Persistent Singultus Associated with Lumbar Epidural Steroid Injections in a Septuagenarian: A Case Report and Review.

Singultus are rare but notable adverse effect of epidural steroid injections (ESIs). To date, reports of persistent hiccups associated with ESIs have been reported mostly in adults aged 65 years or older. We present the first case of persistent hiccups in a septuagenarian who underwent repeated transforaminal ESIs for chronic lumbar radiculopathy. Under fluoroscopic guidance, 1.5 mL of 1% lidocaine (preservative free) and 0.8 mL of dexamethasone solution (10 mg/mL) was injected into the bilateral L4-L5 neural foramen and epidural space.After the first epidural injection, episodes of singultus occurred at a frequency of 5 to 7 episodes per minute and lasted for 36 hours. One month later, he was treated with the second epidural injection after which he immediately developed singultus, occurring at 2- to 3-hour intervals. Interventions for the singultus included drinking small sips of water, vagal maneuvers, and oropharyngeal stimulation with ice chips. The singultus eventually resolved without medical intervention within 5 days of onset. A major take-home point is that preprocedure informed consent should include singultus as one of the potential adverse effects of ESIs. Increased awareness and appropriate planning may help curb the incidence of adverse outcomes in older adults undergoing ESI.

Minding the Gaps in Cancer Pain Management Education: A Multicenter Study of Clinical Residents and Fellows in a Low- Versus High-Resource Setting.

PURPOSE: Inadequate pain management training has been reported as a major cause of undertreatment of cancer pain. Yet, past research has not comprehensively compared the quality of cancer pain management education among physicians in training in high-resource countries (HRCs) with those in low-resource countries (LRCs). The purpose of this study was to examine and compare gaps in cancer pain management education among physician trainees in an HRC (United States) versus an LRC (Ghana). METHODS: A cross section of physicians at four major academic medical centers completed surveys about the adequacy of cancer pain training. Participation in the study was completely voluntary, and paper or online surveys were completed anonymously. RESULTS: The response rate was 60% (N = 120). Major gaps were identified in cancer pain management education across the spectrum of medical school training. Training was rated as inadequate (by approximately 80% of trainees), although approximately 10% more trainees in HRCs versus LRCs felt this way; 35% said residency training was inadequate in both settings; and 50% in LRCs versus 44% in HRCs said fellowship training was less than good. On the basis of the lowest group means, the three key areas of perceived deficits included interventional pain procedures (2.34 ± 1.12), palliative care interventions (2.39 ± 1.12), and managing procedural and postoperative pain (2.94 ± 0.97), with significant differences in the distribution of deficits in 15 cancer-pain competencies between LRCs and HRCs (P < .05). CONCLUSION: This study identifies priority areas that could be targeted synergistically by LRCs and HRCs to advance cancer care globally. The findings underscore differential opportunities to broaden and improve competencies in cancer pain management via exchange training, in which physicians from HRCs spend time in LRCs and vice versa.

Differential activity of caspase-3 regulates susceptibility of lung and breast tumor cell lines to Paclitaxel.

Recent development of tumor resistance to paclitaxel presents a major problem to cancer treatment. An unsettled controversy in the cancer chemotherapy field, however, is whether caspases play a prominent role in paclitaxel-induced death in tumors. Previous studies suggest that cleavage of caspase-3 is not instrumental for the execution of death in tumors treated with paclitaxel, while other reports indicate that caspase-dependent pathways may be critical for paclitaxel cytotoxicity. In this study, we investigated the role of caspase-3 in breast and lung tumor cell line sensitivity to paclitaxel. Clonogenic survival and live/dead viability-assays, together with enzymatic activity and cell proliferation assays, reveal that the levels of paclitaxel-induced caspase-3 enzymatic activity in tumor cells correlate directly with tumor sensitivity to the drug.We observed a 2-fold increase in caspase-3 activity in 4T1-Luc breast tumor cells, but a 3-fold and 4-fold decrease in A549 and A427 lung tumor cell lines, respectively. Together, our results suggest that caspase-activation and activity levels are not only key determinants of paclitaxel-induced death in tumors but also serve as good indicators for tumor susceptibility to paclitaxel therapy. Our studies also indicate that within clinically relevant doses of paclitaxel, the ability to rid tumor populations of dormant tumor cells controls the rate of tumor recurrence.