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Dependent Clause: Definition and Examples
Is it a noun clause, adverb clause, or adjective clause?
DonNichols / Getty Images
An Introduction to Punctuation
Richard Nordquist
English and Rhetoric Professor
Ph.D., Rhetoric and English, University of Georgia
M.A., Modern English and American Literature, University of Leicester
B.A., English, State University of New York
Dr. Richard Nordquist is professor emeritus of rhetoric and English at Georgia Southern University and the author of several university-level grammar and composition textbooks.
In English grammar, a dependent clause is a group of words that has both a subject and a verb but (unlike an independent clause) cannot stand alone as a sentence. It's a clause that implies that there is more to come and is incomplete. It is also known as a subordinate clause.
Types of Dependent Clauses
Dependent clauses include adverb clauses, adjective clauses, and noun clauses. They can appear at any point in a sentence and start with signal words. Adverbial clauses start with a subordinating conjunction and answer wh- questions such as when something happened, where, and why as well as how and to what degree, such as "As soon as winter hits, her nephew earns money shoveling the neighbors' driveways." It answers the question when (with the subordinating conjunction as soon as) and has a verb in it, hits. The subject of that verb is winter, but the clause cannot stand on its own as a sentence, as it is incomplete.
An adjective clause functions to describe a noun in the sentence and starts with a relative pronoun, as in, "Her nephew, who is industrious, shovels neighbors' driveways in the winter to earn money." The clause describes the nephew, contains a verb (is) and starts with a relative pronoun (who).
A noun clause functions as a noun in the sentence, as in, "That looks delicious. I want some of whatever she's having." The clause functions as a noun in the sentence (it could be replaced by a noun or noun phrase, such as that cake), contains a subject (she) and a verb (is having) but cannot stand on its own. Some signal words for dependent noun clauses include relative pronouns and subordinating conjunctions such as: what, whoever, whether, that, which, how, and why.
You'll be able to tell what kind of clause something is by looking at how it functions in the sentence. For example, the clause in "The city where I come from is Spokane" is an adjective clause because it describes the noun city. In this next example, "Where I come from is much larger than this town" the clause functions as a noun. In "She's planning to move to where I come from," the clause functions as an adverb because it answers the question of where the person will move.
Locations in a Sentence
Although exceptions can be found, a dependent clause at the beginning of a sentence is usually followed by a comma (as in this sentence). However, when a dependent clause appears at the end of a sentence, it's not usually set off with a comma, though again (as in this sentence), there are exceptions. They can also be located inside other dependent clauses. Authors Peter Knapp and Megan Watkins explain:
There can be levels of complexity within complex sentences. Within a dependent clause, for instance, there can be another dependent clause. For example, in the following sentence there is a main clause..., a dependent clause in an adverbial relationship with the main clause (in italics), and a dependent clause [bold italics] in an adverbial relationship with the first dependent clause:
If you want to survive the elements when you go hiking, you should remember to bring along a drink, pocket knife, whistle, map, torch, compass, blanket and food.
(Knapp and Watkins)
Knapp, Peter, and Megan Watkins. Genre, Text, Grammar Technologies for Teaching and Assessing Writing. Orient Blackswan, 2010.
Nordquist, Richard. "Dependent Clause: Definition and Examples." ThoughtCo, Aug. 29, 2020, thoughtco.com/dependent-clause-grammar-1690437. Nordquist, Richard. (2020, August 29). Dependent Clause: Definition and Examples. Retrieved from https://www.thoughtco.com/dependent-clause-grammar-1690437 Nordquist, Richard. "Dependent Clause: Definition and Examples." ThoughtCo. https://www.thoughtco.com/dependent-clause-grammar-1690437 (accessed February 1, 2023).
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Identifying Independent and Dependent Clauses
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Examples and Usage of Conjunctions in English Grammar
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Subordination With Adjective Clauses
What is a Main Clause in English Grammar?
What Is an Independent Clause in English?


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Shut down LGBTQI office now – Catholic Bishops tell Akufo-Addo [ARTICLE]
A statement signed by the president of the GCBC, Most Reverend Philip K. Naameh, said the Church will never recoginse same sex marriages.
He noted that the LGBTQI agenda is a "complete disorder of the fundamental law of God in creating man and woman".
READ ALSO: Parliament must decide whether they want to decriminalise LGBT laws – Ayorkor Botchwey
The Ghana Catholic Bishops' Conference
"According to the Church's understanding of human rights, the rights of homosexuals as persons do not include the right of a man to marry a man or of a woman to marry a woman.
"For the Church, this is morally wrong and goes against the purpose of marriage," a section of the statement said.
He urged the Executive and legislature "never to be cowed down or to succumb to the pressure to legalize the rights of LGBTQI in Ghana, adding that the Bible considers homosexuality in the Old Testament as a 'perversion and a pagan abomination'".
"We, the Catholic Bishops of Ghana write to condemn all those who support the practice of homosexuality in Ghana. We also write to support the position of Lawyer Foh-Amoaning and the Coalition who for years has been championing the crusade against homosexuality," the statement added.
The issue of gay rights remains a controversial topic in Ghana, with many Ghanaians currently strongly against is legalisation.
#Shut #LGBTQI #office #Catholic #Bishops #AkufoAddo #ARTICLE

redpajama_set_name: RedPajamaCommonCrawl


text:
Q: How to make a start tile reference the desktop AND modern mode of an app? I've made an app for the Windows desktop and also created it for the modern (metro) interface in Windows 8.1. I wanted to group them under the same start tile and have a setting that allowed the user to open the app in the chosen mode by clicking the start tile. I got this idea from Chrome, which has both modes referenced by the same tile in the start menu or the link on the taskbar. I thought that maybe when the setting was changed I would delete the current one and replace it with one that referenced the other mode, but positioning is a problem, as a new tile always appears at the far right of the start screen. How would I resize the tile correctly and how would I delete and replace a link on the taskbar? I am using VB right now, but I can write C# and C++ so feel free to post code or links to code that are written in these languages.
If you have any suggestions, please post a reply or a ask a question in the comments.
I also should note that I prefer to use native libraries only and do not like using third-party dlls.
Thanks in advance for the help.
P.S. I've already tried Google.

A: I've figured it out!
The best way to do this is to create two registry keys referencing the two interfaces but make both the desktop and modern version not have a start tile! Then create a third app that has a tile and make it open the files, check for the active interface, and send the data to that interface with the file as a param.
Thanks for everyone's help, though :)

redpajama_set_name: RedPajamaStackExchange


Bendix launched its ADB22X™ air disc brake in 2005, and in 2016, unveiled its first air disc brake specifically for trailers: the Bendix® ADB22X™-LT.
A lot went into those last two letters.
Everyone on the Bendix team was committed to maintaining the brake performance of the industry-leading ADB22X. And while the ADB22X was designed to handle both trailer and tractor applications, it was critical that we specifically engineer the LT for use with the chambers that are more commonly equipped in trailer applications – that's a key differentiator between the LT and other trailer brakes. Our approach has always been to adjust brake chamber size to provide the appropriate braking force necessary for a trailer wheel-end.
We also knew we wanted to keep maintenance, training, and inventory needs to a minimum, so the LT shares replacement wear items with the ADB22X. Plus the same skill sets used to install and maintain the ADB22X are equally applicable to the trailer brake.
So how did we strike that balance between what to keep and what to change?
Bendix was already using a slightly altered version of the ADB22X for trailers, with a different bolt pattern on the carrier and different machining of the caliper due to the placement of the air chamber.
Now, even though just about everyone in the trucking industry is a fan of lower cost and lighter weight brakes, we asked for additional customer feedback, and that encouraged us to look a little further and explore even more improvements for the LT.
That led us to implement proven technology from our European colleagues at Bendix parent company Knorr-Bremse: a new adjustment mechanism with improved vibration sensitivity and a greater running clearance. (In fact, all of Bendix's next-generation air disc brakes will include this adjuster.) We also developed a new pad—BX276—that features more total wearable volume and extends pad life beyond current ADB standards. All of these changes add value, so now we have a brake that's more than just a lower-priced, lighter version.
Trailer brakes can face unique usage challenges. While they definitely take lower brake loads than their tractor counterparts, there's also an opportunity for them to generate excess energy if a driver regularly chooses to use the trailer brakes as the sole or dominant stopping force of the vehicle.
Putting more energy into a wheel-end it wasn't designed for can lead to serious issues, which is another very good reason why we engineered the LT specifically to perform at the proper and safe levels for trailers.
– or give us a call at 1-800-AIR-BRAKE.


