of MHD turbulence, which may include the creation of synthetic observations, and are often formulated on theoretical expectations for compressible magnetized turbulence. We stress the use of multiple techniques, as this can provide a more accurate indication of the turbulence parameters of interest. We conclude by describing several open-source tools for the astrophysical community to use when dealing with turbulence.

IntroductionAlthough High Thoracic Epidural analgesia (HTEA) has been replaced as a gold standard in minimal invasive surgical procedures, it still is a viable technique in open major surgery (e.g., vascular, thoracic, abdominal).1 Performing a HTEA is difficult to master.2 Published failure rates average from moderate to high.3,4 Reduced caseloads further diminish training and competence proficiency, augmenting the problem.5 We will examine common pitfalls and barriers, while determining factors for success. Finally evaluate novelties to improve favorable results and investigate all modalities to aid successful placement.DiscussionEnhanced Recovery programs and minimal invasive surgical techniques have had a detrimental impact on the choice for thoracic epidural as regional analgesic technique. Multimodal analgesic strategies, including fascial plane blocks, are indeed a key element in modern day low impact surgery.6 However, postoperative pain management for major surgery like esophagectomies, thoracotomies, open abdominal aortic surgery and any major open hepatobiliary surgery remain a challenge for anesthesiologists. Even if the effect on morbidity and mortality is controversial, HTEA still has major benefit in reducing opioid consumption combined with a well-known effect on surgical inflammatory cascade.7 Aiding Success.First of all, to adapt to diminishing caseloads it is imperative that modern teaching methods are implemented. Simulators, online tools, webinars, video tutorials can have a tremendous impact on training. A basic (lumbar) epidural simulator is a small investment for any anesthetic department to make, with a great return on investment.8 Video-based learning systems have shown to provide some gains.2 While online tools like Virtual Spine: lumbar anatomy, 3D model, vertebra, spinal cord, dura, meninges, cauda equina, ultrasound (utoronto.ca) have a profound influence on our anatomical knowledge, unfortunately there is currently not enough evidence on beneficial impact on performance.Secondly ultrasound (US), although not mandatory to perform thoracic epidurals, can make life easier and also increase enthusiasm of young colleagues for the technique. US has not proven to increase success rates yet, however it facilitates identifying midline and familiarize the unfamiliar with the anatomy.9 Thirdly the thoracic epidural should be taught properly with respect to all small clinical pearls. Positioning, preparation, adequate communication, effective local anesthesia, organization and adaptation are extremely important and will probably be the best advice to improve your prowess. A locoregional fellowship where a sufficient number of thoracic epidurals are still placed is your best bet when fishing for these pearls.10 Lastly the loss of resistance technique is a subtle art indeed. Even with excellent coaching and teaching, this skill cannot be easily transferred to the onlooker. To help ascertain a correct loss of resistance technique there are some tips and tricks up our sleeves. The hanging drop approach can help needle advancement meticulously and carefully, while using both hands. Various spring-loaded syringes have also been developed to aid the developing skills. Results with these devices have been mostly mixed.11 Ascertaining success.As described above, assistance of clinical pearls in ascertaining the accurate placement of an epidural needle and catheter play a crucial role. Generally, you can scrutinize three different clinical questions. Was the loss clear? Was the threading of the catheter easy (or even possible) and did patients feel a slight paresthesia while threading the catheter? And finally, is saline column in the epidural catheter dropping steadily when elevated?There are several