The Emergence of the Old Drug Captagon as a New Illicit Drug: A Narrative Review.

First developed in the 1960s in Europe and approved briefly for use in the United States, fenethylline (sold as Captagon, one of its early trade names) is now a prominent drug of abuse in the Eastern Mediterranean Region. The drug was withdrawn from the United States market because of side effects that included hallucinations, visual distortions, and psychosis; it has also been linked to rare cases of myocardial infarction, seizures, and delusions. The chemical synthesis of fenethylline is straightforward and inexpensive. Manufactured in clandestine labs in Southern Europe and the Middle East, these amphetamines had been used by affluent Middle Eastern young people for recreation or study aids. Captagon has periodically emerged as a drug used in combat and conflict, and it was implicated in the 2015 riots in Paris. It has been described as "chemical courage" for combatants giving them focus, energy, and endurance in battle situations. Captagon is addictive but no cases of direct captagon-associated mortality have been reported. The use of drugs in war is nothing new, but captagon is also used heavily in the civilian population in war-torn areas to help them cope with food insecurity and maintain courage in dangerous situations. Captagon production and distribution drives the Syrian economy, but the drug's use is limited to certain regions and is rarely seen in North America. The drug is available online, but product may be contaminated with the inclusion of procaine, caffeine, or other substances.

Wooden Chest syndrome: The atypical pharmacology of fentanyl overdose.

WHAT IS KNOWN AND OBJECTIVE: A large percentage of opioid overdose fatalities involve fentanyl or one of its legal or illegal analogs (F/FAs). Is there something about the pharmacology of these drugs that make them unusually dangerous in an overdose? COMMENT: Some of the reasons for the dangers of overdose of F/FAs is their high potency and low cost (that leads to wide distribution). But it is rarely asked if the basic pharmacology of F/FAs differ in some fundamental way from conventional opioids such as morphine and heroin. In addition to centrally mediated respiratory depression via opioid receptors, F/FAs cause rigidity in the key respiratory muscles of the chest, upper airway and diaphragm ("wooden chest syndrome," WCS) by a non-opioid mechanism. WHAT IS NEW AND CONCLUSION: WCS is an atypical pharmacology of F/FAs. Because of its rapid onset and non-opioid mechanism, WCS makes F/FA overdose particularly dangerous.

Predictors of emergency department opioid administration and prescribing: A machine learning approach.

INTRODUCTION: The opioid epidemic has altered normative clinical perceptions on addressing both acute and chronic pain, particularly within the Emergency Department (ED) setting, where providers are now confronted with balancing pain management and potential abuse. This study aims to examine patient sociodemographic and ED clinical characteristics to comprehensively determine predictors of opioid administration during an ED visit (ED-RX) and prescribing upon discharge (DC-RX). METHODS: ED visit data of patients ≥18 years old from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2014 to 2017 were used. Opioid prescriptions were determined utilizing Lexicon narcotic drug classifications. Visit characteristics studied included sociodemographic variables, and ED clinical variables, such as chief complaint, and discharge diagnosis. Machine learning methods were used to determine predictors of ED-RX and DC-RX and weighted logistic regressions were performed using selected predictors. RESULTS: Of the 44,227 ED visits identified, patients tended to be female (57.4%), and White (74.2%) with an average age of 46.4 years (SE = 0.3). Weighted proportions of ED-RX and DC-RX were 23.2% and 18.9%, respectively. The strongest predictors of ED-RX were CT scan ordered (OR = 2.18, 95% CI = 1.84-2.58), abdominal pain (OR = 1.93, 95% CI:1.59-2.34) and back pain (OR = 1.81, 95% CI:1.45-2.27). Tooth pain (OR = 6.94, 95% CI = 4.40-10.94) and fracture injury diagnoses (OR = 3.76, 95% CI = 2.72-5.19) were the strongest predictors of DC-RX. CONCLUSIONS: These findings demonstrate the utility of machine learning for understanding clinical predictors of opioid administration and prescribing in the ED, and its potential in informing standardized prescribing recommendations and guidelines.

Diagnosis of abdominal mural aortic thrombus following discovery of common femoral artery and vein thrombosis by point-of-care ultrasound.

Acute limb ischemia (ALI) is a limb-threatening and life-threatening disease process. Mural aortic thrombosis (MAT) is a rare cause of ALI. While there is limited evidence on the use of bedside ultrasound for the detection of ALI or MAT, duplex ultrasound remains the standard in the diagnosis and ultimate medical decision-making in patients with acute and chronic limb ischemia. Point-of-care ultrasound may be used in the evaluation of patients with signs and symptoms of this disease entity. This is a case of a 79-year-old female with a complicated medical history, who presented with a pulseless right leg and abdominal tenderness. The patient quickly decompensated requiring intubation for airway protection. A post-intubation arterial blood gas (ABG) was unsuccessfully attempted in the right femoral artery, prompting an ultrasound-guided ABG. On B-mode ultrasound evaluation, echogenic material was visualized in the right common femoral artery without evidence of Doppler flow signal. Additionally, a partially obstructing echogenic material was also noted at the femoro-saphenous vein junction with only partial compressibility by compression sonography. A computed tomography angiography of the aorta was performed indicating extensive infrarenal aortic thrombosis. The patient expired despite the relatively prompt diagnosis, highlighting the importance of early identification of acute arterial occlusion.