Liposomal bupivacaine nerve block provides better pain control post-total shoulder arthroplasty than continuous indwelling catheter.

BACKGROUND: Pain control is essential to successful total shoulder arthroplasty (TSA). MATERIALS AND METHODS: This non-blinded, randomized clinical trial compared shoulder pain, narcotic use, interscalene (IS) block application time, and costs in 76 subjects who were randomly assigned to receive either a single injection IS nerve block of 10 cc (133 mg) liposomal bupivacaine mixed with 10 cc of 0.5% bupivacaine (Group 1), or 20 cc of 0.5% ropivacaine direct injection combined with an indwelling IS nerve block catheter delivering 0.2% ropivacaine at a continual 4 cc/h infusion for the initial 3 post-operative days (Group 2). Surgical time, local anesthesia duration, hospital stay length, morphine milligram equivalents (MME) consumed, worst shoulder pain at 24, 48 and 72 h, and complications were recorded. Patient reported function, pain and activity level surveys were completed before, and 6-week post-TSA (P < 0.05). RESULTS: Group 1 had less pain 24-h (0.72 ± 0.8 vs. 3.4 ± 2.9, p < 0.0001) and 48-h (2.5 ± 2.2 vs. 4.8 ± 2.6, p = 0.005) post-TSA. At 24-h post-TSA, MME consumption was similar (Group 1 = 4.5 ± 6.4 vs. Group 2 = 3.7 ± 3.8, p = 0.54), but was lower for Group 1 at 48 h (0.0 ± 0.0 vs. 0.64 ± 0.99, p = 0.001). Group 2 had longer IS block application time (10.00 ± 4.6 min vs. 4.84 ± 2.7 min, p < 0.0001). Only group 2 had a strong relationship between MME consumption over the first 24-h post-TSA and pain 24-h post-TSA (r = 0.76, p < 0.0001), a moderate relationship with pain 48-h post-TSA (r = 0.59, P = 0.001), and a weak relationship with pain 72-h post-TSA (r = 0.44, P = 0.02). Significant relationships for these variables were not observed for Group 1 (r ≤ 0.30, p ≥ 0.23). Group 1 IS block costs were less/patient than Group 2 ($190.17 vs. $357.12 USD). CONCLUSION: A single shot, liposomal bupivacaine interscalene nerve block provided better post-TSA pain control with less narcotic consumption, less time for administration and less healthcare system cost compared to interscalene nerve block using a continuous indwelling catheter. LEVEL OF EVIDENCE: Level I, Prospective, Randomized.

Live free or die: tales of homeless (cells) in cancer.

Anoikis, programed cell death that occurs on cell detachment from the extracellular matrix, thus disrupting integrin-ligand interactions, is a critical mechanism in preventing ectopic cell growth or attachment to an inappropriate matrix. Anoikis prevents shed epithelial cells from colonizing elsewhere and is thus essential for maintaining tissue organization. Lack of integrin ligation leads to decreased focal adhesion kinase and integrin-linked kinase activity, which impairs downstream survival signaling. Consequently, targeting tumor cell survival by triggering anoikis provides a unique molecular basis for novel therapeutic targeting of tumors before initiation of metastasis. The two major cell death pathways involved in anoikis signaling are apoptosis and autophagy; growing evidence suggests an extensive cross-talk between the two killing modes as well as context-dependent cooperation and antagonism. This review discusses the functional integration between the two modes of cell death converging at anoikis, including key molecules of interaction such as Beclin 1, reactive oxygen species, extracellular signal-related kinase, and death-associated protein kinase. The involvement of other apoptotic effectors such as Bcl-2, p53, and FLICE inhibitory protein in cancer cell anoikis is also discussed. Dissecting the mechanistic players in the cellular response may be of high clinical significance in identifying effective approaches in reversing anoikis resistance in primary tumor cells and, consequently, impairing metastasis.