more robust ways to confirm success. Fluoroscopy has already shown to be one of the best predictors of exact epidural catheter placement. It also has the added advantage of lowering failure rate and almost eliminating dislodgements completely. However, the investment in equipment, training, radiological protection and interpretation of imaging has hindered any broad implementation.Waveform analysis12 can either be used with an auditive sound adapter, which requires a specific device.12 In addition, it can be used by placing a pressure transducer on the epidural needle and examining the presence of a pulsatile pressure wave.Tsui test13 or epidural electrical stimulation test (EST) is in my humble opinion the best way to detect perfect positioning of the catheter.13 However, it is very underutilized, probably due to poor understanding and lack of availability of a ‘Johans Adapter’ (figure 1).Abstract SP17 Figure 1Johans AdapterOther devices and future developments like bioimpedance or optical reflectance spectroscopy may still impact the way we place thoracic epidurals, however fall beyond the scope of this lecture.ConclusionHTEA is a very effective anesthetic technique which should be reserved for major surgery and preserved for future generations. The training of this approach is progressively more difficult with ever decreasing numbers. Online resources, ultrasound and simulators should be implemented to reach proficiency. Clinical pearls, optimal caseload and training by experts is the best way to go. More research is needed in tools like special syringes and waveform analysis devices to analyze their usefulness. The Tsui test is the ultimate practical test to evaluate successful catheter placement.ReferencesBachman SA, Lundberg J, Herrick M. Avoid suboptimal perioperative analgesia during major surgery by enhancing thoracic epidural catheter placement and hemodynamic performance. Regional Anesthesia & Pain Medicine 2021; 46: 532–534.Seering M, Campos JH. Educational Methods to Improve Thoracic Epidural Block Proficiency for Residents: Video-Based Education Versus Bedside Education. Journal of Cardiothoracic and Vascular Anesthesia 2020; 34: 3049–3051.Hermanides J, Hollmann MW, Stevens MF, Lirk P. Failed epidural: Causes and management. British Journal of Anaesthesia 2012; 109: 144–154.Elsharkawy H, Sonny A, Chin K. Localization of epidural space: A review of available technologies. Journal of Anaesthesiology Clinical Pharmacology 2017; 33: 16.Tran DQH, van Zundert TCRV, Aliste J, Engsusophon P, Finlayson RJ. Primary failure of thoracic epidural analgesia in training centers: The invisible elephant? Regional Anesthesia and Pain Medicine 2016; 41: 309–313.Sondekoppam R v., Tsui BCH. ‘Minimally invasive’ regional anesthesia and the expanding use of interfascial plane blocks: the need for more systematic evaluation. Canadian Journal of Anesthesia/Journal canadien d’anesthésie 2019; 66: 855–863.Pöpping DM, Elia N, van Aken HK, Marret E, Schug SA, Kranke P et al. Impact of Epidural Analgesia on Mortality and Morbidity After Surgery. Annals of Surgery 2014; 259: 1056–1067.Vaughan N, Dubey VN, Wee MYK, Isaacs R. A review of epidural simulators: Where are we today? Medical Engineering & Physics 2013; 35: 1235–1250.Auyong DB, Hostetter L, Yuan SC, Slee AE, Hanson NA. Evaluation of Ultrasound-Assisted Thoracic Epidural Placement in Patients Undergoing Upper Abdominal and Thoracic Surgery. Regional Anesthesia and Pain Medicine 2017; 42: 204–209.Lorin MI, Palazzi DL, Turner TL, Ward MA. What is a clinical pearl and what is its role in medical education? Medical Teacher 2008; 30: 870–874.Riley ET, Carvalho B. The EpisureTM Syringe: A Novel Loss of Resistance Syringe for Locating the Epidural Space. Anesthesia & Analgesia 2007; 105: 1164–1166.McKendry RA, Muchatuta NA. Pressure waveforms to assess epidural placement: is there a role on delivery suite? Anaesthesia 2017; 72: 815–820.Kwofie MK, Launcelott G, Tsui BCH. Determination of thoracic epidural catheter placement: electrical epidural stimulation (Tsui test) is simple, effective, and under-utilized. Canadian Journal of Anesthesia/Journal canadien d’anesthésie 2019; 66: 360–364.

