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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.

Labor is one of the most intense and painful conditions requiring analgesia.1 Neuraxial anesthesia is the gold standard to provide effective, safe and reliable pain relief during labor and delivery.2 Numerous neuraxial techniques exist such as spinal anesthesia, traditional epidural (EPL), combined spinal-epidural (CSE) and dural puncture epidural (DPE).3 Over time, various refinements have been made to optimize the efficacy of the traditional labor epidural. Modifications include the type of neuraxial technique chosen, local anesthetic (LA) concentration and volume, varying strategies for initiation and maintenance of analgesia with different pump delivery systems and addition of adjuncts to LA (most commonly lipophilic opioids).4 The simplest but likely least used technique is spinal anesthesia. This single shot technique is used when rapid onset of analgesia is required, and delivery is expected to occur within an hour (of administration).3 Although quick and effective, there is no means to supplement analgesia once the spinal effect wears off and in the event that anesthesia is required a repeat single shot spinal, epidural or general aesthesia may be necessary.3 Lumbar epidural is the gold standard against which other pain relief measures are evaluated for labor analgesia. 2 The epidural space is identified with the loss of resistance technique and a catheter is inserted into the epidural space. Local anesthetic (with or without adjuvants) is delivered to the epidural space via the catheter.3 Epidural medication can be administered in various ways: manual boluses by the physician, continuous infusion (CEI), patient controlled epidural anesthesia (PCEA), programmed intermittent epidural boluses (PIEB) or a combination of these.4 Although safe and reliable, time to onset of analgesia is relatively slow.5 There may be limited sacral spread of medication, resulting in inadequate analgesia in the second stage of labor. Repeated epidural top-ups may result in large volumes of local anesthetic being given which increases the risk of motor blockade.6 7 In the CSE technique, the dura is intentionally punctured to allow administration of intrathecal medication. The epidural space is located with the loss of resistance technique. Thereafter, a small gauge spinal needle is used to puncture the dura in a needle-through-needle technique. Free flow of cerebrospinal fluid (CSF) confirms correct identification of both the spinal and epidural spaces and accurate midline placement. Intrathecal medication is administered before insertion of the epidural catheter. Maintenance analgesia is provided via the catheter. CSE has a much faster onset time and provides a reliable sacral block due to intrathecal medication when compared to EPL.8 The rate of unilateral and inadequate blocks is lower and fewer physician top-ups are required. This is possibly due to translocation of epidural medication to the intrathecal space via the dural puncture.3 Although CSE allows for rapid pain relief, the sudden decrease in maternal catecholamines may result in uterine hypertonus and fetal bradycardia.9 Other side effects such as maternal hypotension and pruritis may also occur.10 Due to the intrathecal medication, the epidural catheter cannot be immediately tested to exclude intrathecal, intravascular or malpositioned catheters.The DPE was first described by Suzuki et al .11 in a cohort of abdominal surgery patients. As with CSE, the epidural space is located with the loss of resistance technique. The dura is then punctured with a small gauge spinal needle, but no intrathecal medication is administered. It is hypothesised that medication administered in the epidural space will move via the dural puncture into the intrathecal space allowing for faster onset of analgesia, better sacral spread, less unilateral block and lower rate of motor block compared to EPL.6 As no intrathecal medication is given the unwanted side effects such as uterine hypertonus, fetal bradycardia, maternal hypotension and pruritis are minimized.9 12 As the dura is punctured and CSF visualised, confirmation of midline placement is made and a test dose can be administered to rule out an intrathecal or intravascular catheter if desired.13 Thus, the DPE technique proposed to offer the ‘best of both worlds’ providing most of the benefits of the CSE technique without the unwanted side effects, but a faster and more reliable block when compared to EPL. However, the benefits have not consistently been confirmed in the literature when DPE is compared to EPL or CSE due to heterogenous results.Three reviews conducted in 2018 and 2019 by Layera et al.14, Gunaydin et al.15 and Heesen et al.13 were unable to provide clear evidence of benefit when DPE was compared to EPL. However, some helpful conclusions could be drawn. DPE offered a more reliable benefit if a 25 gauge(G) spinal needle was used as opposed to the smaller 26G and 27G needles. This