Rate Of Neurological Impairment Research Articles

Long-Term Outcomes of Patients with Primary Brain Tumors after Acute Rehabilitation: A Retrospective Analyses of Factors.

Although primary brain tumors are relatively rare, they cause significant morbidity and mortality due to the high rates of neurological impairment. The purpose of this study was to examine the physical and functional outcomes of patients with primary brain tumors who had undergone inpatient rehabilitation. This was a retrospective study which recruited 163 patients who had been admitted for inpatient rehabilitation. Rehabilitation outcomes, including the Functional Independence Measure (FIM) and Glasgow Outcome Scale (GOS), were recorded up to 1 year post-discharge. The majority of patients (79.1%) had low-grade (WHO Class I-II) tumors, 35 (21.5%) were diagnosed with GBM and 52 (31.9%) had recurrent brain tumors. Rehabilitation outcomes were sustained, with 125 (76.7%) and 113 (69.3%) patients having a GOS of ≥4 at 6 months and 1 year after discharge, respectively. A GOS of ≥4 at 1 year was negatively associated with high-grade tumors (p < 0.001) and radiotherapy (p = 0.028), and positively associated with a higher discharge FIM motor score (p < 0.001) and the presence of a caregiver after discharge (p = 0.034). Our study demonstrates significant positive functional benefits from 4 weeks of inpatient neuro-oncological rehabilitation for patients with primary brain tumors, as well as the importance of supportive care from caregivers.

Effect of Graded Targeted Temperature Management on Cerebral Glucose Spatiotemporal Characteristics after Cardiac Arrest.

Cardiac arrest (CA) is a fatal disease with high rates of neurological impairment. At present, targeted temperature management (TTM) is the only strategy with firm clinical evidence to prove its effectiveness. However, there is still controversy on the implementation of TTM, particularly on its depth, with a lack of elucidated underlying therapeutic mechanisms. Six Wistar rats were subjected to 8 min asphyxia-CA and randomly divided into TTM at 33oC(n=3) or 35° C groups (n=3). The spatiotemporal characteristics of cerebral glucose metabolism after CA were investigated by 18F-FDG microPET/CT. Myelin Basic Protein (MBP) immunofluorescence staining was used to assess acute injury and recovery of oligodendrocytes. Functional recovery was evaluated using the neurological deficit score (NDS). There was a significant improvement in functional recovery by NDS (p < 0.05) in the 33oC group compared with the 35° C group. Glucose metabolism of the 33° C group was higher than that of the 35oC group early after resuscitation (within 10 minutes). Immunofluorescence analysis showed that positive MBP signals in the cortex and hippocampus in the 33oC group were greater than in the 35oC group. In conclusion, compared to 35oC TTM, 33° C TTM changed the spatiotemporal characteristics of brain glucose metabolisms with improved neurological function, which may be through oligodendrocyte participation.

HIV viral transcription and immune perturbations in the CNS of people with HIV despite ART.

People with HIV (PWH) on antiretroviral therapy (ART) experience elevated rates of neurological impairment, despite controlling for demographic factors and comorbidities, suggesting viral or neuroimmune etiologies for these deficits. Here, we apply multimodal and cross-compartmental single-cell analyses of paired cerebrospinal fluid (CSF) and peripheral blood in PWH and uninfected controls. We demonstrate that a subset of central memory CD4+ T cells in the CSF produced HIV-1 RNA, despite apparent systemic viral suppression, and that HIV-1–infected cells were more frequently found in the CSF than in the blood. Using cellular indexing of transcriptomes and epitopes by sequencing (CITE-seq), we show that the cell surface marker CD204 is a reliable marker for rare microglia-like cells in the CSF, which have been implicated in HIV neuropathogenesis, but which we did not find to contain HIV transcripts. Through a feature selection method for supervised deep learning of single-cell transcriptomes, we find that abnormal CD8+ T cell activation, rather than CD4+ T cell abnormalities, predominated in the CSF of PWH compared with controls. Overall, these findings suggest ongoing CNS viral persistence and compartmentalized CNS neuroimmune effects of HIV infection during ART and demonstrate the power of single-cell studies of CSF to better understand the CNS reservoir during HIV infection.

Chronological Analysis of Primary Cervical Spine Infection: A Single-Center Analysis of 59 Patients over Three Decades (1992-2018).