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Trade serves casual cuisine, main courses $10-50.
Empeccable stay. The service and staff was very professional and courteous. Valet members JB and Jordan did a fantastic job and were always eager to help and recommend outings. Bartenders at both terrace and interior bars were professional, fun to speak with and very friendly. Overall stay, environment was amazing.
Love Hotel Republic. Fantastic vibe. Beautiful room. Accommodating staff. Perfect location. Cool outdoor bar. Oh, and free yoga.
At check in we were given a room with double bed and accessible showers. Would have been nice to know this before hand, or be able to pick the bed type upon booking.


Outpost of Freedom blog » Blog Archive » Camp Lone Star – Domestic Terrorist! Really?
So, we have a felon in possession case taken away from the ATF, by the FBI, and they have tagged Massey as a member of a terrorist organization, armed, dangerous, and having violent tendencies." It is no wonder that the government needed 15 armed agents to arrest Massey after the Indictment was issued. After all, they put him up on the level of Osama bin Ladin.
But, wait, we're not done, yet. We know that the government likes to label patriots with sinister sounding titles. I have no doubt that they have identified me as a "White Nationalist", After all, I am White and I believe in my country (nation). However, they would have a hard time demonizing me with the latter.
So, volunteers, working with or without the cooperation of the Border Patrol in protecting our borders, detaining or discouraging illegal immigrants, are, well, Domestic Terrorists. And, that, my friends, is what our country has come to be.


Recently Pickle has wanted to watch films. I don't know if it is something about hitting a certain age or if his concentration has suddenly got better but he actually looks through the DVDs and picks which one he wants to watch and then will actually sit and watch it. I find it wonderful as sometimes there is nothing better than snuggling up on the sofa to watch a film...especially if that film is a Disney film. Luckily for me, Pickle seems to have got my Disney gene and he is falling in love with all of the films and I couldn't be happier.
It started with Pickle asking to watch Cars one day. I think it is because he has seen lot's of adverts for the Cars 3 film recently. I thought we would put it on and he would watch the first 5 minutes then be bored, which is what normally happens but I was completely wrong. He sat and watched the entire thing. That was about three weeks ago and since then we have watched it at least 20 times. It's to the point now where he knows what's going to happen and tells you before it does. He is Cars obsessed at the moment and carries some of the little diecast cars around with him everywhere...even to bed. It is so cute and I think I love it so much because I feel that he is sharing my love of all things Disney.
And it wasn't just a fluke that he liked Cars. Since he has started watching films we've watched Finding Nemo, Finding Dory, The Lion King and Peter Pan. He loved them all and I was so bloody proud :) I'm getting him ready for when we go to Florida next year. I really hope he will continue to want to watch the films so that when we go away he will be excited to meet the characters unlike he was last year when we went (which means I will have an excuse to meet the characters too!).
I think we are even going to venture to the cinema with him to see the new Cars film in a few weeks when my foot is better. We have never taken him to the cinema before but I am hoping that because it is Cars he will happily sit through and watch the film. If not hubby will have to take him out so I can watch it :) Joking!!!


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Nase: Bantoffee pie, vanilla and tart bramble sauce. Karamell und Sahnebonbon, Vanilleschote.
Gaumen: Cider apples, blood orange and green tea. Flan Pudding, Aprikose und Fruchtkompott.
Finish: Lip-smacking umami notes of soy and savoury biscuits.


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By SnoringDragon December 21, 2018
7 min read	4 Comments
A moment later, Xiao Yu, Nicholas and Leonardo went to the other side of the river and looked at the narrow valley.
The trio talked about something from time to time, although all of it was nonsense.
"These people are really interesting. They have great patience! If I am them, I can't help but come out. Oh, it's really admirable!" Xiao Yu praised them, what he said was true.
"Oh, this is normal, the people of the church are mad-man, and I think you will understand more in the future!" Nicholas smiled; his understanding of this church was definitely much higher than Xiao Yu.
Xiao Yu nodded. The people in the church should be really mad because the church would often brainwash its followers. As long as they were successfully brainwashed, there was no way to cut off these shackles. Scarlet Crusade was strong. The reason for that was being brainwashed more thoroughly, and some high-grade equipment were provided to them.
Leonardo stretched out his hand and said, "What do you think when they will come out? Do you want to make a bet? Let's see whose eyes are more precise."
Bet?
Xiao Yu smiled, he really liked it. Anyway, betting is a very interesting thing, let alone they had nothing to do now.
"What are we gambling on?" said Xiao Yu while touching his chin.
Nicholas looked at the two men and smiled while saying: "Why not we gamble on 10 million gold coins. We will deduce in how much time will church's people come out? The one who guessed most accurately, will be the winner, how?"
Nicholas's idea soon got the approval of the two, this was indeed very good.
"I said half an hour! It's been ten minutes. They should already know that we are here, maybe they are preparing for it." Leonardo smiled and said with confidence.
Xiao Yu furrowed his brows, pondered for a while then immediately said: "Well, we cannot repeat same time, understand?"
Nicholas nodded and then reacted. He smiled helplessly and said: "Xiao Yu, Xiao Yu, you didn't say it before, what do you mean?"
"I really don't mean anything. I am afraid that the two of you will bully me!" Xiao Yu said innocently. He had already thought of many possibilities. If these two joined hands then he was out of luck.
"You think we are evil, right?" said Nicholas.
"Let's not talk about it!" said Xiao Yu because he did not want to waste time.
Nicholas nodded and said, "Okay, then I will gamble that they will come out after 25 minutes!"
25 minutes?
Xiao Yu had idea about what was going on in Leonardo's mind but he did not point it out, just to see how Nicholas would play.
"Since all of you have finished, then it's my turn! Well, I think they will come out after ten minutes!" said Xiao Yu with a mysterious smile and looked at the two with a provocative look.
Ten minutes?
The two were surprised. Their hearts thumped and felt like being cheated because Xiao Yu's smile was really familiar to them. Every time he wanted to trick someone, he would use this kind of Smile.
"Xiao Yu, Do you still have any tricks left?" asked Nicholas, Xiao Yu was not an impulsive person and he also knew how to preserve strength.
Coupled with Xiao Yu's loyalty to money which would definitely be much stronger than the two of them!
"Hey, you will know it later! Now let's wait!" Xiao Yu's mysteriously smile, but did not intend to say anything more.
The three people continued to wait. After five minutes, Xiao Yu revealed a panicked look.
"Xiao Yu! Are you okay? Why are you so anxious?" said Nicholas. His mood was quite good.
Leonardo looked at Xiao Yu with a disdainful look, and said: "Oh, after ten minutes, we will earn 10 million gold coins! It's really good! Good!"
Xiao Yu snorted, but did not speak, when only 59 seconds were left, Xiao Yu suddenly stood up straight and roared.
The bloodhoof blinked his eyes, and he did not except that the momentum of the battle roar that Xiao Yu showed up was not worse than himself!
The sound was directly transmitted to the place where the people of Church were hiding. People of Church who were hiding to ambush Xiao Yu came out!
Who had expected that Xiao Yu would just roar to force them out!
Seeing this, Nicholas and Leonardo's face became quite ugly. They finally knew why Xiao Yu would have such a reaction.
"Xiao Yu! You are really something! Really admirable!" Nicholas said, he really did not expect Xiao Yu to put down his identity and do something like this for money.
You must know that when the strength and status reach their level, money was already floating clouds, and what they really care about was their interests and their precious face!
"Hey, what? I am uncomfortable, my heart is uncomfortable!" said Xiao.
Sure enough, after Xiao Yu's roar, the church's people began to pop their heads on the hills to look around.
"Haha! money! Their heads have already emerged!" Xiao Yu said proudly. This feeling was cool.
The two men were helpless and they were once again tricked by Xiao Yu and lost 10 million gold coins just like that.
After talking about the money, Xiao Yu didn't care about their mood. He smiled and said to the two men: "Okay, let's go back and wait for the church. People come to see us!"
After Xiao Yu finished speaking, he turned around and left, no matter what the reaction between the two people behind him.
"Got it! Let's go! We met such a master, we are unlucky!" Nicholas said helplessly, only Leonardo did not speak.
The three of them quickly returned to their original positions and waited for the people of church.
After 20 minutes, a group of people from the Church came over with flags.
"Hey? Isn't this the flag of the Scarlet Crusade? It's really interesting. Even the Scarlet Crusades are pulled out. Are they really wanted to kill these talents that are hard to cultivate?" Xiao Yu said with some surprise. The Scarlet Crusade and silver right-handed Knights are all famous.
The people of the Church of Light had drawn the Scarlet Crusade to the Marsh, and their purpose was self-evident.
"Oh! I have come to a Golden Lion King! Yes! Good!" Looking at the people of the church that were approaching them, Xiao Yu said.
"Xiao Yu, I think this time you have to be careful, the golden lion who said to be a sixth-order powerhouse! Sixth-order paladin, Cremos! Oh, it's really interesting." Nicholas had already known that Xiao Yu didn't know who these men were, in order to prevent Xiao Yu from angering the sixth-order powerhouse he informed Xiao Yu beforehand.
"Oh? Sixth order? It's just that. The sixth order is actually not terrible!" Xiao Yu smiled, but he didn't care much. Even if the two sides couldn't talk about it, it wouldn't matter.
After a while, the group came to the front.
"Hello! I am Chris Mo, I am very glad to meet you!" The Golden Lion King said politely.
Vianney Pereira says:
Muchas gracias por el capítulo
ClosetWeeb101 says:
Many thanks for the chapter!~~
Haku says:
I don't really care about the names of OC except for some people, However, Changing the names of people who already had an existing name makes me feel uncomfortable. For the TL, I hope you can research a little bit about warcraft instead of being oblivious.