Pain is a significant problem in patients with cancer. Half of patients undergoing active therapy have pain, more than one-third of cancer patients have pain after curative-intent therapy, and up to two-thirds of patients with advanced or metastatic cancer have pain (Everdingen et al. 2016). Chronic pain is also present in about half of the cancer survivors (Marnangeli et al. 2022).The etiology of pain in patients with cancer is multifactorial and may be related not only to the underlying cancer but also to comorbidities, cancer therapies, or the psychosocial factors that often accompany chronic or terminal illness.Breakthrough cancer pain(BTcP), a transient exacerbation of pain that occurs within the context of stable and adequately controlled background pain, is part of this complex problem.(Portenoy et al. 1999)There is no universally accepted definition to describe breakthrough cancer pain. Additionally, there is disagreement as to what constitutes breakthrough cancer pain (Zeppetella 2009). More recent definitions do not include regular opioid medication or background pain as prerequisites for BTcP(Løhre et al. 2020, Mercadante et al. 2016).BTP is highly variable, (Davies et al. 2013) with a prevalence ranging from 40% to 80%, (Deandrea et al. 2014) but prevalence rates of 90% have been reported (Zeppetella et al. 2000) and may result from the disease itself, disability caused by cancer, anticancer treatment or other factors. It usually has a rapid onset - that is, a time to peak severity of 5–30 min, but with a wide range extending to1 hour (Caraceni et al. 2004). Its duration is often shortlasting and<60 min but may last for >3 hours.The differences reported are probably because of different settings and meanings attributed to the definition of breakthrough pain. In an international survey of cancer pain characteristics and syndromes, large differences in the diagnosis of breakthrough pain by clinicians of different countries have been found, suggesting that this phenomenon is diagnosed differently in various countries (Caraceni et al 1999). These controversial aspects, both semantic and clinical, were discussed in a consensus meeting of an expert working group from the Research Network of the European Association for Palliative Care during the 2nd International and Hellenic Conference on Pain Relief and Palliative Care (PA.RH.SYA) held in Athens in March 1999. (Mercadante et al. 2002)BTcP may be nociceptive, neuropathic or a mixture of both. (Vadalouca et al. 2012)Cancer BTP is often severe and can greatly interfere with all aspects of daily living.One of the biggest problems with breakthrough cancer pain is its underassessment, and it is therefore underrecognized and undertreated. Pain assessment usually consists of questions about pain location, intensity, quality, and temporal factors. However, a lack of standardized assessment approaches exists for breakthrough cancer pain (Brant and Stringer 2018). Clinical Practice Guidelines (CPGs) are statements that include recommendations intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options. Recommendations are the core components of CPGs and should be presented as clear, specific and actionable statements. Several Clinical Practice Guidelines (CPGs ), consensus statements, and recommendations currently exist for the diagnosis and management of breakthrough cancer pain (BTcP). Generic Cancer Pain Guidelines providing recommendations about the management of BTcP, have been developed by: the European Association of Palliative Care (Caraceni et al. 2012) European Society for Medical Oncology (Ripamonti et al. 2012), the Cancer Council Australia (Cancer Guidelines Wiki), the Japanese Society Palliative Medicine (Yamaguchi et al. 2013), the Ministry of Health and Welfare and National Cancer Center South Korea, the National Comprehensive Cancer Network (2016). Specific BTcP Guidelines were also generated by: the Association for Palliative Medicine of Great Britain and Ireland (Davies et al. 2009), the EAPC (Mercadante et al. 2002), the European Oncology Nursing Society (Wengström et al. 2014), the Sociedad Espanola del Dolor (Escobar Álvarez et al. 2013), an international pharmaceutical company-sponsored experts team in BTcP (Caraceni et al. 2013), the German Pain Society, the Italian Oncologic Pain Survey expert group (Mercadante et al. 2016), a meeting that produced the Canadian recommendations (Daeninck et al. 2016), and an interdisciplinary group of Spanish pain experts (López Alarcón et al. 2019).French guidelines also discuss the use of the so-called rapid-onset opioids (ROOs) for BTcP( Poulain et al. 2012).A recent systematic review of the above specific BTcP and international generic cancer pain guidelines concluded that current guidelines agree on many aspects of the management of BTcP. However, the evidence to support current guidelines remains low grade, and so more research is needed in this area of care. Moreover, there needs to be an international consensus on the definition and diagnosis criteria of BTcP.