Primary cervical spine infections progress quickly and cause neurological impairment at an early stage. Despite their clinical significance, few studies have investigated primary cervical spine infections, owing to the rarity of the condition. This study analyzed the characteristics of 59 patients treated for primary cervical spine infections between 1992 and 2018 at our hospital. Clinical and radiological analyses were conducted. Moreover, a comparative analysis was performed, incorporating each patient’s underlying disease, mortality and complications, and treatment results. Comparison between groups based on the chronological period (1992–2000, 2001–2009, and 2010–2018) revealed that the mean age of onset has increased significantly in recent years. The rate of neurological impairment, duration of antibiotic use, and frequency of underlying disease increased significantly with time. No significant differences among groups were observed in the hematological and microbiological analyses. The incidence rate of epidural abscess and multisegmental infection increased significantly in recent years. There was no statistically significant difference in the complication and mortality rates, according to the time period. We think that prompt diagnosis and appropriate treatment are necessary, considering the current trends in primary cervical spine infection.

The association between ACLS guideline deviations and outcomes from in-hospital cardiac arrest

Aim of studyIn hospital cardiac arrests occur at a rate of 1–5 per 1000 admissions and are associated with significant morbidity and mortality. We aimed to investigate the association between deviations from ACLS protocol and patient outcomes. MethodsThis retrospective review was conducted at a single academic medical center. Data was collected on patients who suffered cardiac arrest from December 2015-November 2019. Our primary endpoint was return of spontaneous circulation. Secondary endpoints included survival to discharge and discharge with favorable neurological outcomes. Results108 patients were included, 74 obtained return of spontaneous circulation, and 23 survived to discharge. The median number of deviations from the ACLS protocol per event in ROSC group was 1 (IQR 0–3) compared to 6.5 (IQR 4–12) in non-ROSC group (p < .0001). The probability of obtaining ROSC was 96% with 0−2 deviations per event, 59% with 2–5 deviations per event, and 11% with greater than 6 deviations per event (p < .0001). The median deviation per event in patients who survived to discharge was 0 (IQR 0–1) vs. 3 (IQR 1–6, p < .0001) in those who did not. Lastly, survival to discharge with a favorable neurological outcome may be associated we less deviations per event (p < .006). ConclusionOur findings highlight the importance of adherence to the ACLS protocol. We found that deviations from the algorithm are associated with decreased rates of ROSC and survival to discharge. Additionally, higher rates of protocol deviations may be associated with higher rates of neurological impairments after cardiac arrest.

Effects of repeat prenatal corticosteroids given to women at risk of preterm birth: An individual participant data meta-analysis.

BackgroundInfants born preterm compared with infants born at term are at an increased risk of dying and of serious morbidities in early life, and those who survive have higher rates of neurological impairments. It remains unclear whether exposure to repeat courses of prenatal corticosteroids can reduce these risks. This individual participant data (IPD) meta-analysis (MA) assessed whether repeat prenatal corticosteroid treatment given to women at ongoing risk of preterm birth in order to benefit their infants is modified by participant or treatment factors.Methods and findingsTrials were eligible for inclusion if they randomised women considered at risk of preterm birth who had already received an initial, single course of prenatal corticosteroid seven or more days previously and in which corticosteroids were compared with either placebo or no placebo. The primary outcomes for the infants were serious outcome, use of respiratory support, and birth weight z-scores; for the children, they were death or any neurosensory disability; and for the women, maternal sepsis. Studies were identified using the Cochrane Pregnancy and Childbirth search strategy. Date of last search was 20 January 2015. IPD were sought from investigators with eligible trials. Risk of bias was assessed using criteria from the Cochrane Collaboration. IPD were analysed using a one-stage approach.Eleven trials, conducted between 2002 and 2010, were identified as eligible, with five trials being from the United States, two from Canada, and one each from Australia and New Zealand, Finland, India, and the United Kingdom. All 11 trials were included, with 4,857 women and 5,915 infants contributing data. The mean gestational age at trial entry for the trials was between 27.4 weeks and 30.2 weeks. There was no significant difference in the proportion of infants with a serious outcome (relative risk [RR] 0.92, 95% confidence interval [CI] 0.82 to 1.04, 5,893 infants, 11 trials, p = 0.33 for heterogeneity). There was a reduction in the use of respiratory support in infants exposed to repeat prenatal corticosteroids compared with infants not exposed (RR 0.91, 95% CI 0.85 to 0.97, 5,791 infants, 10 trials, p = 0.64 for heterogeneity). The number needed to treat (NNT) to benefit was 21 (95% CI 14 to 41) women/fetus to prevent one infant from needing respiratory support. Birth weight z-scores were lower in the repeat corticosteroid group (mean difference −0.12, 95%CI −0.18 to −0.06, 5,902 infants, 11 trials, p = 0.80 for heterogeneity). No statistically significant differences were seen for any of the primary outcomes for the child (death or any neurosensory disability) or for the woman (maternal sepsis). The treatment effect varied little by reason the woman was considered to be at risk of preterm birth, the number of fetuses in utero, the gestational age when first trial treatment course was given, or the time prior to birth that the last dose was given. Infants exposed to between 2–5 courses of repeat corticosteroids showed a reduction in both serious outcome and the use of respiratory support compared with infants exposed to only a single repeat course. However, increasing numbers of repeat courses of corticosteroids were associated with larger reductions in birth z-scores for weight, length, and head circumference. Not all trials could provide data for all of the prespecified subgroups, so this limited the power to detect differences because event rates are low for some important maternal, infant, and childhood outcomes.ConclusionsIn this study, we found that repeat prenatal corticosteroids given to women at ongoing risk of preterm birth after an initial course reduced the likelihood of their infant needing respiratory support after birth and led to neonatal benefits. Body size measures at birth were lower in infants exposed to repeat prenatal corticosteroids. Our findings suggest that to provide clinical benefit with the least effect on growth, the number of repeat treatment courses should be limited to a maximum of three and the total dose to between 24 mg and 48 mg.

