Efficacy of prehospital administration of fibrinogen concentrate in trauma patients bleeding or presumed to bleed (FIinTIC): A multicentre, double-blind, placebo-controlled, randomised pilot study

BACKGROUND

Trauma-induced coagulopathy (TIC) substantially contributes to mortality in bleeding trauma patients.

OBJECTIVE

The aim of the study was to administer fibrinogen concentrate in the prehospital setting to improve blood clot stability in trauma patients bleeding or presumed to bleed.

DESIGN

A prospective, randomised, placebo-controlled, double-blinded, international clinical trial.

SETTING

This emergency care trial was conducted in 12 Helicopter Emergency Medical Services (HEMS) and Emergency Doctors' vehicles (NEF or NAW) and four trauma centres in Austria, Germany and Czech Republic between 2011 and 2015.

PATIENTS

A total of 53 evaluable trauma patients aged at least 18 years with major bleeding and in need of volume therapy were included, of whom 28 received fibrinogen concentrate and 25 received placebo.

INTERVENTIONS

Patients were allocated to receive either fibrinogen concentrate or placebo prehospital at the scene or during transportation to the study centre.

MAIN OUTCOME MEASURES

Primary outcome was the assessment of clot stability as reflected by maximum clot firmness in the FIBTEM assay (FIBTEM MCF) before and after administration of the study drug.

RESULTS

Median FIBTEM MCF decreased in the placebo group between baseline (before administration of study treatment) and admission to the Emergency Department, from a median of 12.5 [IQR 10.5 to 14] mm to 11 [9.5 to 13] mm (P = 0.0226), but increased in the FC Group from 13 [11 to 15] mm to 15 [13.5 to 17] mm (P = 0.0062). The median between-group difference in the change in FIBTEM MCF was 5 [3 to 7] mm (P < 0.0001). Median fibrinogen plasma concentrations in the fibrinogen concentrate Group were kept above the recommended critical threshold of 2.0 g l-1 throughout the observation period.

CONCLUSION

Early fibrinogen concentrate administration is feasible in the complex and time-sensitive environment of prehospital trauma care. It protects against early fibrinogen depletion, and promotes rapid blood clot initiation and clot stability.

TRIAL REGISTRY NUMBERS

EudraCT: 2010-022923-31 and ClinicalTrials.gov: NCT01475344.

ISMAR: an autotherapeutic device assisting patients from drooling to articulated speech

This overview of three decades of clinical experience with oral therapies complemented by oral devices-vestibular screens (VS) and ISMARs (Innsbruck sensory motor activators and regulators)-tries to put these devices into an oral functional context including postural control of mobile structures both inside and outside the mouth-down to the feet. ISMARs have certain unique features which teach a person not only better postural control of the lower jaw and, hence, hyoid bone and tongue, but also to stimulate movements of lips and tongue to improve salivary control, functions of eating and drinking and the domain of communication, e.g. facial movements and articulation of speech. A review of the relevant postural background is provided and the mechanisms are explained and may serve as models for other oral therapies. The inter-relation and multi-functionality of muscular connections throughout the body explains the uniformity of facial, oral and pharyngeal dysfunctions in different conditions such as cerebral palsy, Moebius syndrome, chronic nasal congestion or developmental retardation and exposes patients with oral dysfunctions to the risks of vicious circles. However, at the same time the opportunity is given to trigger beneficious circles. Three principles of postural control in and for the neck region are postulated. Clinical observations and experiments with volunteers are described and some supporting information is given-hopefully enough to stimulate clinical work and give rise to further experimental work to illuminate this field which is extremely important for both human communication and inter-relation.

Use of an Innsbruck sensorimotor activator and regulator (ISMAR) in the treatment of oral motor dysfunctions: a single case report

Many patients with cerebral palsy have difficulties during the oral preparatory phase and also during the food transport phase (swallowing), and oral-sensorimotor therapy is practised with these individuals. With oral-sensorimotor therapies, the functioning of the lips, cheeks, tongue and pharyngeal structures, and the interplay between these structures, can be improved. An Innsbruck sensorimotor activator and regulator (ISMAR) is one of the appliances used for oral-motor therapy. The purpose of this study is to describe the appliance and report a patient using ISMAR.

Association of occlusion with eating efficiency in children with cerebral palsy and moderate eating impairment

PURPOSE

This study focused on the contribution ofthe dental occlusion to chewing efficiency in a group of children with cerebral palsy (CP).

METHODS

Twenty children aged 8.3 +/- 0.9 years participated in this study. Chewing efficiency was measured and biting and drinking skills were noted. Occlusion was determined from extra- and intra-oral photographs and from orthodontic plaster models.

RESULTS

Significant correlatons were found between chewing efficiency and age (r:0.6, P=.006) and the total number of posterior teeth (r:0.7, P<.001). A marginally significant negative correlation was found between the total number of teeth and chewing time for the viscous texture (r:-0.4, P=.06).

CONCLUSIONS

A possible association between chewing efficiency and occlusal wear may exist, but will need further examination. There was also a higher frequency of drooling (23%) in children who had an open bite compared to those with a normal bite. These results suggested that occlusal problems affected the efficiency of ingestion in children with CP.

