Direct application of sevoflurane onto vascular ulcers resulted in an intense and long-lasting analgesia and was associated with a progressive reduction of ulcer size.

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Recently, it has been reported that topical irrigations of liquid sevoflurane on the bed of painful wounds produce a rapid, intense, and lasting analgesic effect. In this paper, A cohort of 112 patients with painful pressure ulcers who were refractory to opioids (or who exhibited undesirable adverse events to them) was treated with topical sevoflurane as per local institutional policy. These patients were recruited from an intensive care unit for a period of 3 years. The main aim was to determine the effectiveness of topical sevoflurane in reducing the pain of PUs and reducing the ulcer area. Study findings are reported and discussed herein and suggest that sevoflurane is a viable and promising treatment option for PUs.

A Caucasian 39-year-old male patient with a poorly-differentiated infiltrating epidermoid penile carcinoma with urethral invasion was diagnosed. The patient received concomitant adjuvant chemotherapy with radiotherapy in the palliative setting, which produced painful ulceration of tumour lesions at loco-regional level (Numerical Rate Scale, NRS=9). The patient consented for treatment with direct topical sevoflurane instillations, at initial doses of 1 mL/cm2 of ulcerated area, as per unit protocol. The local use of undiluted sevoflurane achieved a marked reduction of the pain score in both nociceptive and irruptive pains (average NRS=3 immediately post-application). This improvement was corroborated by a decline in total morphine needs, any adverse events associated with major opiates. PGI-I and CGI-I scales were used before and after treatment with topical sevoflurane to assess patient and clinician perceptions of improvement in the quality of life. The pharmacy of our hospital had the responsibility to elaborate pre-loaded syringes with sevoflurane so that the patient was instilled simply and comfortably.

BackgroundDecitabine is indicated for the treatment of adult patients with newly diagnosed acute myeloid leukaemia (AML) de novo or secondary, according to the classification of the WHO, who are not candidates for conventional induction chemotherapy. There is a general recommendation about the maximum refrigerated (2–8°C) storage time for decitabine of 3 hours, but studies designed to explore stability beyond this period have not been conducted to date.PurposeTo evaluate the physical and chemical stability of decitabine stored in polyethylene syringes over a 24 hour period using proton nuclear magnetic resonance (1H-NMR) spectroscopy.Material and methodsCommercial solutions of decitabine (Dacogen) 5 mg/mL (50 mg in 10 mL of sterile water for injection) were packaged in polyethylene syringes. The syringe was stored in a refrigerator at 4°C±2°C for 24 hours in a digitalised temperature controlled chamber. The following physical parameters were monitored: turbidity and colour. Chemical stability was assessed by means of 1H-NMR spectroscopy. The 1H-NMR spectrum of a reference molecule was acquired. Spectroscopic signals were interpreted and assigned to the chemical structure of decitabine, and then consecutive spectra were acquired every hour during the 24 hour period. Signals obtained in these experiments were compared with those of the reference compound. All spectra were acquired using a Bruker Avance DRX 300 MHz spectrometer equipped with a 5 mm single axis z gradient quattro nucleus probe (Bruker Biospin GmbH, Rheinstetten, Germany).ResultsPhysical parameters monitored remained unchanged over the 24 hour period. During 7 hours, the chemical structure of the molecule was maintained unaltered, as demonstrated by 1H-NMR spectra identical to those of the reference compound. However, several signals corresponding to byproducts appeared in the sample stored at 4°C after 7 hours, proving that decitabine had suffered a degradation pathway.ConclusionDecitabine preserved its physical and chemical properties when stored packaged in polyethylene syringes for up to 7 hours at 4°C±2°C. This study comes into conflict with the information data sheet provided with decitabine, which recommends a maximum time of refrigerated (2–8°C) storage of 3 hours.References and/or acknowledgementsUniversity of Almería.No conflict of interest

Proper symptom management to improve quality of dying is mandatory in palliative care patients. Home-based control of pain caused by leg ulcers is challenging, especially when the pain is severe and refractory to conventional analgesics, the patient is intolerant to opioids and refuses invasive measures. This was the case for an 87-year-old woman under oncological palliative care who suffered from a leg ulcer causing refractory pain, which produced suicidal ideation. Leg amputation was indicated, but she had signed a living will refusing any invasive measures. After obtaining written informed consent, sevoflurane was applied topically on the ulcer, which resulted in a rapid and long-lasting reduction of pain. Daily self-administration of sevoflurane successfully controlled the wound pain and the patient abandoned her suicidal ideation, the wound healed 35 days later, and her quality of dying improved remarkably. Topical sevoflurane deserves further research on ulcers of vascular and also neoplastic aetiology.

BackgroundNatalizumab increases the risk of progressive multifocal leukoencephalopathy (PML), a potentially lethal brain disorder caused by JC polyomavirus (JCV). The antimalarial mefloquine has shown activity against JCV in vitro, but little evidence supports its use in vivo.PurposeTo analyse the efficacy and safety of mefloquine in a case of natalizumab related PML.Material and methodsA 51-year-old Caucasian woman was admitted to the emergency department in March 2013 complaining of ongoing limb weakness and slurred speech. Relevant past medical and drug history: relapsing remitting multiple sclerosis diagnosed in 2004, receiving monthly natalizumab since July 2010 (last infusion 4 days previously). High dose corticoid therapy plus supporting measures were started immediately. 10 days after admission, PML infection was confirmed based on contrast enhanced MRI findings and positive CRP for JCV DNA in cerebrospinal fluid. Patient consent and institutional ethics committee approval were obtained and a trial of mefloquine (250 mg for 3 days, and then 250 mg weekly) plus plasmapheresis (to accelerate removal of the antibody) were initiated.ResultsEfficacy: the patient experienced progressive motor and cognitive impairment. MRI on days 15 and 30 revealed further demyelination with areas extending into the deep white matter and the splenium of the corpus callosum. The patient died on day 55. Safety: on day 45, the patient had seizures that were treated with levetiracetam 1 g twice daily.ConclusionDespite mefloquine therapy, clinical and radiological progression was observed. Moreover, mefloquine was associated with CNS toxicity. To date, only routine MRI has ameliorated the outcome of this neuropathy at the very early stages of infection (pre-symptomatic). With the lack of firstline evidence, mefloquine has been used with mixed success in the treatment of PML although larger studies are required to assess its efficacy and safety.No conflict of interest.