(Davies et al. 2018)Also, this year a quality appraisal of CPGs has been performed for the diagnosis and management of BTcP using the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool. Scaled domain scores were generated and the threshold used for satisfactory quality was >60%. Additionally, intraclass correlation coefficients (ICC) were calculated to determine level of agreement between reviewers.Eleven guidelines were selected for final evaluation. Only one guideline was classified of ‘average’ quality while the rest were classified as ‘low’ quality. The ‘Editorial Independence’ (70.46 ± 35.7) and ‘Scope and Purpose’ (64.78 ± 12.5) domains received the highest mean scores, while the ‘Applicability’ (32.58 ± 13.5) and ‘Rigor of Development’ (35.04 ± 9.0) domains received the lowest mean scores. ICC statistical analysis showed high magnitude of agreement between reviewers with a range of (0.790–0.988).Reflecting upon this quality appraisal, it is evident that the quality and methodologic rigor of BTcP guidelines can be improved upon in the future. These findings also elucidate the existing variability/discrepancies among guidelines in diagnostic criteria and management of BTcP( Suresh et al. 2022).ConclusionA comprehensive pain management approach that addresses the various presentations of pain in patients with cancer is required, including appropriate management of breakthrough pain (Caraceni et al 2013). Because pain is heterogeneous, the best management of an individual’s pain, including breakthrough pain in cancer, requires a thorough assessment to tailor the treatment strategies. The developed guidelines support this approach and recommend treating breakthrough pain using rapid- or short-acting opioids with pharmacodynamics that mirror the rapid onset and short duration of the presenting pain. This approach should be part of a comprehensive strategy to treat pain within the context of the primary disease trajectory, offering continuity of care and access to specialized Pain therapy and Palliative care services.ReferencesVan den Beuken-Van Everdingen MH, Hochstenbach LM, Joosten EA, Tjan-Heijnen VC, Janssen DJ (2016) Update on prevalence of pain in patients with cancer: systematic review and meta-analysis. Journal of Pain and Symptom Management 51(6):1070–1090.e9. doi:/10.1016/j.jpainsymman.2015.12.340Marnangeli F, Saetta A, Lugini A (2022) Current management of cancer pain in Italy: Expert opinion paper. Open Medicine 2022(17): 34–45.Portenoy RK, Payne D, Jacobsen P (1999) Breakthrough pain: characteristics and impact in patients with cancer pain. Pain, 81(1–2): 129–134. doi:10.1016/s0304-3959(99)00006-8Zeppetella G (2009) Impact and management of breakthrough pain in cancer. Current Opinion in Supportive and Palliative Care 3(1): 1–6. doi:10.1097/SPC.0b013e3283260658Løhre ET, Thronæs M, Klepstad P (2020). Breakthrough cancer pain in 2020. Current Opinion in Supportive and Palliative Care 14(2): 94–99. doi:10.1097/SPC.0000000000000494Mercadante S, Marchetti P, Cuomo A, Mammucari M, Caraceni A, IOPS MS study Group (2016) Breakthrough pain and its treatment: critical review and recommendations of IOPS (Italian Oncologic Pain Survey) expert group. Supportive Care in Cancer: Official Journal of the Multinational Association of Supportive Care in Cancer 24(2): 961–968. doi:10.1007/s00520-015-2951-y.Davies A, Buchanan A, Zeppetella G, Porta-Sales J, Likar R et al (2013) Breakthrough cancer pain: an observational study of 1000 European oncology patients. Journal of Pain and Symptom Management 46(5): 619–628. doi:10.1016/j.jpainsymman.2012.12.009.Deandrea S, Corli O, Consonni D, Villani W, Greco MT, Apolone G (2014) Prevalence of breakthrough cancer pain: a systematic review and a pooled analysis of published literature. Journal of Pain and Symptom Management 47(1):57–76. doi:10.1016/j.jpainsymman.2013.02.015.Zeppetella G, O’Doherty CA, Collins S (2000) Prevalence and characteristics of breakthrough pain in cancer patients admitted to a hospice. Journal of Pain