Impact of oral appliance therapy: are oral skills and growth maintained one year after termination of therapy?

To determine the impact of intraoral appliance (ISMAR) therapy on functional feeding skills and growth, children with cerebral palsy and moderate dysphagia were followed a full year after termination of one year of ISMAR therapy. Seventeen children, 6.6-15.4 years old (mean age = 10.2 +/- 3.0 years), were divided into two groups: group A (n = 9) continued to wear the appliance and group B (n = 8) no longer wore the appliance. Generalized estimating equations (GEE) were used to test differences between the two groups over time while accounting for the dependence for the repeated within-subject measurements. No significant differences were found in the 7 domains of functional feeding. Significant time x group interactions for weight (kg and z-score 0.01 < p < 0.05) were found. However, post hoc analyses showed that there were no significant differences in weight changes between the two groups at either 18 or 24 months of followup. These results suggest that during a one-year period of followup, maturation was equally effective as ISMAR therapy.

Feeding skills and growth after one year of intraoral appliance therapy in moderately dysphagic children with cerebral palsy

We determined changes in functional feeding skills and growth after one year of intraoral appliance therapy in dysphagic children. Twenty children, 4.2-13.1 years of age (average 8.3 +/- 0.9 years), participated in this study. Children wore the appliance daily. Phase I of treatment (6 months) aimed primarily at stabilizing the mandible and phase II aimed at facilitating ingestive skills. A control period of 6 months preceded treatment. Functional feeding skills improved significantly during phase I beyond changes seen during the control period. Further significant improvement occurred in chewing during phase II. All children significantly gained weight (kg) during the control period, as well as during the two treatment phases. This weight gain was sufficient for children to maintain their growth trajectory. There was also significant growth in height (cm). This growth spurt was characterized by marginal catch-up. Jaw stabilization was a major contributor to the significant improvement in functional feeding skills. Weight gain cannot be attributed to intervention because it occurred during the control period and was the same in magnitude through both treatment phases. However, it permitted a period of growth in stature which previously had been described only after tube feeding.

"Whole body" mobility after one year of intraoral appliance therapy in children with cerebral palsy and moderate eating impairment

The reciprocal influence of body postures on the oral structures, but also of the oral structures on body postures, has been proposed by clinicians and is taken into consideration when treating children with poor postural control and moderate to severe eating impairments. However, this relationship has not been rigorously investigated. The purpose of this study was to document the possible relationships among oral-motor, postural, and ambulatory control. Ambulatory skills [exclusive use of wheelchair (w/c) vs w/c and ambulation], postural control when sitting, "pathologic" reflexes, and lip and tongue posture were recorded before and after one year of therapy with an intraoral appliance (ISMAR) in 20 children with cerebral palsy and moderate eating impairment. Significant improvement occurred in sitting (head-trunk-foot control) following one year of ISMAR therapy. Ambulatory status also significantly improved above the level of maturation. Half of the children showed marked improvement in oral posture, i.e., their resting mouth posture was closed rather than open. These results support an hypothesis of interaction between oral structures and postural control of the "whole body." Further studies are needed to determine the controls of such a relationship.

The Innsbruck Sensorimotor Activator and Regulator (ISMAR): construction of an intraoral appliance to facilitate ingestive functions

Oral sensorimotor therapy is practiced widely with children who have neuromotor impairments, such as cerebral palsy and eating problems. Although improvement in ingestive skills can be achieved in the short term (5 months), long-term effects (over 12 months) remain to be examined. Interventions with intraoral appliances are used in children with moderate impairments of the oral-motor system and offer an opportunity for long-term treatment. Instead of the daily oral sensorimotor exercises, which must be provided by a qualified therapist, the intraoral appliance is worn during the night, so that the "therapy" is initiated and controlled by the child. The purpose of this paper is to describe the appliance: its prescription, fabrication and therapeutic use. A case study illustrates that improvement in ingestive skills, efficiency of eating, and marked weight gain can be achieved.

[Development of premature children below a birth weight of 1,500 g]

5,928 newborn infants were admitted between the years 1974 and 81 to the University of Innsbruck, Department of Pediatrics. 418 (7%) of them were premature infants with a birthweight of less than 1,500 g. 21 (18%) of the premature infants with a birthweight below 1,000 g survived (21 of 117). Among those 21 surviving infants only 7 (33%) had an appropriate birthweight, 14 (67%) were too small for their gestational age. Survival in the weight range between 1,000-1,500 g was 71% (213 of 301). The percentage of dystrophic infants was 23% (49 of 213). The place of birth has a significant influence on the survival of these very small immature infants. 24% (n = 84) of patients delivered in the nearby Clinic of Obstetrics survived in contrast to only 3% (n = 33) of those born in peripheral hospitals. This is reemphasized by the evaluation of psychomotor development of surviving infants; of 14 patients with normal psychomotor milestones 13 were delivered at our obstetric department. 157 patients were regularly followed up during their first year of life. 43% can be considered normal by all parameters. 57% show some abnormalities in their development during the first years of life. During their second year of life only 13% showed psychomotor problems and this number decreased to 5% in the third year. All these children show varying degrees of hemi- or diplegia and/or seizure activities. A routine check up at 12 month of life seems important as all patients with permanent retardation can be correctly diagnosed at this age.(ABSTRACT TRUNCATED AT 250 WORDS)

