Implementation of isopropyl alcohol (IPA) inhalation as the first-line treatment for nausea in the emergency department: practical advantages and influence on the quality of care.

BACKGROUND: Nasal inhalation of isopropyl alcohol (IPA) seems an effective anti-emetic for the symptomatic treatment of nausea in the emergency department (ED) compared to conventional anti-emetics (Ondansetron and Metoclopramide). However, it is not yet known what the practical consequences are related to the use of IPA in the ED. OBJECTIVES: The purpose of this study was to assess the practical implications for patient care associated with IPA use and to evaluate the viability of permanent implementation of IPA inhalation as a first-line therapy for nausea in the ED. METHODS: We conducted a prospective, single-center implementation study comparing ED-based care for nauseated patients before (n=106) and after (n=104) the introduction of IPA. We evaluated the treatment process and cost and assessed implementation using a survey based on recommended implementation outcome measures. RESULTS: Comparing baseline phase to implementation phase, we found a significant increase in the percentage of patients receiving nausea treatment (66.0% versus 97.1%; p<0.001) and a reduction in time to treatment initiation (7 versus 1 min, p<0.001). Additionally, IPA introduction was associated with a decrease in the administration of conventional anti-emetics (0.52 versus 0.23 administrations per patient, p<0.001) and a notable drop in treatment cost (€1.33 versus €0.67 per patient). Nurses were content with IPA implementation and regarded definitive implementation as feasible and sustainable. CONCLUSION: Implementation of IPA as the first-line nausea treatment in the ED can increase the quality of care and improve care efficiency. Definitive implementation of IPA as a first-line treatment in the ED is both viable and practically feasible. TRIAL REGISTRATION: NTR, NL7717 , Registered on March 23, 2018 - Retrospectively registered.

Deep brain stimulation of the rostromedial tegmental nucleus: An unanticipated, selective effect on food intake.

The rostromedial tegmental nucleus (RMTg) is a relatively newly described brainstem structure. The RMTg is extensively connected to both dopaminergic (DA) and serotoninergic key areas and it fulfills a pivotal role in the regulation of mesolimbic and nigrostriatal DA release. The RMTg may directly influence DA- and 5-HT associated motor and possibly also mood related behavior, the latter of which has not yet been well described. The current study explored the consequences of RMTg manipulation on DA- and 5-HT related behavior through the application of RMTg deep brain stimulation (DBS) with both high and low frequency stimulation (LFS and HFS). We used a wide array of motor and mood tests to assess changes in behavior. RMTg DBS did not change behavioral outcomes in the Skinner box task, nor in the Catwalk, the sucrose intake test, the open field test, the elevated zero maze, or the place preference test, but LFS did induce a significant decrease in food intake. This seems to be a selective effect as no motor or anxiety changes were observed that could lead to attenuated food intake. This finding not only underlines the RMTg's braking effect on the VTA, but possibly also on the forebrain, where GABA-ergic RMTg efferent may cause suppression of feeding in the lateral hypothalamus.

Ultra-High Field MRI Post Mortem Structural Connectivity of the Human Subthalamic Nucleus, Substantia Nigra, and Globus Pallidus.

INTRODUCTION: The subthalamic nucleus, substantia nigra, and globus pallidus, three nuclei of the human basal ganglia, play an important role in motor, associative, and limbic processing. The network of the basal ganglia is generally characterized by a direct, indirect, and hyperdirect pathway. This study aims to investigate the mesoscopic nature of these connections between the subthalamic nucleus, substantia nigra, and globus pallidus and their surrounding structures. METHODS: A human post mortem brain specimen including the substantia nigra, subthalamic nucleus, and globus pallidus was scanned on a 7 T MRI scanner. High resolution diffusion weighted images were used to reconstruct the fibers intersecting the substantia nigra, subthalamic nucleus, and globus pallidus. The course and density of these tracks was analyzed. RESULTS: Most of the commonly established projections of the subthalamic nucleus, substantia nigra, and globus pallidus were successfully reconstructed. However, some of the reconstructed fiber tracks such as the connections of the substantia nigra pars compacta to the other included nuclei and the connections with the anterior commissure have not been shown previously. In addition, the quantitative tractography approach showed a typical degree of connectivity previously not documented. An example is the relatively larger projections of the subthalamic nucleus to the substantia nigra pars reticulata when compared to the projections to the globus pallidus internus. DISCUSSION: This study shows that ultra-high field post mortem tractography allows for detailed 3D reconstruction of the projections of deep brain structures in humans. Although the results should be interpreted carefully, the newly identified connections contribute to our understanding of the basal ganglia.

Changes in 5-HT2A receptor expression in untreated, de novo patients with Parkinson's disease.

BACKGROUND: Serotonin (5-HT) has long been implied in the pathophysiology of Parkinson's disease (PD). In addition, the 5-HT2A receptor is associated with the regulation of motor function and mood. OBJECTIVE: To assess regional 5-HT2A receptor expression in unmedicated patients with de novo PD. METHODS: Eight de novo, drug naïve patients with PD and eight healthy control subjects underwent a single photon emission computed tomography (SPECT) scan with the highly selective 5-HT2A radioligand 123I-5-I-R91150. RESULTS: In de novo PD patients 5-HT2A receptor binding was significantly reduced in the anterior striatum and the premotor cortex in PD patients compared to controls. In addition, occipital binding was elevated in PD patients. No changes in 5-HT2A receptor binding were found in the prefrontal and parietal cortex. CONCLUSION: In de novo PD patients, 5-HT2A receptor expression is changed in key areas of the basal ganglia-thalamocortical motor circuit and occipital cortex. This suggests altered 5-HT neurotransmission to contribute to development of PD motor and non-motor symptoms.