Spoonflower makes it possible for individuals to create, print, and sell their own designs on fabric, wallpaper and gift wrap. Since launching in 2008 as a small, bootstrapped startup in a former sock mill, it has been featured in publications all over the world, including the New York Times, Martha Stewart Living, and Apartment Therapy, as well as in posts on thousands of DIY blogs and websites. Spoonflower offers the largest marketplace of unique surface designs anywhere, and its products are custom printed on demand from its headquarters in Durham, NC.
Spoonflower's founders, Gart Davis and Stephen Fraser, have relied on the CED's community for advice, support and connections since they first met for coffee and talked about launching the world's first online service for creating custom fabric. The connections they have made through CED -- service providers, fellow entrepreneurs, and investors -- have been invaluable.
Thanks to CED's Connections to Capital program, Stephen met Holly Maloney McConnell from North Bridge Growth Equity at a CED event. That introduction resulted in a $25 million round of funding for Spoonflower led by North Bridge Capital.
For more on Spoonflower, view Spoonflower's Strategic Partner Spotlight.


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text:
Q: Select option in react class Select extends React.Component {
  constructor(props){
    super(props);
    this.state = {
      values: "testing"
    };

    this.handleChange = this.handleChange.bind(this);
  }

  handleChange(event){
    this.setState({values: event.target.value});
    this.props.onSelect(this.state.values);
    console.log("valus is " +this.state.values + " event is " + event.target.value);
  }

  render() {
    return (
       <select value={this.state.values} onChange={this.handleChange}>
          <option value="">
            Select one...
          </option>
          {this.props.question.map(obj => (
            <option key={obj.id} value={obj.percentage}>
                {obj.question}
            </option>
          ))}
      </select>
    );
  }
}

Right now I am creating a select menu, the default selecting value is empty. there is here option here (select one = "", question1= "1",
question2=2) I have no idea why I chick question1, it consoles the value
is the previous one "testing", but the event.target.value is correct.
Someone can give me a help? Thank You

A: The behaviour your are noticing is due to the setState() method being asynchronous. To log the updated state to console, consider doing this via the callback for setState(), which is called when the state change has been applied to the component:
handleChange(event){

    this.setState({values: event.target.value}, () => {
        console.log("valus is " + this.state.values +
                    " event is " + event.target.value);
    });

    this.props.onSelect(this.state.values);
}

A: As Dacre stated this.setState is asynchronous. A cleaner way to fix this is with async-await.
class Select extends React.Component {
  constructor(props){
    super(props);
    this.state = {
      values: "testing"
    };

    this.handleChange = this.handleChange.bind(this);
  }

  async handleChange(event){
    await this.setState({values: event.target.value});
    this.props.onSelect(this.state.values);
    console.log("valus is " +this.state.values + " event is " + event.target.value);
  }

  render() {
    return (
       <select value={this.state.values} onChange={this.handleChange}>
          <option value="">
            Select one...
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text:
Los Alamos Revisited
by William Eggleston
Between 1965 and 1974 William Eggleston and Walter Hopps traveled together in the US, Eggleston taking photographs, Hopps driving. During these travels the title Los Alamos was born. At the turn of the century Eggleston, Hopps, Caldecot Chubb and Winston Eggleston edited the photographs into a set of five portfolio boxes containing dyetransfer prints, which were produced in an edition of five with three sets of artist proofs. In addition to this selection, a further thirteen images were printed and released as individually available dye-transfer prints, which were referred to as "cousins" of the Los Alamos project. Hopps' original vision was to make a vast exhibition of the project, but plans fell through and the idea was abandoned. At some point the negatives became separated, Hopps retaining roughly half of the project in Houston. Later Hopps carefully returned what was assumed to be the remainder of the negatives to Memphis and they were catalogued as Box #17. After Hopps' death in 2005 his widow Caroline found another box of negatives that had never been accounted for. These were then catalogued as Box #83 and documented in a hand-made reference book called Lost and Found Los Alamos. In 2011, William Eggleston III (son of William) and Mark Holborn came together to review the now complete set of negatives for a final edit and sequence. They finished their sequence in Göttingen with Winston Eggleston in 2012. It is presented in its entirety in this three-volume set. An earlier edition of Los Alamos edited by Thomas Weski was published by Scalo in 2003. Weski's original essay is included in this revised edition. Los Alamos Revisited has been drawn from the complete set of photographs, including the long lost negatives from Box #83.
Publisher: Steidl
Hardcover : 588 pages


