Quantity of phenibut in dietary supplements before and after FDA warnings.

INTRODUCTION: Phenibut is used to treat anxiety, insomnia, alcohol withdrawal and other conditions in Russia. The drug, however, has abuse potential and may cause lethargy, delirium, psychosis and coma. In the United States (US), the US Food and Drug Administration (FDA) has never approved the use of phenibut as a prescription medication, but the drug is available over-the-counter in dietary supplements. More than 80 cases of coma and death have been associated with phenibut consumption and withdrawal, and the FDA recently warned that the drug is not permitted in over-the-counter supplements. We designed our study to determine the presence and quantity of phenibut in over-the-counter supplements before and after the FDA warnings. METHODS: Phenibut products were included if they (a) listed phenibut or a synonym as an ingredient on the label, (b) were labeled as a dietary supplement, and (c) were available for sale both before and after the FDA warning. Supplements were analyzed by liquid chromatography time-of-flight mass spectrometry; quantification was performed by isotope dilution method. RESULTS: Four brands of dietary supplements labeled as containing phenibut met the inclusion criteria. Prior to the FDA warnings, two of the four brands contained phenibut, at dosages of 484 mg and 487 mg per serving. After the FDA warning, all four products contained phenibut, ranging in dosages from 21 mg to 1,164 mg per serving. Phenibut was first detected only after the FDA warnings in two brands, and the quantity of phenibut increased in three of four products after the FDA warnings. Quantities detected per dose were as much as 450% greater than a typical 250 mg pharmaceutical tablet manufactured in Russia. CONCLUSION: Following FDA issuing an advisory that phenibut is not permitted in dietary supplements, the quantity of phenibut increased in 3 of 4 brands of over-the-counter phenibut supplements.

Expanding the use of topical anesthesia in wound management: sequential layered application of topical lidocaine with epinephrine.

UNLABELLED: Topical anesthesia eliminates the need for injection of anesthetic. Most studies on the use of topical anesthesia were done on children, using 3 active ingredients (lidocaine, epinephrine, tetracaine, or tetracaine, adrenaline, cocaine) for relatively small wounds of the face and scalp. OBJECTIVES: To demonstrate that topical anesthesia is effective and safe in adults of all ages and for larger wounds, using a preparation with 2 active ingredients, topical lidocaine and epinephrine (TLE). METHODS: One hundred patients were enrolled in a randomized controlled trial, with 50 in each group. The study group received TLE using a unique method of "sequential layered application." The control group received 2% lidocaine infiltration anesthesia. Patients rated the pain from the application of anesthesia and from suturing, using a 0 to 10 visual analog pain scale. Follow-up interviews were conducted to assess for complications and to rate patients' wound repair experience. RESULTS: Patients in the study group reported significantly less pain from TLE application, with 66% reporting no pain vs 0% reporting no pain from the infiltration in the control group (P < .001). There was no difference in pain during wound repair between the 2 groups (P approximately .59). On follow-up, 95% of patients contacted in the TLE group rated their experience in regard to pain as "excellent," compared to 5% of patients in the control group (P < .001). CONCLUSION: Topical lidocaine and epinephrine "sequential layered application" is an effective, safe, and less painful method of anesthesia for a wide variety of lacerations. Patients recall their experience with this technique very favorably.

New needle cricothyroidotomy setup.

We propose a simple and flexible connection setup for needle cricothyroidotomy. Needle cricothyroidotomy is a life-saving procedure. It is technically easy to perform, but it cannot provide adequate ventilation for a long period of time. The standard recommended ventilation equipment for needle cricothyroidotomy consists of a jet insuflator connected to a source of oxygen with 50 psi pressure. Such a setup is not always available in emergency situations. Alternative setups using ventilation with a bag-valve had been proposed. All of them are either too bulky or rigid, which increase the chance of cricothyroidotomy catheter dislodgment. Connection proposed by us is flexible, readily available, and easy to set up.