was shown by Cappiello et al.6 and Chau et al.16 with significantly decreased onset times, improved sacral block, decreased unilateral block and decreased top-ups in the DPE groups. A 27G needle for the dural puncture was used in two trials. Firstly, Thomas et al.12 found no difference in quality of analgesia evidenced by no difference in catheter manipulation rates, sacral root sparing, unilateral block, peak block level, number of top-up doses and LA consumption. A higher incidence of dry taps also occurred. In contrast, Yadav et al.17 observed some benefits noting lower visual analogue scale (VAS) scores at 5 and 10 minutes (p<0.008), faster onset time and improved analgesia quality (p<0.05). However, there was no difference in the time to first top up request, LA consumption and duration of labor.17 Wilson et al.5 used a 26G needle for dural puncture. They found although time to VAS <10 was shorter in the DPE group, the percentage of patients with adequate labor analgesia at 10 minutes did not differ between groups.5 No differences in complications or post dural puncture headaches (PDPH) were noted in any studies, however due to small sample sizes, complications occurring less frequently may not have been identified.14 All trials used varying types, concentrations and volumes of LA which made comparison of results challenging.14 Three additional randomized control trials have been conducted since these reviews, but again heterogenous results were found. Two of the trials have incorporated the use of PIEB delivery systems found to be more effective18 and possibly better suited for use with DPB. The proposed mechanism is that during the administration of a LA bolus, pressure within the epidural space will increase thus facilitating movement of medication into the intrathecal space.Song et al.19 compared 3 groups: DPE combined with PIEB, EPL combined with CEI and EPL combined with PIEB including a total of 116 patients. A 25G needle was used for dural puncture. The primary outcome was time to adequate analgesia. As hypothesized, faster onset of analgesia and lower LA consumption was noted in the DPE + PIEB group. Reliable sacral block was also achieved. The incidence of side effects including pruritis, PDPH and maternal hypotension were comparable in all groups. Despite these findings, no difference in maternal satisfaction was found. Unfortunately, due to the lack of a fourth group (EPL and PIEB) in this study, the effect of the PIEB itself is unclear. The extent to which the DPE alone contributed to the favourable outcomes cannot be isolated from the possible effect of the PIEB.20 Bakhet21conducted a study comparing EPL, DPE and CSE combined with a loading dose followed by PCEA in 120 parturients. A 25G needle was used for dural puncture. Primary outcome was mean hourly LA consumption. CSE outperformed both DPE and EPL with regards to LA consumption, time to onset of analgesia, numeric pain rating scale (NPRS) and time to achieve T10 block. There were no significant differences between the DPE and EPL for these observations. Occurrence of motor blockade, side effects and maternal satisfaction were comparable amongst all three groupsMost recently, Tan et al.22 has reported results from a double-blinded randomized controlled trial comparing DPE to EPL in 132 obese parturients. They suggested that the DPE technique may be useful in this patient population as the dural puncture would confirm midline placement resulting in a lower failed epidural rate. Dural puncture was made with a 25G spinal needle and after an initial loading dose, PIEB with a PCEA function provided maintenance analgesia. The primary outcome was a composite of: (1) asymmetrical block, (2) epidural top-ups, (3) catheter adjustments, (4) catheter replacement and (5) failed conversion to regional anesthesia for cesarean section. No significant difference was found for the primary composite outcome between the two groups. However, the authors acknowledge that the confidence intervals were wide and contained potentially clinically relevant differences. There were also no differences in the secondary outcomes including motor block, LA consumption, top-ups, side effects and maternal satisfaction.One possible explanation for continued conflicting results may be that the mechanisms determining flux through the meninges rely on multiple factors. The size of the dural hole is an important determinant as shown by Bernards et al.23, where more morphine and lidocaine crossed the dural orifice when the dura was pierced with an 18G versus 24G needle. This would explain why less favourable results were seen in some studies with 26G and 27G spinal needles.5 12 Other important factors include: total epidural drug mass and inherent rate of drug transfer through intact meninges.14 23 24 25 A greater effect is seen with medications with an inherently slow diffusion rate. Studies using lower volumes and concentrations of LA also had less favourable outcomes.12 22 Higher injectate pressures generated