text:
Postoperative pain management in obstetrics and gynecology
10.4274/jtgga.galenos.2020.2020.0024
Henning Ohnesorge
Veronika Günther
Nicolai Maass
İbrahim Alkatout
Received Date: 27.02.2020 Accepted Date: 15.05.2020 J Turk Ger Gynecol Assoc 2020;21(4):287-297 PMID: 32500680
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The efficiency and quality of postoperative pain management may be considered unsatisfactory in Europe, as well as in the United States. Notwithstanding our better understanding of the physiology of pain and the development of new analgesia procedures, the improvement in satisfaction of patients has not be enhanced to the same degree. Obstetrics and gynecology are no exception to this statement. In fact, obstetrics and gynecology are surgical departments in which patients experience the greatest severity of postoperative pain. Current concepts of postoperative pain management are largely based on the administration of systemic non-opioid and opioid analgesics, supplemented with regional analgesia procedures and/or peripheral nerve blockades and, in some cases, the administration of other pain-relieving pharmaceutical agents. Based on the existing body of evidence, it would be appropriate to develop procedure-related concepts of analgesia. The concepts are based on the special circumstances of the respective department, and the scheme of analgesia is aligned to the respective interventions. Generally, however, a surgeon's individual experience in dealing with the procedures and substances could be more significant than the theoretical advantages demonstrated in preceding investigations.
Keywords: Pain management, obstetrics, gynecology, nerve block, anesthesia
Despite significant progress in our comprehension of the mechanisms of pain, pain physiology, and the pharmacology of effective analgesic substances, postoperative pain management remains a major challenge in medicine. Insufficiently treated postoperative pain impairs postoperative convalescence in many ways and thus also influences perioperative morbidity and the duration of hospital stays. Despite the advancements made in some areas with regard to the treatment of postoperative pain, the quality of postoperative pain management is generally unsatisfactory in Europe, as well as in the United States (1,2,3). This does not necessarily mean that major operations are associated with very intense pain and minor procedures involve less pain. Rather, it has been noted in patient surveys that analgesia is rather poor after routine and frequently performed operations, whereas - contrary to general expectations - major operations are rated positively by patients (4). One of the reasons for this discrepancy could be the patients' expectations. Those who undergo major operations tend to anticipate and accept pain.
Postoperative pain management needs to be improved to a large extent in obstetrics and gynecology as well. This is reflected by the fact that the pain scores of patients in Departments of Obstetrics and Gynecology, German Hospitals are higher than those at all other surgical departments (5). Gynecological operations are also reported to cause high levels of pain. Especially open operations in the uterus are associated with severe pain; the latter is comparable with pain scores after spondylodesis. Thus, open operations in the uterus are followed by the highest pain scores in Germany. However, complex operations in the female breast and supposedly minor laparoscopic interventions such as adenectomies are also associated with significant postoperative pain (6). In fact, pain scores in the afore-mentioned settings exceed those reported after major operations in the upper abdomen (such as partial resection of the liver) (5).
Current concepts of postoperative pain therapy are usually based on a combination of various analgesics and/or regional anesthesia to achieve a balanced analgesia regimen and adequate pain relief while causing acceptable side effects.
Aims of postoperative pain management
The foremost aim of pain management is not to alleviate the intensity of pain but to reduce the patient's suffering. The principle that applies here is: "Suffering may be associated with the significance of pain to the same extent as it is with the intensity of pain. A persistent feeling of helplessness and hopelessness may be the basic cause of a patient's suffering when he/she experiences chronic pain. This is reflected in high pain scores" (7). Extrapolated to the postoperative situation, this means that the patient's satisfaction and well-being should be given greater attention (8). In an investigations of patients who had undergone a caesarean section alone, questions focusing on the patient's well-being rather than pain were able to influence their feedback concerning postoperative pain and their desire to receive more analgesics (9).
Factors other than the severity of pain were also found to influence a patient's postoperative well-being. Especially the occurrence of nausea and vomiting are significant factors. The possibility of independent mobilization, particularly going to the toilet and personal hygiene, having sufficient sleep at night, being able to dispense with drainages, catheters and intravenous accesses, and a largely normal oral intake of food are important in this context. In summary, in the postoperative phase patients wish to achieve sufficient control over their physical symptoms as well as restore their autonomy rapidly. Interestingly, the wishes of patients are very similar to the postoperative goals of the Enhanced Recovery after Surgery (ERAS) Programme (10).
Despite these long-term goals, the severity of postoperative pain must be recorded regularly. This is usually achieved with the aid of a numeric rating scale (NRS) extending from 0 (no pain) to 10 (worst pain). However, the use of the NRS requires a certain capacity for abstraction on the part of the patient. Basically, postoperative pain should be recorded regularly and after any type of pain therapy in order to evaluate the success of the respective measure.
Systemic analgesics
Non-opioid analgesics constitute the basis of analgesia in postoperative pain management. The regular administration of individual non-opioids, such as paracetamol, traditional non-steroidal anti-inflammatory drugs (NSAIDs), selective cyclooxygenase-2 (COX-2) inhibitors or metamizole in standard doses provides sufficient pain relief after interventions associated with mild or moderate pain (11). The analgesic potency of non-opioid analgesics after oral administration has been extensively investigated (12) (Figure 1). We lack similar investigations for intravenous forms of application. In patients undergoing operations that involve severe pain, the regular administration of non-opioid analgesics as part of a balanced concept of analgesia may contribute to a reduction of opioid doses as well as side effects, and improve the quality of analgesia.
Of all non-opioid analgesics, paracetamol is regarded as the substance with the least analgesic potency (Figure 1). The analgesic efficacy of intravenous administration is more pronounced than that of oral or rectal administration. Paracetamol is well tolerated in therapeutic doses and has no relevant cardiovascular, gastrointestinal, or renal side effects. It also has no clinically significant impact on the function of thrombocytes. However, the use of paracetamol is controversially discussed because of its limited therapeutic spectrum and the risk of irreversible liver damage in case of overdosage. The highest daily dose for oral or rectal administration is 100 mg/kg body weight, and for intravenous administration 4 g/24 h (for those with a body weight less than 50 kg the dose is 60 mg/kg BW). Previous damage to the liver, a glutathione deficiency, such as that caused by excessive alcohol consumption, or the induction of the CYP-450 enzyme system, are listed as contraindications for the use of paracetamol.
Metamizole
In addition to its favorable pain-relieving effect, metamizole has spasmolytic effects which may intensify its analgesic effect, especially in cases of colic or convulsive pain. However, in view of the fact that metamizole could trigger agranulocytosis, its use in Germany is restricted to five indications:
1. Acute and severe pain after injuries and/or operations,
2. Colic,
3. Tumor pain,
4. Any other acute or chronic severe pain, provided other therapeutic measures are not indicated,
5. High fever that does not respond to other measures.
These indications do not necessarily include the postoperative use of metamizole after operations. Rather, they refer to its use in the event of anticipated or existing severe postoperative pain. Owing to the risk of shock reactions, the parenteral administration of metamizole is explicitly indicated only when oral administration is not feasible (13).
Although the incidence of metamizole-induced agranulocytosis is considered to be rather low compared to that of other pharmacological agents, explaining the risks of using metamizole to the patent prior to its intended use has become an avidly discussed issue again. Agranulocytosis may also occur after prolonged treatment with metamizole and after a period of several days following its last administration. Therefore, it would be meaningful to inform the patient after the administration of metamizole about potential early symptoms of metamizole-induced agranulocytosis (fever, throat pain, inflammatory changes in the mucous membranes).
Notwithstanding these limitations, metamizole remains an essential component of the concept of balanced postoperative pain management because of its high tolerability and low or non-existent organ toxicity. Therefore, metamizole still is the preferred non-opioid analgesic for postoperative pain management in German-speaking countries (14).
Non-steroidal antiphlogistic drugs
Traditional non-selective COX inhibitors as well as selective COX-2 inhibitors are marked by their significant analgesic effect in postoperative pain management. However, the use of traditional NSAIDs and coxibs is limited because of their spectrum of side effects. These especially include cardiovascular, renal, and gastrointestinal effects. Basically, the risk of gastrointestinal events is markedly higher during the long-term intake of nearly all NSAIDs and coxibs (15). The latter rule out the use of NSAIDs or coxibs in nearly all patients with relevant cardiovascular risk factors (CHD, heart failure NYHA II-IV, peripheral arterial occlusive disease, cerebrovascular disease). The same considerations apply to the risk of gastrointestinal bleeding. Substances with a gastrointestinal risk profile are associated with a higher risk of cardiovascular events as well.
As these substances have an effect on renal function, their postoperative use is contraindicated, especially in patients with a pre-existing limitation of renal function or hypovolemia. The latter can never be ruled out after major operations.
Furthermore, when using non-specific NSAIDs, one must take into account the fact that the inhibition of COX-1 may lead to a disorder of thrombocyte function. Thus, these substances may be associated with a higher risk of hemorrhage after surgery. In a recent meta-analysis, however, no elevated incidence of hematoma or post-surgical hemorrhage was registered after plastic operations (including those in the breast) and the intake of NSAIDs (16).
Opioid analgesics
In patients with severe postoperative pain that cannot be adequately controlled with non-opioid analgesics, opioids still are the gold standard in postoperative pain management. In Germany piritramide has been established as a standard medication, although we lack robust evidence of the superiority of this substance over other opioids such as morphine, fentanyl or sufentanil. Intravenous administration is advantageous in the short term because of its rapid efficacy and the easy titration of these substances.
Opioids are marked by their favorable analgesic effect and the absence of organ toxicity. However, the spectrum of acute side effects of opioids in the postoperative phase is of considerable relevance. The administration and dosage of opioids for postoperative pain management is one of the major risk factors for the occurrence of nausea and vomiting. Furthermore, the inhibition of bowel motility, which occurs frequently under opioid treatment, is responsible for the delayed postoperative restoration of normal gastrointestinal function. The deleterious effects of opioids on respiratory depression in case of overdosage are a matter of great concern (17). The highly variable need for opioids in patients and the absence of predictive tools to address this problem are further difficulties (4). Thus, the administration of opioids in the postoperative phase is usually titrated according to the individual patient's needs.
