Fake Xanax: Designer Emerging Benzodiazepine Epidemic Linked to Morbidity and Mortality a Narrative Review.

Etizolam is a thienodiazepine derivative which produces an anxiolytic effect similar to benzodiazepines such as alprazolam (Xanax). Like classic benzodiazepines, etizolam has a high affinity towards the GABAA receptor, and allosterically potentiates the effects of GABA resulting in neuronal hyperpolarization related to chloride influx. When taken in therapeutic doses, etizolam produces a similar effect to Xanax. Counterfeit Xanax tablets contain variable amounts of etizolam. Tablets with high amounts of etizolam can cause toxicity if ingested, especially when combined with other substances. When toxic symptoms occur in patients, they may include severe sedation, unconsciousness, and depression of the medullary respiratory center. In this regard, there is the potential for death. Additionally, the rise in fake Xanax tablets containing etizolam and other counterfeit medications has been exacerbated by the difference in regulations regarding these substances in different countries as well as the illegal drug trade. Healthcare providers may also play a role through the over- or underprescribing of certain medications. Thus, in order to combat the rise in counterfeit medications such as fake Xanax, international cooperation, regulation, and enforcement of laws pertaining to the manufacture, prescription, and distribution of these substances are needed.

Hyponatremia With Anticonvulsant Medications: A Narrative Review.

Hyponatremia is an adverse effect of many antiseizure medications (ASMs). It occurs with interference with the normal balance of electrolytes within the body. Various risk factors associated with the development of hyponatremia in patients taking these medications include age, gender, dosage, and combinations with other drugs. ASMs such as carbamazepine (CBZ), oxcarbazepine (OXC), and valproic acid have a higher risk of hyponatremia. Hyponatremia induced by an antiseizure medication can occur through various mechanisms depending on the drug's specific mechanism of action. Hyponatremia can be a potentially fatal side effect. Patients taking these medications need to be monitored closely for the signs and symptoms of hyponatremia. Acute hyponatremia, defined as developing in <48 hours, is more likely to show symptoms than chronic hyponatremia. Signs of acute hyponatremia include delirium, seizures, decerebrate posturing, and cerebral edema with uncal herniation. Chronic hyponatremia, defined as developing in >48 hours, can cause lethargy, dizziness, weakness, headache, nausea, and confusion. Hyponatremia is associated with longer hospital stays and increased mortality. Treatment varies based on the degree of severity of hyponatremia. Choosing a treatment option should include consideration of the drug causing the electrolyte disturbance, the patient's risk factor profile, and the severity of symptoms as they present in the individual patient. Healthcare providers should be aware of hyponatremia as a potential side effect of ASMs, the signs and symptoms of hyponatremia, the different treatment options available, and the potential complications associated with rapid correction of hyponatremia.

Cefiderocol (Fetroja) as a Treatment for Hospital-Acquired Pneumonia.

With increasing resistance to conventional antibiotic treatments, especially among gram-negative bacilli, the search for new antibiotics has become critical on a global scale. Among infections with multidrug-resistant bacteria is hospital-acquired pneumonia (HAP), which is nosocomial pneumonia in patients who have been hospitalized for more than 48 hours. HAP carries a high mortality rate and continues to be a challenge with regard to adequate treatment. The typical multidrug-resistant gram negatives found in HAP include Pseudomonas aeruginosa, Klebsiella pneumoniae, and Acinetobacter baumannii. Many new antibiotics have been studied and tested against these pathogens as possible solutions, and the search continues. Cefiderocol, a novel siderophore cephalosporin, is effective against these pathogens. Cefiderocol is an iron-chelating agent that makes use of iron pumps on the membrane of bacteria via a catechol moiety on the C3 side chain of the molecule. This allows for easy access into the cytoplasm, where it can inhibit peptidoglycan synthesis by binding to penicillin-binding proteins. Cefiderocol displays linear pharmacokinetics and is mainly excreted through the kidneys. It is well tolerated in healthy individuals but may need adjustments of dosage in patients with impaired renal function. Studies have shown that both healthy subjects and those with impaired renal function experienced some adverse effects, including nausea, diarrhea, abdominal pain, and increased creatinine kinase; however, these adverse effects were limited and experienced in placebo groups. It has demonstrated efficacy in treating infections caused by many multidrug-resistant gram-negative pathogens and has demonstrated high stability against many classes of b-lactamases. There have been multiple phase 3 trials, such as the CREDIBLE-CR trial and the APEKS-NP trial, that demonstrated efficacy in treated nosocomial pneumonia caused by multidrug-resistant gram negatives, such as carbapenem-resistant Acinetobacter baumannii, Klebsiella pneumoniae, and Pseudomonas aeruginosa, compared to the best available treatment. While clinical data remain limited, a few studies are showing clinical efficacy and few adverse effects. Cefiderocol demonstrated effectivity in treating multidrug-resistant gram-negative pneumonia in patients with multiple comorbidities, such as chronic kidney disease, chronic-obstructive pulmonary disease, and diabetes mellitus. Cefiderocol shows promise as a novel antimicrobial agent in treating multidrug-resistant gram-negative in HAP.