In the last two decades high resolution ultrasound (HRU) revolutionised our approach to regional anaesthesia and interventional pain management. Author of this manuscript has witnessed and actively taken part in development, clinical assessment, and teaching of new ultrasound guided techniques.Ultrasound guided procedures have their strengths and weaknesses and in this narrative review author critically looks specifically at spinal procedures which were originally performed under fluoroscopy guidance.Introducing ultrasound to daily pain practice has unquestionable benefits: portability of device, cost effectiveness in regards of system purchase and maintaining, no need of an assistant/radiographer, and avoidance of radiation.The main questions to answer however are:1. Is it doable and easier under US guidance?2. Is it safer under US guidance?3. Is it more precise under US guidance?Abstract SP34 Table 1compares fluoroscopy and ultrasound for spinal interventions 1Cervical medial branch blockFluoroscopy guided cervical medial branch blocks has been well described and established however there is a large variability in clinical practice and the same end point might be reached with patient in prone, lateral or supine position depending on operator confidence and expertise. Recently consensus practice guidelines on interventions for cervical spine pain has been published in RAPM by international working group. 2 Ultrasound out of plane technique has been described by Siegenthaler, Eichenberger and Curatalo 3,4 in patient lateral position, with needle orientation from medial to lateral to minimize accidental vertebral artery puncture.Abstract SP34 Figure 1Demonstrates longitudinal scan in patient’s lateral position. Red circle depicts vertebral artery cranially. Yellow lines highlight facet joints, asterixis show MB position including TON on top of C2-C3 joint. Yellow arrows simulate needle direction out of planeScanning longitudinally from cranial to caudal starting with C2–3 facet joint which has characteristic appearance identified by the presence of a steep step at its upper border, indicating the lamina of C2 and third occipital nerve (TON) crossing over the joint. Following ‘hills’ (joints) and ‘valleys’ (waist of articular pillars with medial branches), from cranial to caudal one reaches superior articular process of C7 with C7 MB crossing over.It is simple and elegant technique suitable for diagnostic block but less so for radiofrequency denervation as needle/electrode is perpendicular to the course of the nerve. Newer electrodes such as ‘trident’ and ‘venom’ may allow for OOP approach in experience hands.Finlayson et al described in plane technique from posterior approach visualising the whole needle trajectory through posterior neck muscles and resting safe on the articular pillar5,6,7. One can assess structures cranial and caudal from the needle as well as in the front identifying posterior tubercle, nerve root and vessels prompting needle reposition. Precise electrode position close to articular pillar and along the medial branch could make it very safe technique, suitable for radiofrequency ablation with good outcome.There is a drawback of this technique requiring constant checking of the cervical level often requiring longitudinal scan as described previously.For safety, accuracy, precision and time efficiency at St George’s University Hospital Chronic Pain Service (author’s institution), combined fluoroscopy- ultrasound technique has been introduced and widely taught 7,8. Since 2012 we performed more than 500 CMB blocks and CMB RF.8,9 For patient in prone position, fluoroscopy helps to define the desired level and initial direction of the needle to achieve ‘tunnel vision’ and further progress to the upper middle part of articular pillar (Fig 2 a). Ultrasound helps to confirm the final needle position, parallel to the medial branch close to the articular pillar. Surrounding neurovascular structures such as the vertebral artery, radicular artery and the anterior nerve root can be identified before proceeding to perform a thermal lesion as illustrated in Figure 2 c. The needle position is verified in both longitudinal and transverse scanCervical RootsCervical peri radicular injections or selective nerve roots blocks (SNRB) have been well established in interventional pain practice. Sufficient evidence exists to support such an intervention in clinical situation of radicular pain as both diagnostic and therapeutic measures. One study demonstrated that more than 70% patients who responded to cervical nerve root block avoided surgical intervention.10 Cervical region with complex anatomyspinal cord and emerging neural structures, vertebral artery, radicular artery, spinal segmental artery, the ascending cervical artery, deep cervical artery has been potentially vulnerable. More than 100 neurological complications involving brain or spinal cord infarction have been reported. It has become an established practice to avoid particulate steroids at least in the cervical region as intraarterial injection