Opioids are titrated by the nursing staff and the substance is usually given in the form of short intravenous infusions, but these may be associated with the risk of relative overdosage. Therefore, if a patient needs opioids regularly, it would be advisable to use patient-controlled application systems patient-controlled analgesia (PCA). As the latter is administered frequently in smaller individual doses, this form of analgesia is associated with a lower risk of overdosage (Figure 2). Simultaneously, the use of PCA systems improves the quality of postoperative pain management (18).
The disadvantage of traditional PCA systems that permit intravenous administration of an opioid through a pump system is the indispensable need for an intravenous access and the consequent limitation of the patient's mobility. A new system that permits patient-controlled administration of sufentanil sublingual microtablets is an alternative that, according to preliminary data, provides at least equivalent pain relief as intravenous PCA; it causes no limitation of the patient's mobility and provides a greater degree of satisfaction for patients (19).
The perioperative use of retarded opioids is a further alternative to the purely need-oriented administration of opioids. The notion of administering a fixed dose of a retarded opioid does contradict the observation that the postoperative requirement of opioids varies very markedly from one patient to another. Therefore, recent American guidelines for postoperative pain therapy explicitly advise against the use of long-acting opioids in the early postoperative phase (20). The summaries of product characteristics for retarded opioids also clearly mentions that the substances should not be administered preoperatively or during the first 12-24 hours post-surgery. Nevertheless, clinical experience concerning the long-term administration of retarded opioids and the need-oriented administration of a non-retarded oral opioid has been quite favorable (21) (Figure 3).
Gabapentinoids
In addition to traditional non-opioid and opioid analgesics, particularly gabapentin and pregabalin have been established in the management of postoperative pain. The preoperative administration of these substances, which are approved for the treatment of chronic neuropathic pain, appears to reduce the need for opioids as well as the incidence of nausea and vomiting after breast surgery and open hysterectomy (22,23). The effective dose remains unclear. The use of higher doses is quite evidently associated with a sedative effect.
Systemic local anesthetics
The perioperative systemic administration of lidocaine is, in part, propagated as the "poor man's epidural" because initial studies have shown a marked effect on the postoperative need for analgesics, the duration of gastrointestinal atony, and the incidence of opioid-related undesirable effects. In a recent Cochrane analysis (24), the effect of this procedure could not be clearly proven in comparison with placebo or traditional epidural analgesia. Therefore, the results of further studies are required before this procedure can be recommended as a standard for the management of perioperative pain.
Regional anesthesia procedures
For many operations in obstetrics and gynecology, regional anesthesia procedures can be used to reduce the patient's need for systemic analgesics and simultaneously improve the management of postoperative pain. The spectrum extends from wound infiltrations and peripheral nerve blockades to analgesia procedures in the vicinity of bone marrow, especially epidural and peridural analgesia.
Wound infiltration
Wound infiltrations can be performed as a single-shot procedure or a continuous procedure, usually through a subcutaneous catheter connected to an elastomeric pump. While wound infiltrations in patients undergoing general and traumatological surgery have shown marked effects, the data reported in the obstetric and gynecological setting have been disappointing. Wound infiltrations as a means of postoperative pain management are recommended neither in laparoscopic surgery of the lower abdomen nor in surgery on the female breast (25,26). After caesarean section, wound infiltrations may reduce the need for opioids without influencing the incidence of opioid-related undesirable effects (27).
Peripheral nerve blockade
Various types of peripheral nerve blockades may be used for postoperative pain management in obstetrics and gynecology. Paravertebral blockades (PVB) and pectoral nerve blockades (PECS I + II) in breast surgery, as well as the transversus abdominis plane (TAP) block in surgery of the lower abdomen are worthy of mention.
Paravertebral blockade
PVB are regarded as a unilateral alternative to epidural analgesia procedures and are mainly used in the chest. After injection of local anesthetics in the paravertebral space, the anesthetist administers analgesia that usually reaches several segments and thus influences the roots of spinal nerves. PVB's have been successfully used for many years in breast surgery as a means of perioperative pain management (28). It should be noted that a PVB may also be used to reduce the occurrence of chronic pain after breast surgery in women (29). The risk of undesirable effects (nerve injury, pneumothorax, vessel puncture) is considered negligible (28). However, a disadvantage is that PVB must be administered preoperatively or postoperatively with the patient in sitting position and wide awake. This reduces the acceptance of the procedure.
Pectoral nerve block
The pectoral fascia block was first described in 2011 as an alternative to PVB (30). This was followed by various modifications of the procedure. Currently, a combination of fascia blocks between the pectoralis major and pectoralis minor muscles (PECS I block), and the pectoralis minor and serratus anterior muscles (PECS II block) at the level of the fourth rib has been established as a standard procedure. This combination appears to be as effective as a PVB (31). Its advantages are that it has a low risk profile even when administered after the induction of general anesthesia in a supine position (32).
Transversus abdominis plane block
TAP block is a field block, similar to PECS. It encompasses the abdominal wall branches of the thoracic spine and lumbar spine nerve roots, and is used as a means of perioperative analgesia, especially when performing surgery in the lower abdomen. A depot of a local anesthetic is injected into the layer of fascia between the internal oblique muscle and the transversus abdominis muscle, in the medioclavicular line between the costal arch and the iliac crest. In gynecology, operations performed through a laparotomy of the lower abdomen are a favorable indication for this procedure. However, these operations require a bilateral blockade. Rather high volumes (15-20 mL each) are needed to achieve adequate distribution of the anesthetic. In particular, when administering a bilateral blockade, the concentration of the local anesthetic must be adjusted to avoid overdosage (33).
Epidural analgesia
Regional anesthesia procedures used in the vicinity of bone marrow, especially epidural analgesia, are regarded as the gold standard in postoperative analgesia for several abdominal operations. However, the risk-benefit ratio beyond the obstetric setting is a critically debated issue. Therefore, indications for epidural analgesia as a means of perioperative pain management are on the wane (34).
This is because the advantages of epidural anesthesia, as compared to systemic analgesia procedures in combination with other less invasive regional anesthesia procedures (see above), was not very pronounced in recent studies, as in older ones. The reason for this development could be the more consistent use of "ERAS" concepts. Poor bowel preparation and the limitation of preoperative fasting, early enteral nutrition, the omission of drains, and consistent early mobilization of the patient appear to be more significant for the outcome of surgery than the elimination of sympathetic innervation, the opioid-saving effect, and improved analgesia through epidural anesthesia.
On the other hand, according to recent investigations, the risk of relevant undesirable effects of epidural analgesia outside the field of obstetrics, are higher than previously estimated. In an assessment of more than 1.3 million procedures performed in the USA, the risk of spinal hematoma after epidural analgesia procedures for abdominal surgery was reported to be 1:7500 (95% confidence interval: 1:5,663-1:9,736) (35). One of the major unmodifiable risk factors is the Charlson Comorbidity Index. In view of the potentially fatal consequences of epidural hematoma, a careful risk-benefit analysis should be performed, especially in multimorbid patients.
Currently, epidural procedures are no longer recommended as a means of perioperative pain therapy for laparoscopic operations. In multivisceral resection for ovarian cancer, depending on the individual risk profile of the patient, epidural analgesia procedures still constitute a standard approach. However, even for these operations, the positive impact of epidural analgesia on the severity of postoperative pain appears to be limited to the first three days post-surgery. Epidural analgesia was found to have no effect on morbidity, especially the duration of gastrointestinal atony or the incidence of other opioid-induced side effects (36).
The risk-benefit ratio of epidural analgesia procedures is still rated positively in obstetrics. On the one hand, the superiority of peripartum analgesia compared to systemic analgesia procedures is still undisputed. Due to the widespread absence of comorbidities and the highly regulated coagulation system, the risk of severe complications is lower than that in a general postoperative setting; for example, the risk of epidural hematomas is reported to be about 1:150,000 (35). Nevertheless, the suitability of epidural analgesia for postoperative pain management after caesarean section is limited because the injection is given at the level of the lumbar spine, and motor disabilities in the lower extremities cannot be ruled out.
Preemptive analgesia
Preemptive analgesia is any treatment given to the patient prior to surgery, in order to reduce or prevent subsequent pain. This specifically means that by initiating analgesia (and anaesthesia) prior to the initiation of noxious stimuli, peripheral, and central nervous system pain receptor activation is blocked. This leads to a reduced activity of pain neurotransmitters, processing can be modified, which results in improved short-term and long-term pain control and reduced side effects from narcotic analgesics (37).
Long et al. (38) analyzed a total of 324 studies concerning preemptive analgesia in minimally invasive gynecologic surgery (MIGS). Preemptive blocks, like paracervical, triple antibiotic paste, or pudendal block appear to have the most consistently beneficial effect on postoperative pain in MIGS with an excellent cost-benefit ratio. Preemptive anticonvulsants, ketamine and dexmedetomidine have a positive effect on postoperative pain and opioid use but are limited by side effects. Preemptive dexamethasone, acetaminophen, and NSAIDs have a modest effect on postoperative pain control (38).
Another study group from the US analyzed the effectiveness of preemptive analgesia for pain control in women undergoing total abdominal hysterectomy (39). Sixty-nine randomized controlled trials were included. Concerning nonnarcotic medications, paracetamol, gabapentin, and rofecoxib combined with gabapentin led to improvements in pain assessment compared with placebo and other nonnarcotic medications. The use of preemptive paracetamol, gabapentin, bupivacaine, and phenothiazine resulted in less narcotic usage than placebo (39).
Fast-track surgery (FTS) programs - also known as ERAS - have the aim of ERAS, allowing earlier discharge with improved patient outcomes. Such programs derive their success from their multidisciplinarity, including surgeons, nurses, anesthetists, pain specialists, ward nursing staff, social workers, occupational and physical therapy staff (40). Concerning the anesthesiologic side, the following subjects should be considered: preoperative sedative premedication should be avoided in order to allow early patient mobilization, initiation of early oral feeding and catheter removal (41).