Chaperones Utilization in Clinical Practice: Intimate and Sensitive Physical Examination Best Practice Strategies and Concepts in Modern Urological Medicine.

The intention of utilizing chaperones during sensitive physical exams is to show respect to the patient, while simultaneously providing protection to both the patient and the medical provider. Despite clinical practice recommendations to offer chaperones for sensitive urologic exams, there is no data regarding the consistency of chaperone utilization. Our aim was to summarize the patient and provider perspectives on the role of chaperones in urology as well as identify barriers to implement chaperone consistency. In the present investigation, we conducted a systematic review of prospective, case-control, and retrospective studies and followed the PRISMA 2020 guidelines for data reporting. Studies were identified from PubMed, MEDLINE, and PMC using the Medical Subject Headings (MeSH) terms "chaperones, patient", "chaperones, medical", and keywords "chaperones", and "urology". Studies were included if they addressed patient/provider perspectives on chaperone utilization in urology specifically and were excluded if they investigated perspectives on chaperone utilization in other specialties. Preliminary study identification yielded 702 studies, 9 of which were eligible for this review after applying the inclusion and exclusion criteria. Of these, 4 studies focused on the patient perspective and 5 focused on the provider perspective. The percentage of patients that did not have a chaperone present during their urologic exam ranged from 52.9-88.5%. A greater proportion of these patients were male. Patients (59%) prefer a family member compared to a staff member as a chaperone. Physicians (60%) prefer staff member chaperones compared to family members. One study reported that 25.6% of patients did not feel comfortable to ask for a chaperone if they were not offered one. Two studies reported the percentage of patients who believed chaperones should be offered to all urology patients, ranging from 73-88.4%. Three studies reported the use of chaperones in the clinic which ranged from 5-72.5%. Two studies reported chaperone utilization documentation, ranging between 16-21.3%. Two studies reported the likelihood of chaperone utilization depending on gender of the physician, showing that male physicians were more likely to utilize chaperones and were 3x more likely to offer chaperones to their patients compared to female physicians. Research suggests that there are differing perspectives between patients and physicians regarding the specific role and benefits chaperones offer during a sensitive urologic examination, as well as differences in preferences of who should perform the role of the chaperone. While more work needs to be done to bridge the divide between clinical practice and patient/physician preferences, the act of offering chaperones to urologic patients, regardless if they want to utilize a chaperone for their examination is respectful of patient privacy and decision making.

Attenuation of the haemodynamic responses to tracheal intubation with gabapentin, fentanyl and a combination of both: A randomised controlled trial.

BACKGROUND AND AIMS: We conducted a prospective, randomised, double-blind, controlled clinical trial to examine (1) whether a single preoperative dose of 800 mg gabapentin would be as effective as 2 µg/kg of intravenous (IV) fentanyl in blunting the haemodynamic response to tracheal intubation and (2) whether a combination of both would be more effective in this regard. METHODS: Seventy-five patients (American Society of Anaesthesiologists physical status I), aged 20-50 years were allocated into one of three groups: 2 µg/kg IV fentanyl, 800 mg oral gabapentin or a combination of both. Gabapentin was administered 2 h and fentanyl 5 min before induction of anaesthesia, which was achieved with 5 mg/kg thiopentone, and tracheal intubation facilitated with 0.1 mg/kg vecuronium. Laryngoscopy lasting a maximum of 30 s was attempted 3 min after administration of the induction agents. Serial values of mean arterial pressure (MAP) and heart rate (HR) were compared among the three groups and with the respective preinduction measurements. RESULTS: Patients receiving gabapentin 800 mg alone showed remarkable increases in HR and MAP in response to tracheal intubation (P < 0.05). The increases were similar for the other two regimens. These haemodynamic changes were lesser in patients receiving fentanyl and the combination of gabapentin and fentanyl. CONCLUSION: Oral gabapentin does not produce significant reduction in laryngoscopy and tracheal intubation induced sympathetic responses as compared to IV fentanyl or the combination of gabapentin and fentanyl.

Case report: telelaryngoscopy-guided flexible fiberoptic intubation for laryngeal rhinosporidiosis.

Rhinosporidiosis is a chronic granulomatous disease endemic in India and Sri Lanka. The causative microorganism, Rhinosporidium seeberi, remains a poorly understood pathogen, which has been described as an aquatic protistan parasite. Rhinosporidiosis presents as multiple polypoidal lesions affecting the mucosa of the nasal cavity, nasopharynx, and oropharynx. Intralaryngeal rhinosporidiosis is a rare entity and poses a challenge for management of the airway. In this case report, we highlight our technique in the management of the airway in a case of laryngeal rhinosporidiosis using a combination of fiberoptic bronchoscope and an endoscope. The technique was atraumatic and also avoided the potential for autoinoculation, which is a frequent cause of recurrence of this disease.