of aforementioned may lead to fatality. Direct needle trauma could be another common cause of complications and in author’s humble opinion fluoroscopy guided intervention lacks the safety with no appreciation of the surrounding structures chiefly nerves and vessels. Ultrasound is not an ultimate solution, and it may lead to image misinterpretation and wrong needle position but potentially makes it less likely.Figures 3 and 4 demonstrate both ultrasound and fluoroscopy imaging for the most performed C6 and C7 nerve root both following characteristic pattern of recognition.The other safety measure advocated by the author of this review is applying injection pressure monitoring to avoid pressure higher than 15 psi as a detection of intraneural needle positioning. Too vigorous injection may also increase injection pressure resulting in untoward spread.11 Finally, motor response at low current 0.2–0.3 mA indicates needle- nerve contact and should be avoided. 12 Abstract SP34 Figure 2Ultrasound and fluoroscopy combined for cervical medial branch radiofrequency denervation. a) Lateral and A-P view of fluoroscopy images in patient in prone position. Note needle ‘tunnel vision’ in A-P position. Lateral view showsneedle position at the level of articular pillar from single entry point. b) Ultrasound probe position in longitudinal and transverse neck scans to assess needle position. c) Ultrasound images in transverse scan. Needle alongside and close to the articular pillar, parallel to the medial branchAbstract SP34 Figure 3From top left – Ultrasound image in transverse view showing from left to right: Th-Thyroid gland, SCM- Sternocleidomastoid Muscle, LC-Longus Coli muscle, AT-anterior tubercle of C6 transverse process, C6 – C6 nerve root transverse and longitudinal view. From bottom left – Ultrasound probe on skeleton model, AP and Lateral fluoroscopy projection with contrastAbstract SP34 Figure 4From top left -Ultrasound images showing C7 nerve root in transverse view including colour doppler and depiction in red. Note vertebral artery in front of the C7 nerve root and lack of anterior tubercle. From bottom left - Ultrasound probe on skeleton model, AP, and Lateral fluoroscopy projection with contrastAbstract SP34 Figure 5A)Patient in lateral position for extraforaminal cervical nerve root block. B) Cadaver dissection demonstrating cervical roots C5, C6, C7 root stained with dye after injection of 1 ml methylene blue. C) Lateral fluoroscopy with needle. D) AP fluoroscopy view with needle through foramen within spinal cord. ( simulated on cadaver)The discussion may spark about terminology of transforaminal and extraforaminal needle position. Intra foraminal nerve course varies between 6–8mm. Ultrasound guided injection are extraforaminal as needle does not advance beyond the point where it cannot be seen. This is paramount for safety of ultrasound guided interventions. To author’s knowledge there is no data comparing the clinical outcome of both techniques.From author’s own data there is more than sufficient dye spread along nerve root with extraforaminal injection and further needle advancement into tight foramen may bring the risk of vascular or neural damage including spinal cord injury as presented in figure 5Thoracic SpineThoracic spine and surrounding structures are amenable for US guided interventions, the most advanced being thoracic nerve root, epidural injections, paravertebral block. The least erector spinae plane block with its various descriptions and outcomes. Ventral ramus (intercostal nerves) and dorsal ramus giving off medial and lateral branch are frequent targets along with costotransverse ligaments being common pain triggers.Chronic pain interventions are often diagnostic, searching for the source of pain and ultrasound helps to identify anatomical topography.Abstract SP34 Figure 6Thoracic spine with ventral and dorsal rami and probe position with obtained sono images. From the top: at the level of costo-transverse joint,Abstract SP34 Figure 7From left to right. Paravertebral spread of contrast dye. Skeleton of thoracic spine. Thoracic spine with ventral and dorsal rami, contrast dye along thoracic nerveIn the middle: transverse probe position at the level of paravertebral space limited posteriorly by superior transverse ligament. At the bottom sagittal paramedian probe position at the level of paravertebral space. The latest often leads to too lateral probe position and in fact intercostal nerve blockFollowing the golden rule of not advancing the needle beyond the point of visibility, the combination with fluoroscopy and assessment of contrast spread seems like a good practice.One will find difficult to identify exact thoracic level with ultrasound only - fluoroscopy can be of a great help hereLumbar SpinePain procedures at the lumbar level has been traditionally performed under fluoroscopy guidance.

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. 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(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 (