The method of action concerning preemptive analgesia was described earlier in the last section. For preemptive local anaesthesia, a TAP block can be performed just after intubation and just before surgery is commenced. For preemptive analgesia, the administration of Gabapentin can be used. A large number of randomized controlled trials have confirmed decreased analgesic requirements after preoperative gabapentin (42,43).
Further preemptive analgesia is initiated with COX-2 inhibitors given intravenously pre- and intra-operatively (parecoxib) with intravenous paracetamol (44). In addition, intravenous (and oral) paracetamol has opioid sparing effects (45).
Early mobilization and early oral feeding are both central components for a successful FTS.
Both can be better managed through good postoperative pain management. The mobilization is associated with an increased blood circulation and helps to reduce the risk of venous thrombo-embolism. Furthermore, improved pulmonary function with an expansion of the lung bases and better tissue oxygenation should be noted (37).
Special features of postoperative pain management during puerperium and lactation
Postoperative pain management in the postpartum period is challenging because the patient has a significant need for analgesia, especially after a caesarean section, and the analgesic agents are associated with a risk of toxic effects on the colostrum and breast milk, with potentially harmful effects on the breast-fed infant. At least in German-speaking countries, the need for analgesia in this period is underestimated while the risks for the newborn are overestimated. This miscalculation does not restrict the use of analgesic treatment on the part of the treating physicians alone. Patients also tolerate a high level of pain before they ask for analgesics that, in their estimation, may potentially affect breast milk. This is because of their (unwarranted) concern regarding toxic effects on the newborn. Sufficient analgesia is especially important during the puerperium, because it is a prerequisite for early mobilization of the patient and the avoidance of postpartum thrombosis, and is also a predictor of the success of breastfeeding. Last but not least, one must consider the fact that the risk and severity of puerperal depression are linked with the severity of postpartum pain. These ideas mentioned before, form a contrast to pain management in oncological gynecology. In many cases, oncological patients have become accustomed to their pain over a long period of time and often take analgesics as permanent medication - sometimes in increasing doses due to increasing pain or an incipient habituation effect. This is in contrast to obstetric patients who experience a new form of pain from complete health.
Blood-milk barrier
The blood-milk barrier has similar properties as the placental barrier and hinders the entry of pharmaceutical agents into breast milk to a limited extent. In many cases, small molecules and lipophilic substances can be freely transferred to breast milk. The pH-dependent load of the substances is of crucial importance (Figure 4). Acidic substances, such as ibuprofen, are virtually absent from breast milk, whereas alkaline substances, such as opioids, accumulate in breast milk. In addition to the milk/plasma ratio, which describes the extent of transfer of a pharmaceutical agent into breast milk, the quantity of breast milk ingested by the newborn infant is also a significant determinant of the neonatal dose. While infants ingest breast milk at a rate of about 150 mL/kg body weight, the quantity of colostrum is much less during the first few days postpartum. Consequently, even if the mother is given high doses of opioids during the puerperium, the load on the newborn infant is negligible. For instance, even after mothers were given high doses of oxycodone during the first 48 hours postpartum, only one of 41 breast-fed infants had detectable and clinically relevant oxycodone levels in plasma (46).
Regrettably, we lack robust data for many pharmaceutical agents and their use in the postpartum period and during lactation. The largest body of clinical experience is available for paracetamol (M/P coefficient 1), ibuprofen (M/P coefficient 0.008) and fentanyl, which is widely used in English-speaking countries. However, due to similar pharmacodynamics and pharmacokinetics, this experience is also applicable to other opioids such as tramadol, piritramide or oxycodone (M/P coefficient 2-3.6). Codeine and pethidine are exceptions. Their use should be avoided during pregnancy and lactation because of their cumulative metabolic effects. The establishment of a maximal dose of opioids during the postpartum period is not meaningful because neither maternal plasma levels nor levels of the substances in breast milk are correlated with the doses of opioids (46).
Procedure-specific pain management in obstetrics and gynecology
The surgical spectrum of obstetrics and gynecology is wide. No general concept of postoperative pain management can be recommended for these specialties. Rather, it would be meaningful to develop procedure-specific concepts of postoperative pain management in cooperation with the involved clinical departments (obstetrics and gynecology, anesthesia, nursing staff, and pediatrics if applicable). We have evidence-based recommendations of the European Society of Regional Anaesthesia and Pain Therapy for some operations. However, some of these are outdated. In view of the above mentioned therapy options, one alternative for procedure-specific pain management in obstetrics and gynecology is listed in Table 1. When aligning these therapy concepts to specific clinical conditions, one must consider the fact that the clinician's experience of the various procedures and pharmaceutical agents could be more important than the theoretical advantages reported in published studies.
The current non-optimum quality of postoperative pain therapy is not restricted to German-speaking countries alone. Furthermore, obstetrics and gynecology are not excepted from this statement. Rather, these surgical specialties are associated with the most severe postoperative pain.
Current concepts of postoperative pain management are largely based on the administration of systemic non-opioid and opioid analgesics. These are supplemented with regional anesthesia procedures, and in some cases with other pharmaceutical analgesics. Based on the existing body of evidence, it would be appropriate to develop procedure-specific analgesia concepts that take the special characteristics of the specialties into account. In general, however, the clinician's personal experience of the procedures and substances could be more important than the theoretical advantages reported in published studies.
Peer-review: Externally peer-reviewed.
Conflict of Interest: No conflict of interest was declared by the authors.
Financial Disclosure: The authors declared that this study received no financial support.
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Cheung CW, Ching Wong SS, Qiu Q, Wang X. Oral oxycodone for acute postoperative pain: a review of clinical trials. Pain Physician 2017; 20: SE33-52.
Rai AS, Khan JS, Dhaliwal J, Busse JW, Choi S, Devereaux PJ, et al. Preoperative pregabalin or gabapentin for acute and chronic postoperative pain among patients undergoing breast cancer surgery: a systematic review and meta-analysis of randomized controlled trials. J Plast Reconstr Aesthet Surg 2017; 70: 1317-28.
Li XD, Han C, Yu WL. Is gabapentin effective and safe in open hysterectomy? A PRISMA compliant meta-analysis of randomized controlled trials. J Clin Anesth 2017; 41: 76-83.
Weibel S, Jelting Y, Pace NL, Helf A, Eberhart LH, Hahnenkamp K, et al. Continuous intravenous perioperative lidocaine infusion for postoperative pain and recovery in adults. Cochrane Database Syst Rev 2018; 6: CD009642.
Lirk P, Thiry J, Bonnet MP, Joshi GP, Bonnet F. Pain management after laparoscopic hysterectomy: systematic review of literature and prospect recommendations. Reg Anesth Pain Med 2019; 44: 425-36.
Cheng GS, Ilfeld BM. A review of postoperative analgesia for breast cancer surgery. Pain Manag 2016; 6: 603-18.
Bamigboye AA, Hofmeyr GJ. Local anaesthetic wound infiltration and abdominal nerves block during caesarean section for postoperative pain relief. Cochrane Database Syst Rev 2009: CD006954.
Schnabel A, Reichl SU, Kranke P, Pogatzki-Zahn EM, Zahn PK. Efficacy and safety of paravertebral blocks in breast surgery: a meta-analysis of randomized controlled trials. Br J Anaesth 2010; 105: 842-52.
Hussain N, Shastri U, McCartney CJL, Gilron I, Fillingim RB, Clarke H, et al. Should thoracic paravertebral blocks be used to prevent chronic postsurgical pain after breast cancer surgery? A systematic analysis of evidence in light of IMMPACT recommendations. Pain 2018; 159: 1955-71.
Blanco R, Fajardo M, Parras Maldonado T. Ultrasound description of pecs II (modified pecs I): a novel approach to breast surgery. Rev Esp Anestesiol Reanim 2012; 59: 470-5.
Kulhari S, Bharti N, Bala I, Arora S, Singh G. Efficacy of pectoral nerve block versus thoracic paravertebral block for postoperative analgesia after radical mastectomy: a randomized controlled trial. Br J Anaesth 2016; 117: 382-6.
Ueshima H, Otake H. Ultrasound-guided pectoral nerves (PECS) block: complications observed in 498 consecutive cases. J Clin Anesth 2017; 42: 46.
Griffiths JD, Barron FA, Grant S, Bjorksten AR, Hebbard P, Royse CF. Plasma ropivacaine concentrations after ultrasound-guided transversus abdominis plane block. Br J Anaesth 2010; 105: 853-6.
Bos EME, Hollmann MW, Lirk P. Safety and efficacy of epidural analgesia. Curr Opin Anaesthesiol 2017; 30: 736-42.
Rosero EB, Joshi GP. Nationwide incidence of serious complications of epidural analgesia in the United States. Acta Anaesthesiol Scand 2016; 60: 810-20.
Bardia A, Sood A, Mahmood F, Orhurhu V, Mueller A, Montealegre-Gallegos M, et al. Combined epidural-general anesthesia vs general anesthesia alone for elective abdominal aortic aneurysm repair. JAMA Surg 2016; 151: 1116-23.
Carter J. Fast-track surgery in gynaecology and gynaecologic oncology: a review of a rolling clinical audit. ISRN Surg 2012; 2012: 368014.
Long JB, Bevil K, Giles DL. Preemptive analgesia in minimally invasive gynecologic surgery. J Minim Invasive Gynecol 2019; 26: 198-218.
Steinberg AC, Schimpf MO, White AB, Mathews C, Ellington DR, Jeppson P, et al. Preemptive analgesia for postoperative hysterectomy pain control: systematic review and clinical practice guidelines. Am J Obstet Gynecol 2017; 217: 303-13.e6.
Carli F, Charlebois P, Baldini G, Cachero O, Stein B. An integrated multidisciplinary approach to implementation of a fast-track program for laparoscopic colorectal surgery. Can J Anaesth 2009; 56: 837-42.
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Gilron I, Orr E, Tu D, O'Neill JP, Zamora JE, Bell AC. A placebo-controlled randomized clinical trial of perioperative administration of gabapentin, rofecoxib and their combination for spontaneous and movement-evoked pain after abdominal hysterectomy. Pain 2005; 113: 191-200.
Ajori L, Nazari L, Mazloomfard MM, Amiri Z. Effects of gabapentin on postoperative pain, nausea and vomiting after abdominal hysterectomy: a double blind randomized clinical trial. Arch Gynecol Obstet 2012; 285: 677-82.
Ong CK, Seymour RA, Lirk P, Merry AF. Combining paracetamol (acetaminophen) with nonsteroidal antiinflammatory drugs: a qualitative systematic review of analgesic efficacy for acute postoperative pain. Anesth Analg 2010; 110: 1170-9.
Maund E, McDaid C, Rice S, Wright K, Jenkins B, Woolacott N. Paracetamol and selective and non-selective non-steroidal anti-inflammatory drugs for the reduction in morphine-related side-effects after major surgery: a systematic review. Br J Anaesth 2011; 106: 292-7.
Seaton S, Reeves M, McLean S. Oxycodone as a component of multimodal analgesia for lactating mothers after caesarean section: relationships between maternal plasma, breast milk and neonatal plasma levels. Aust N Z J Obstet Gynaecol 2007; 47: 181-5.
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Q: Xcode formatting of objective C code I am use to using a feature in eclipse that formats all of my code in a file to the same syntax position by hitting Shift + Ctrl + F. I don't even know what this feature is called but I was wondering if you can do something similar in Xcode for objective-c programming. Thanks in advance.