[Follow-up study of children with hypoxia following pneumothorax]

A group of 23 children suffering from neonatal hypoxia (pO2 less than 50 mm Hg) due to pneumothorax was examined at an average age of 14 months. Evaluation at this early developmental stage was accomplished by combination of "Motoscopy", "Vojta's postural reactions" and the "Concept of provocation of normal behaviour under adverse conditions". Development of the group as a whole was found to be unexpectedly good: Two children with cerebral palsy, and seven with yet undefinable developmental course versus fourteen obviously normally developing children. Pneumothorax and drainage did not cause the frequent transient postural asymmetries in this group.

[Interaction of general body posture, oral and facial region. I. Literature and clinical findings (author's transl)]

Postural control of head and trunk is basic for adequate posture and movement of eyes, facial, oropharyngeal and limb muscles. On the other hand there are also influences of ocular and oro-pharyngeal movements on posture and movements of neck, trunk and limbs. After a review of experimental and clinical observations several pertinent own observations are presented. The advantage of the systematic use of these phenomena for habilitation and rehabilitation of patients with motor handicaps is stressed.

Asymmetry in children with cerebral palsy and oral structure

Twenty-six children with cerebral palsy were examined with respect to structural asymmetry of the mouth. In 19 children there were clear cut correlations between symmetry/asymmetry of voluntary function and the oral findings. Patients with symmetrical patterns of movements had symmetrical dentition, while in those with asymmetrical function the favoured side corresponded to the side with structural changes. Apparent exceptions to this rule in 7 children could be resolved in 6 by analysis of their complex case histories. Fifty normal controls showed oral asymmetries of nearly identical frequency and magnitude. In this respect there is no difference between the normal and handicapped group.

Appliances for treatment of oral sensori--motor disorders

Cerebral palsied children with predominant oral sensori-motor disorders were treated with functional appliances. Clinical experience with the coordination and the synchronization of interdependent functional chains is reported. Reasonable therapeutic success in control of drooling, masticatory and swallowing defects as well as of perioral dysfunction, dysphonia and dysarticulation suggests a wider use of such functional methods.

Influence of tonic reflex activities on the slow auditory evoked potential

Possible influences of tonic reflex activities on the slow auditory evoked potential were investigated. For this purpose, the slow auditory evoked potential was picked up in 18 volunteers with normal hearing in relaxed position and in postures corresponding to reflex-induced positions and in 15 patients with cerebral palsy (CP) in tonic reflex patterns. No influence on latency for N120 and P215 due to postures could be observed. Latency within CP patients was age-dependent. The effect of the reflex-inhibiting pattern (RIP) - the pattern inhibiting tonic reflex activity in CP patients as far as possible - on potential amplitude was different in the two groups. The effect of RIP in CP patients was comparable to the relaxed position in volunteers. This difference points toward an influence of tonic reflex activity on the slow auditory evoked potential.

Sequelae of head and neck positions on auditory performance

Stapedius reflex level, slow auditory evoked potential (AEP), and hearing threshold level of 18 normal adult probands (11 female, 7 male) as well as of 14 normal hearing cerebral palsied children between 4 and 12 years of age (5 female, 9 males)--were determined in different postures which correspond to the influence of tonic reflex activities in supine and prone, and in the so-called "reflex inhibiting pattern" (Bobath) and in a symmetrical relaxed position of neck, trunk and extremities in supine (the last one could only be maintained by the normal volunteers). Influence of the postures was small but significant for all parameters in the volunteers group as well as for AEP in the patients group. In the latter group the influence of tonic reflex activities on auditory evoked potential was independent from their strength. The strength of tonic reflex activity had been graded from 1-5 as judged from clinical impression by observation and palpation.

Bobath-therapy, tonic reflex--activities and processing of acoustic stimuli

The influence of tonic reflex activities on the slow auditory evoked potential (AEP) as well as the influence of Bobath's reflex inhibiting patterns (r.i.p.) in a group of 14 cerebral palsied children is compared under the same conditions with simulated tonic reflex patterns in 18 adult normal volunteers and 15 cerebral palsied children. In the adult volunteers group the effect of a relaxed symmetrical position of neck, trunk, and extremities in supine on the AEP is also evaluated. There are none but age specific differences in the latence of AEP between both groups but clear cut differences in the amplitudes and in the specific effect of r.i.p. in both groups.

[The treatment of ptyalism in children with cerebral lesions (author's transl)]

Even after coarse movements have largely become normal, a distrubed motoricity and sensitivity remains in the orofacial region of some children with cerebral lesions, with disordered function of the transport of saliva and masticated food. So far, we have treated 9 children with moderately severe to slight degrees of cerebral disturbances of movement. The first month of treatment with a modified activator showed encouraging results. The apparatus is intended to transform and coordinate the pathological muscular action in the region of the mouth into the most physiological movement possible.