and Symptom Management 20(2): 87–92. doi:10.1016/s0885-3924(00)00161-5Caraceni A, Martini C, Zecca E, Portenoy RK, Ashby MA, et al. (2004) Breakthrough pain characteristics and syndromes in patients with cancer pain. An international survey. Palliative Medicine 18(3): 177–183. doi:10.1191/0269216304pm890oa.Caraceni A, Portenoy RK, A working group of the IASP Task Force on Cancer Pain (1999) An international survey of cancer pain characteristics and syndromes. IASP Task Force on Cancer Pain. International Association for the Study of Pain. Pain 82(3): 263–274. doi:10.1016/S0304-3959(99)00073-1.Mercadante S, Radbruch L, Caraceni A, Cherny N, Kaasa S, Nauck F, Ripamonti C, De Conno F, Steering Committee of the European Association for Palliative Care (EAPC) Research Network (

Introduction the problemPostdural puncture headache (PDPH) is a common iatrogenic complication of neuraxial anesthesia following dural puncture.1 It may occur after inadvertent dura mater puncture in epidural anaesthesia, after spinal anesthesia and after lumbar diagnostic or therapeutic procedures.The overall incidence of PDPH after neuraxial procedures varies from 6 to 36%.1 It is more common in younger populations and is significantly higher in teenagers compared to those aged 20–45 years.2 The elderly may also develop postdural puncture headache.3 The incidence of unintentional dural puncture is estimated to be approximately 1.5%. Furthermore, up to 36% and in some reports as high as 76 to 85% of these patients may experience PDPH symptoms.1 Etiology and clinical manifestationsPDPH is caused by leakage of cerebrospinal fluid through the dural hole created by the needle. It can be considered a clinical model of intracranial hypotension and is characterized by a headache that occurs within 5 days following the puncture, located in the frontal and/or occipital region.4 5 It is usually of postural nature and is accompanied by associated symptoms like neck stiffness, dizziness, nausea, hearing symptoms (tinnitus, hearing loss) and vision changes (diplopia, blurred vision, or photophobia.5 PDPH ConsequencesThe occurrence of PDPH is problematic as it causes functional and socio-professional disability leading to increased patient morbidity, delayed discharge and increased readmission.6 It is also associated with increased risks of major neurological and long-lasting complications.7 Cases of persistent headache have been reported and chronic back pain as well.7 Hypoacusis and tinnitus have been seen after dural puncture and have been thought to stem from the loss of CSF leading to reduced intracranial CSF pressure. There is also increased risk of subdural hematoma (due to rupture of meningeal veins) and cerebral vein thrombosis.8 These complications underscore the importance of prophylaxis, early diagnosis, treatment and follow up of PDPH.4 Risk FactorsThe risk factors for PDPH are classified as nonmodifiable and modifiable. Nonmodifiable factors include the female sex, young age, teenagers, lower body mass index (BMI), previous PDPH, and chronic headaches. Risk factors that are modifiable include needle size, needle shape, direction of the needle bevel, stylet replacement, and operator experience.8 The use of atraumatic, noncutting needles is the most effective intervention for post-lumbar puncture headache prevention.9–11 Frequent attempts during lumbar puncture and increased cerebrospinal fluid leakage were associated with PDPH.12 13 Neither bed rest nor fluid supplementation decreases the incidence of headache after dural puncture14; bed rest may even worsen post-lumbar puncture headache.6 Insertion of an intrathecal catheter at the site of ADP significantly reduces the incidence and severity of PDPH.15 PDPH incidence after lumbar puncture using a 22 G Tuohy needle was higher than that after lumbar CSF drainage using an 18 G Tuohy needle, suggesting that catheter insertion may reduce PDPH risk.12 DiagnosisThe diagnosis of PDPH is made clinically by identifying the typical headache within 5 days after a dural puncture. Other causes may need to be excluded if symptoms are atypical.16 Serious and life-threatening etiologies (eg, hemorrhage, thrombosis, vasculopathy, meningitis), which may or may not be related to the dural puncture, must be ruled out in the presence of focal or worsening neurologic deficits. Neuroimaging is not indicated unless required to exclude differential diagnoses.7 TreatmentThe treatment of PDPH depends upon the severity of headache and its impact on the patient‘s ability to