A: Hit Command + A then Control + I. simple.


Using innovative and engaging activities, this workshop is all about getting people to think about what it is to be LGBT+, breaking down stereotypes and showing that we are all part of the human race. This workshop can be tailored to suit any age and your specific requirements.
Combining group discussions, exercises and presentations, this training session will equip you with all you need to know about working with and understanding LGBT+ clients. This training session lasts for three hours.
Combining group discussions, exercises and presentations, this training session will equip you with all you need to know about working with and understanding trans clients. This training session lasts for three hours.
We are able to provide bespoke half and full day workshops on LGBT+ related topics that are tailored to meet your requirements. Whether it's an awareness day for young people or training for professionals, we can offer you a top notch service. Please contact us to discuss booking a half or full day workshop.
Our talks focus on challenging homophobia, biphobia and transphobia, celebrating diversity, breaking down stereotypes. They are motivational in nature and aim to inspire and empower people. The talks can be talored to suit any age and any requirements that you may have. The talks can last for up to one hour, including a Q&A, and cost is based upon what your requirements are. Please contact us to discuss what you would like the talk to focus on.
To find out more or to book your workshop, talk or training, please contact us to discuss your requirements.


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WBUR News
In Minneapolis, The Patriots Are Surprisingly Popular03:17
<iframe width="100%" height="124" scrolling="no" frameborder="no" src="https://player.wbur.org/news/2018/02/01/patriots-super-bowl-fans"></iframe>
Martin KesslerTwitter
The Patriots are usually unpopular outside of New England -- but in the lead up to the Super Bowl, many Minnesotans are declaring their support for the Patriots. (Eric Gay/AP)
Since most Patriots and Eagles fans hadn't arrived in Minneapolis earlier in the week, it was a mostly local crowd checking out the Super Bowl festivities downtown on Tuesday night.
There were plenty of people in Minnesota Vikings' purple listening to music, ordering from food trucks — and even watching cross country ski races on a short, pop-up course.
Joan Potter from Woodbury, Minnesota, was one Vikings fans in attendance. And like a lot of football fans outside New England, she plans to root against the Patriots on Sunday.
"I don't understand how they've been able to maintain this dynasty, but it's time — it's time for somebody else," she said.
Chris Wilson, a lifelong Vikings fan from Eden Prairie, Minnesota, was there, too. He doesn't mind the Patriots' success — but he dislikes the team for another reason.
"It's great that they're doing as well as they've done," Wilson said. "But there's been some checkered past. The football — the pressure of the footballs — Tom Brady doesn't need to do that."
Wilson is, of course, referring to the infamous Deflategate scandal which resulted in a four-game suspension for Patriots quarterback Tom Brady.
For years it's been like this: Inside New England the Patriots are revered as champions. Outside New England, they're the unlikable dynasty willing to bend the rules to win.
Patriots safety Duron Harmon put it like this on Monday night: "It's either you love us or you hate us."
But this week in Minneapolis it's actually a bit more complicated.
The Philadelphia Eagles — the Patriots' opponent Sunday — reached the Super Bowl by trouncing the hometown Vikings in the NFC Championship.
After that game, video showed Eagles fans cursing and throwing beer cans at Vikings fans and the Minnesota team bus.
That behavior was enough to turn many Minnesota fans like Hunter and Holly Sargent against the Eagles.
"I'm going to go for the Patriots. So, go, Pats. Go," Hunter told me Tuesday.
"Did you guys ever think you'd be in a position where you're rooting for the Patriots?" I asked.
"No," Holly said.
"It's either you love us or you hate us."
Patriots safety Duron Harmon
Randy Holmes from Prior Lake, Minnesota, was also drawn toward the Patriots in part because of Eagles fans' behavior at the NFC Championship, and also because Brady's mother is from a small farming town about two and a half hours from Minneapolis.
"And some good stories of him coming to visit grandma and grandpa over the years — do a little ice fishing, fishing," Holmes said. "It's giving me a reason, and he seems like a real classy guy."
All of these factors put the Patriots in a most unusual spot at Monday's Super Bowl opening night festivities in St. Paul. Before a mostly local crowd, the team got a warmer reception than their opponent: When the emcee asked Eagles fans to cheer, he was met by a mix of boos.
So when the Patriots take the field Sunday it certainly won't be as good as having home-field advantage, but it will probably be better than the reception they're used to getting outside of New England.
This segment aired on February 1, 2018.
Season Ticket: From Minneapolis: Patriots Arrive, Brady Asks For Leniency For WEEI Personality
Here's The 5-Step Concussion Protocol Gronk Is Going Through This Week
Thousands Gather To Send The Patriots Off To Super Bowl 52
Radio Boston: Super Bowl Mania Has Begun, And Only A Game's Bill Littlefield Discusses
Martin Kessler Twitter Producer, Only A Game
Martin Kessler is a producer at Only A Game.


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Dear Parishioners,
For these reasons I am adapting our communion protocol:
* CDC information points to the airborne nature of the virus and the renewed importance of masks.
* Increasing cases and higher hospitalizations in Sangamon county, central Illinois and countrywide.
* Specific concern of individuals under my Pastoral Care.
Option #1: Holy Communion during the Mass will continue with these changes.
Priests and Eucharistic ministers are now required to wear a mask while giving out communion.
• For those who desire to receive Holy Communion, they may do so at the appropriate moment, and those who wish to remain in their places (disability) may do so. The faithful should maintain a 6-foot distance from each other as they come forward for Holy Communion, continue to wear a mask until just before or while receiving the Eucharist. Continue to keep the 6' distance from Priest/EM and as you say 'Amen,' then move forward to receive the Eucharist.
The CDC states: COVID-19 spreads mainly among people who are in close contact with one another (within about 6 feet), so the use of cloth face coverings is particularly important in settings where people are close to each other or where social distancing is difficult to maintain. I add again that it is important that the person receiving communion continue to wear a mask while in the communion line. Then briefly remove it in order to receive the Eucharist.
Father Al Kemme


I spent most of my life living in Sierra Leone and one of the memories that most comes to mind are the plentiful palm trees.
I especially enjoyed going out to my parent's palm and fruit plantation on the weekends and the sight was just breathtaking.
Maybe you can depict in the above that I'm pretty homesick and miss there a lot, so I'm thinking of making the baby room into a palm paradise but unsure if I should paint the mural directly onto the wall or try using a sheet instead.
…. of the new addition to our family.
For the first time, Hanna and I heard the baby(s) heartbeat. (We think we may be having twins but will know for sure on 11-1-2004 during the ultrasound).
So right now, we're just cooling our heels waiting excitedly for Monday to come around so the whole family can share in our new arrival.
I'm Ada wife and mom of two from Northern Virginia.
With our third child due April 2005, I've been looking into a career change but in the meantime need something that will help run the family while I'm in school.
My wish is to become either a Certified Midwife or Obstetrician. Now in my junoir year with a major in nursing, I'm hoping this will give me the neccesary foundation to tackle the MCAT's and later medical school.
For now, I'm toying with the idea of an interior design franchise (like most women, I enjoy decorating) or start a website with prenatal, postnatal and maternity items since I had such a hard time finding these items while on bed rest. I'm doing my research now and was advised that I do some more publishing in my blog to get name recognition if I wanted to follow the website idea, so from now on, I'll be linking to articles that expectant parents or even students doing research could be interested in and see how it goes from there.


