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Fear of withdrawal symptoms has been cited by survey respondents as the main reason that they continued to use opioids. Lofexidine is an α2-adrenergic agonist that decreases the sympathetic outflow that results in the characteristic symptoms of opioid withdrawal. A structural analog of clonidine, lofexidine has a higher affinity and specificity for the α2a receptors and does not reinforce opioid dependence. Withdrawal symptoms correlate approximately to the half-life of the opioid; patient factors such as age, duration of opioid exposure, physical status, and other considerations may influence the nature and duration of withdrawal symptoms. For patients with opioid use disorder and psychiatric comorbidities, withdrawal may be destabilizing and may exacerbate mental health status. Lofexidine has been shown in clinical trials to be safe and effective in helping to manage the symptoms of withdrawal and has been recommended in guidelines for this purpose. Adverse events associated with lofexidine include QT prolongation, hypotension, orthostasis, and bradycardia. The maximum course of treatment is 14 days, and doses should be titrated, with the recommended maximum dose to coincide with the most severe withdrawal symptoms (about 5–7 days after opioid discontinuation).

(1) Background: The ketogenic diet (KD) was developed in the 1920s as a treatment for pediatric epilepsy and is emerging as a possible treatment option for certain mental health disorders. There is a link between certain mental health disorders and epilepsy, suggesting some commonality among underlying mechanisms. (2) Methods: The literature relating to mental disorders and the KD is sparse. The authors attempt to a narrative review of the existing literature to show that there may be validity to studying the KD as a treatment for certain mental health disorders. (3) Results: Various types of mitochondrial dysfunction and impaired oxidative metabolism have been identified in many mental health disorders (bipolar disorder, major depressive disorder, autism, schizophrenia, and others). Mitochondrial deficits may affect neuroplasticity and cause synaptic dysfunction, which could change brain structure and function in a way that might affect behavior. The KD has been associated with epigenetic changes in the genes associated with mitochondrial function. Chronic oxidative stress and inflammation have also been implicated in mental health disorders and may be reduced by the KD. The KD regulates glutamatergic transmission and may initiate extracellular changes as well, in a manner similar to pharmacological agents used to stabilize moods. The KD may be difficult for patient adherence and has been associated with many and potentially severe adverse effects. The role of the KD in addressing treatment-resistant pediatric epilepsy is established and epilepsy is comorbid with a number of mental health conditions. (4) Conclusions: There is a paucity of literature on this subject and there is no robust clinical evidence in support of the use of the KD for treating mental disorders but there are indications that the KD can reduce systemic inflammation, improve cerebral mitochondrial metabolism, and enhance endogenous antioxidation, all of which may be helpful in treating certain mental health conditions. The KD is also associated with serious health risks and clinicians must weigh risks versus benefits.

There is no clear consensus as to the appropriate anesthetic technique for patients undergoing a carotid endarterectomy. Such patients may have comorbid conditions, such as coronary artery disease, hyperlipidemia, and others. The two main anesthetic approaches are general anesthesia, including an endotracheal tube, with neurological monitoring, and regional anesthesia that allows for an awake patient to be assessed neurologically. The objective of our report was to evaluate a novel anesthetic technique that combined general anesthesia with a laryngeal mask airway (LMA) plus regional anesthesia in the form of bupivacaine injected into the surgical site. Anesthesia was maintained with desflurane 4%, so the patient emerged rapidly for neurological assessment at the conclusion of surgery. We report on a case of a 55-year-old patient who underwent a successful carotid endarterectomy using this hybrid technique of general anesthesia with LMA plus regional anesthesia. This technique was safe and effective, and the patient experienced no complications other than a hematoma on the left neck that was likely the result of long-term use of aspirin and Plavix. While further study is warranted, this hybrid technique of general anesthesia with LMA plus regional anesthesia holds promise for carotid endarterectomy patients.

Postoperative nausea and vomiting (PONV) and postdischarge nausea and vomiting (PDNV) in ambulatory patients remain serious problems that affect a substantial subset of surgical patients. Guidelines recommend that patients be stratified for risk, and patients at moderate-to-high risk be administered prophylactic PONV/PDNV therapy. Risk stratification on the four-point Apfel scale assigns one point for each of the following: female sex, nonsmoking status, history of PONV or motion sickness, and the use of postoperative opioids. Patients who score 2 or higher are considered to be at moderate-to-high risk. Other risk factors have been evaluated and discussed in the literature, such as type and duration of surgery. Surprisingly, although PONV/PDNV is more common in the first 24 hours after anesthesia, it may occur for days following surgery, and so, continuous treatment is advantageous. Transdermal scopolamine is a well-established agent with a history of safety and efficacy for PONV/PDNV prevention. Scopolamine is an anticholinergic agent that is generally well tolerated; side effects tend to be mild to moderate. The most frequently reported side effects with transdermal scopolamine are visual disturbances and dry mouth. Once adhered to the skin, the patch administers an initial dose and then a continuous dose of medication over 72 hours. Transdermal scopolamine is easy to administer, safe, effective, and relatively cost-effective, and it should be considered as an important tool to help prevent PONV/PDNV, whether administered as monotherapy or in combination with other agent(s).