function.7Patients with mild PDPH may benefit from conservative treatment including bed rest as needed, caffeine and oral analgesics.1Patients who are unable to tolerate sitting or standing are considered to have moderate to severe PDPH and the epidural blood patch continues to be the most widespread treatment. Though epidural blood patch is recognized as the gold standard in the treatment of severe PDPH is also not without risk. It may either fail or lead to another inadvertent dural puncture. Other potential adverse events/reactions that may occur during a blood patch are back pain, meningitis, subdural abscess, facial nerve paralysis, spastic paraparesis, and cauda equina syndrome.7 The safer alternative therapies for PDPH which are efficacious, easy to administer and with less risk are the bilateral greater occipital nerve block17 18 and transnasal sphenopalatine ganglion block.19 20 In conclusionPDPH is a problematic complication and should not be left unattended and untreated. There is the potential for considerable morbidity, even death. Since lumbar puncture is very common in clinical practice, it is necessary for practitioners to have a holistic knowledge of the risk factors, pathophysiological, diagnostic, differential diagnostic and therapeutic aspects of PDPH. An evidence-based approach with written institutional protocols to the management of unintentional dural puncture and PDPH are important to ensure patients’ safety and optimal care.ReferencesRiki Patel. A Comprehensive Update on the Treatment and Management of Postdural Puncture Headache. Curr Pain Headache Rep (2020) 24:24.DelPizzo et al. Risk of Postdural Puncture Headache in Adolescents and Adults. Anesth Analg. 2020 July ; 131(1): 273–279.Sjövall S et al. Postdural puncture headache and epidural blood patch use in elderly patients. J Clin Anesth 2015 Nov;27(7):574–8.Ljubisavljevic S. Postdural puncture headache as a complication of lumbar puncture: clinical manifestations, pathophysiology, and treatment. Neurol Sci 2020 Dec;41(12):3563–3568.Headache Classification Committee of the International Headache Society (IHS). Cephalalgia 2018, Vol. 38(1) 1–211Cognat E et al. Preventing Post-Lumbar Puncture Headache. Ann Emerg Med.2021 Sep;78(3):443–450.Bateman BT et al. Post dural puncture headache. Uptodate. Last updated: Jul 27, 2021.Bezov D, Lipton RB, Ashina S. Post-dural puncture headache:Part I diagnosis, epidemiology, etiology, and pathophysiology. Headache 2010;50(7):1144–52.Arevalo-Rodriguez I, Muñoz L, Godoy-Casasbuenas N, Ciapponi A, Arevalo JJ, Boogaard S, Roqué i Figuls M. Needle gauge and tip designs for preventing post-dural puncture headache (PDPH). Cochrane Database of Systematic Reviews 2017.B Maranhao. The association between post-dural puncture headache and needle type during spinal anaesthesia: a systematic review and network meta-analysis. Anaesthesia 2021 Aug;76(8):1098–1110.Ane Skaare Sjulstad et al. Occurrence of postdural puncture headache-A randomized controlled trial comparing 22G Sprotte and Quincke. Brain Behav 2020 Dec;10(12):e01886.Kim et al. Postdural Puncture Headache Related to Procedure: Incidence and Risk Factors After Neuraxial Anesthesia and Spinal Procedures. Pain Medicine, 00(0), 2021, 1–6.Weji et al. Incidence and risk factors of postdural puncture headache: prospective cohort study design. Perioperative Medicine (2020) 9:32.Arevalo-Rodriguez I, Ciapponi A, Roque I Figuls M, et al. Posture and fluids for preventing postdural puncture headache. Cochrane Database Syst Rev. 2016.Ahuja P, Singh R, Jain A. Effect of intrathecal catheterisation on incidence of postdural puncture headache after accidental dural puncture in non-obstetric patients. J Anaesthesiol Clin Pharmacol 2019; 35:49–52.Robert R. Gaiser. Postdural puncture headache: a headache for the patient and a headache for the anesthesiologist. Curr Opin Anesthesiol 2013, 26:296–303.Ying-Jen Chang et al. Efficacy of greater occipital nerve block for pain relief in patients with postdural puncture headache: A meta-analysis. Medicine. 2021 Dec 23;100(51):e28438.Nair, et al. Efficacy of bilateral greater occipital nerve block in postdural puncture headache: a narrative review. Korean J Pain 2018; 31: 80–6. S.Takmaz, et al. Transnasal Sphenopalatine Ganglion Block for Management of Postdural Puncture Headache in Non-Obstetric Patients. J Nippon Med Sch 2021; 88 (4)Kuo-Chuan Hung et al.Use of sphenopalatine ganglion block in patients with postdural puncture headache: a pilot meta-analysis. Br J Anaesth. 2021 Jan;126(1):e25-e27.