Today, I'm going to share with you my favorite three-card spread. It's the one I currently work with most frequently, and typically I draw it twice a week. It's pretty much my go-to.
Let's get right down to it.
Being three cards, it may seem very simple on the surface, but the contextual significance of the spread, as well as its layout, creates some very unique interactions with the cards.
Being at the pinnacle of the spread, this card typically demands the most real-estate of the practitioner's attention. It's essentially the "question" card—the subject matter that is advised to maintain awareness and attention on.
In my experience with this spread, this card always feels like it speaks to an inner abstraction that, in maintaining its presence in my mind, enriches my current circumstances. Sometimes, it can be rather tongue-in-cheek, and others, a very healthy guidepost.
Sometimes, this card can entirely change the spread. For instance, a card like The Chariot, with its two beasts, can really "take the wheel" of the interpretation (excuse my horrible pun) by considering how cards 2 & 3 might be driving the Chariot.
In the bottom left is "the arena." It's the primary contextually-supporting position that is intended to depict the arena of life where the spread is relevant.
Depending on what card falls into this position, it can sometimes be difficult to interpret with definitive judgment. Though usually, when I consider my personal interpretation of the card's central ideas, the "arena" becomes clear.
The Emperor. A card that I associate with order-keeping, responsibility, and vision-oriented management and leadership (including self-management & self-leadership). In the arena context, it might convey necessary tasks that have deadlines, or areas in which I am in a leadership position and thus responsible.
The 4 of Cups. While in some positions this card can convey a sense of idleness or despondency, in this position it feels to convey a sense of meditation and searching for inspiration.
The Queen of Wands. I perceive this Queen as a character who expresses a mature level of self-knowledge, expertise, and application of will. When I imagine her entering this position, I feel my attention drawn toward areas in which I am currently expressing proficiency and an advanced level of understanding. If there is a strong Queen of Wands presence in my life in the form of another person, I would consider her appearance in this position as signifying my interactions with that person.
This is the card that is put to action. It is the building block that helps the overarching contemplation move into some observable fruition (if it's favorable) or bring it to resolution (if it presents conflict).
I rarely find this card difficult to interpret, though conflict cards (such as many of the Swords, or any of the 5s) can stir a sense of confusion.
The 5 of Swords. "Don't be intimidated or brought low by assholes with strong opinions."
The 8 of Swords. "Make a decision, already."
The 5 of Cups. "You're focusing too much on the past and its fleeting moments. There are other moments now, and tomorrow that need your attention."
The 10 of Swords. "You know what you need? You need to go out into the woods. And scream. For a long time."
These examples are just to help illustrate flexibility in interpretation—I know a lot of practitioners who, starting out, have a difficult time perceiving how certain cards can connect with the context of their spread positions.
Of course, you undoubtedly have your own relationship to the deck and your experience of this spread will likely yield unique results.
In both my personal and professional practice, my aim is to bring light to the circumstances, and nudge awareness & attention toward the opportunities within them. I find that this spread really excels in executing this style of approach.
This is often a slam dunk spread for events, where usually I am spending under 10 minutes with the participants that sit with me. It's very clear in its purpose and layout, and the participants get really engaged with this spread, with minimal nudging on my behalf.
If the client feels bewildered in regards to their circumstances, sometimes a large, complicated spread just adds to the confusion. This spread can be a great way to gain some focus on the topic, in helping suss out what the real questions are.
During longer sessions, sometimes clients might have difficulty in assessing the key points, particularly in regards to forecast-style sessions that stretch out to an annual period. The aim is always to help clients work toward creating the future they want (with due preparedness), so this spread can really help tie up one of these sessions by providing some focus on the here & now.
So there you have it! This is hands-down my most trusted spread at the moment. I have no doubt that you'll find this spread to be empowering & uncanny! My final recommendation is to let the spread aerate for a couple days, in a spot where you will see it often and can ruminate on it. After all, it is a spread that is geared toward enriching contemplation!
If you'd like some specific advice on your practice or pursuit as a professional practitioner, I recommend taking a gander at the ways I can help!
If you're looking for unconventional methods in tackling the abstract problems of human life, you've come to the right place.
Copyright Kevin Wheeler, Myth & Mask. All rights reserved. 2018.


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Home BREAKING NEWS Death of Indian American nursing student Jeffny Pally in Connecticut: 6 UConn...
Death of Indian American nursing student Jeffny Pally in Connecticut: 6 UConn students charged
Jeffny Pally (Courtesy: Twitter)
Six University of Connecticut students were charged Friday with alcohol-related offenses related to the death of an Indian American student, Jeffny Pally, a 19-year-old Sophomore studying nursing, from West Hartford, CT, who was run over by a fire department vehicle after leaving a party last fall.
The students had been hosting an off-campus party at a fraternity-affiliated house Oct. 16 during homecoming weekend. Police say Pally had been sitting with her back against a garage door of the UConn Public Safety Complex at around 1 a.m. when she was run over by a fire vehicle responding to a call that turned out to be a false alarm. Two additional students have been charged in connection with the false alarm, reported CBS News.
Pally's body wasn't found until about 30 minutes later when firefighters returned. She died from injuries to her head and torso, the medical examiner's office determined. The driver of the vehicle hasn't been charged and the tragedy was ruled an accident.
The charged students are Patrick Callahan, Matthew Moll, Dylan Morose, Austin Custodio, Dominic Godi and Jonathan Polansky. They range in age from 21 to 22 and are from Connecticut, New York and Massachusetts. Some were charged with permitting a minor to illegally possess alcohol.
They were all released pending their arraignment in Superior Court in Rockville on March 8. UConn said all but Godi were seniors, CBS affiliate WFSB reports.
The university noted the Kappa Sigma fraternity recently lost its recognition and housing due to off-campus incidents in September and October unrelated to Pally's death. The fraternity's national office also has revoked the local group's charter.
"Jeffny Pally was a talented, ambitious, promising young woman and her death was a terrible tragedy," the university said. "The entire university community joins her family and friends in continuing to mourn her loss."
An arrest warrant revealed Pally had been with her sorority sisters from Delta Gamma during the day, WFSB reports. They were working on a homecoming float and then, she met back up with them later that evening in a dorm where they were drinking before heading to a fraternity party in Manchester hosted by Kappa Sigma.
When police interviewed some of those arrested, they told investigators they did have a fraternity party, but said there was a bouncer hired to check identifications and give wristbands to make sure only those over 21 were drinking.
But, eyewitnesses told police "there were approximately 50 people there and nobody was wearing wrist bands." Another eyewitness said
According to the arrest warrant, Pally's blood alcohol level was 0.25 that's more than three times the legal limit.
The parents of Jeffny Pally spoke to Eyewitness News and described their daughter as "compassionate," [and] "beautiful, inside and out," with a "smile that could light up a room."
Jeffny Pally's mother, Shiny Pally, and her father, Abraham Pally, cautioned their daughter — a nursing student, who was involved in multiple sports, in countless organizations, and sorority sister at Gamma Delta, was "overbooked." The couple told Eyewitness News that Jeffny would often reassure them that she could juggle it all.
"We still haven't seen our child", said Shiny Pally. "Can you imagine that?" When just weeks ago, Pally was visiting home, they said, indulging on some of her favorite Indian food. "She had high hopes and very hardworking, very compassionate. She always put others first."
The Mayor of West Hartford, Shari Cantor offered her condolences to the grieving family.
"My heart is broken for her family, friends, and for the entire community. This is such a tragic loss. Jeffny was a sweet, intelligent, and beautiful young lady who brightened up everyone around her. She was a dear friend of my son and our family. I extend my deepest and heartfelt condolences to her family," said Mayor Cantor.
The parents told told Eyewitness News that their daughter was a homebody, and chose UConn because of the proximity to home.
"She wants to see us all the time," said Abraham Pally. "She didn't even apply anywhere else."
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