Awake breast surgery combines the reduction of hospitalization, postoperative stress, and postoperative lymphopenia, furthermore local anaesthesia and peripheral nerve block provide better analgesia during glandular displacement techniques, as during oncoplastic and axillary surgery. COVID-19 outbreak determined a strong effect on clinical practice worldwide1 and novel approach as awake breast surgery could combine fast track surgery and cross-infection reduction with an optimization of resources and resource optimization in terms of spaces and economic savings with shorter hospital stays.Fast track awake breast surgery provides a reduction of operative room time length of stay and potentially surgical treatment for a wider number of oncological patients.Costa et al proposed, to perform regional anaesthesia for breast procedures, a combination of three techniques: Pecs II block to cover muscles, axilla and lateral cutaneous branches of intercostal nerves (reliably from T2 to T4), erector spinae block block to cover lateral cutaneous branches from T4 to T7 and parasternal block or transversus thoracic muscle plane block to cover anterior cutaneous branches.The introduction of erector spinae block in breast surgery, represents an alternative to general anaesthesia and locoregional conventional techniques, like epidural anaesthesia or paravertebral block in oncological breast surgery, especially in high-risk patients.Santonastaso et al, wonder if the secret to obtaining perfect anaesthesia/analgesia for radical mastectomy procedures associated with sentinel lymph node biopsy, when we need to avoid general anaesthesia, could be the association of multiple techniques between Pecs, Serratus Anterior Block and Erector Spinae Block. More randomized trials are required to provide a certain answer to this question.ReferencesVanni G, Pellicciaro M, Materazzo M, et al. Awake breast cancer surgery: strategy in the beginning of COVID-19 emergency. Breast Cancer 2021;28:137–144.Costa F, Strumia A, Remore LM, Pascarella G, Del Buono R, Tedesco M, et al. Breast surgery analgesia: another perspective for PROSPECT guidelines. Anaesthesia 2020;75:1404–5.Santonastaso D, Dechiara A, Bagaphou CT, Cittadini A, Marsigli F, Russo E, Agnoletti V. Erector spinae plane block associated to serratus anterior plane block for awake radical mastectomy in a patient with extreme obesity. Minerva Anestesiologica 2021 June;87(6):734–6.

University of Nebraska Medical Center, USAInadequate perioperative pain control delays postoperative mobilization, and may lead to development of chronic postoperative pain, amplified cardiac and pulmonary complications, and increased morbidity and mortality.1 Even though opioids are still widely used,2 more information on their misuse, limitations and side-effects is becoming available, including risk of dependence and opioid-induced hyperalgesia (OIH).3 Multimodal analgesia has been defined as the use of two or more analgesics or techniques that target different mechanisms or pathways in the nociceptive system.4 As drugs are combined, lower doses of each class can be given, thereby lowering the side effects of each individual drug, but increasing overall efficacy.5,6 Drugs commonly used in this framework include acetaminophen, non-steroidal anti-inflammatory drugs (NSAID) or cyclo-oxygenase-2 inhibitors, dexamethasone, gabapentin, clonidine, dexmedetomidine, intravenous lidocaine, magnesium and ketamine. When timed correctly, however, regional anesthesia remains the best and most powerful opioid-sparing technique for many indications.ReferencesGerbershagen HJ, Aduckathil S, van Wijck AJ, et al. Pain intensity on the first day after surgery: a prospective cohort study comparing 179 surgical procedures. Anesthesiology 2013;118:934–44.Ladha KS, Patorno E, Huybrechts KF, et al. Variations in the Use of Perioperative Multimodal Analgesic Therapy. Anesthesiology 2016;124:837–45.Wu CL, Raja SN. Treatment of acute postoperative pain. Lancet 2011;377:2215–25.Manworren RC. Multimodal pain management and the future of a personalized medicine approach to pain. AORN J 2015;101:308–14; quiz 15–8.Kehlet H, Dahl JB. The value of ‘multimodal’ or ‘balanced analgesia’ in postoperative pain treatment. Anesth Analg 1993;77:1048–56.Buvanendran A, Kroin JS. Multimodal analgesia for controlling acute postoperative pain. Curr Opin Anaesthesiol 2009;22:588–93.