Clinical Characteristics of 1378 Inpatients with Spinal Tuberculosis in General Hospitals in South-Central China.

In this retrospective study, charts of inpatients with spinal tuberculosis (STB) treated in large-scale general hospitals in Changsha, Hunan, China, between 2007 and 2016 were reviewed to investigate their clinical characteristics. Demographic, epidemiological and clinical features, imaging findings, treatment methods, and prognosis were summarized and analyzed. There were 1378 patients, 805 males and 573 females, with a mean age of 43.7 years. The mean interval between symptom onset and diagnosis was 16.0 months (range 15 days–240 months). The incidence of back pain, radicular pain and symptoms of systemic toxicity was 92.5%, 40.1%, and 32.1%, respectively. The rate of neurological impairment was 49.9 %. STB was present in two or more vertebrae in 91.1% of patients, with two adjacent vertebrae being involved in 67.9% of them. The lumbar segment (38.2%) was the most frequently affected, followed by the thoracic spine (35.7%). The sacrococcygeal area was the least frequently involved (0.8%). Abscesses were detected in 65.5% of patients. One thousand patients (72.6%) were managed with surgery and 378 (27.4%) with anti-TB drugs only. Cure was achieved in 1215 patients (88.2%), whereas 49 (3.5 %) had relapses. Concomitant pulmonary TB (PTB) was diagnosed in 366 patients (26.6%) and 63 (4.6%) had concomitant diabetes. Compared with the previous five years, the number of older patients, urban patients, and medical staff with STB had increased by 6.1%, 5.2%, and 1.3%, respectively in the five years studied. STB remains a severe public health problem that cannot be ignored. Most of the patients ignored early symptoms and therefore received untimely treatment. Thus, surveillance for and treatment of STB in South-central China requires strengthening. In addition to the current China-wide database of patients with PTB, a China-wide database of patients with STB should also be set up.

Saphenous nerve injury during hamstring tendons harvest: Does the incision matter? A systematic review.

Infrapatellar branch of saphenous nerve injury is a common complication following hamstring graft harvest during anterior cruciate ligament reconstruction. The direction of skin incision performed at proximal tibial metaphysis may affect the rate of iatrogenic nerve damage. Aim of the present systematic review was to evaluate evidence that would substantiate the adoption of one incision over another for hamstring graft harvesting. The available literature was systematically screened searching studies dealing with iatrogenic injury to the saphenous nerve after anterior cruciate ligament reconstruction using hamstring tendons. A search was performed using the keywords "Saphenous" and "Infrapatellar branch" in combination with "Anterior cruciate ligament", "arthroscopy" and "hamstrings", supplying no limits regard the publication year. Coleman methodological score was performed in all the retained articles. Five articles matched the inclusion criteria. There were two randomized controlled trials, one prospective comparative study and two retrospective comparative series. Poor methodological quality was found overall. A vertical incision was found to significantly affect the presence of hypoesthesia and the extent of the area of sensory loss in three articles; no difference was registered in one, and a trend towards a lower rate of iatrogenic nerve damage using an oblique incision was found in the remaining one, without any statistical significance. Although the low methodological quality of the analysed studies does not permit to draw definitive conclusions, the anatomical course of the nerve along with the results obtained in the available studies seems to suggest lower rate of neurological impairment adopting an oblique incision. This kind of incision may therefore be preferred in the routine clinical practice. Systematic review, Level II.

Cognitive and motor function of neurologically impaired extremely low birth weight children.

Rates of neurological impairment among extremely low birth weight children (ELBW [<1 kg]) have decreased since 2000; however, their functioning is unexamined. To compare motor and cognitive functioning of ELBW children with neurological impairment, including cerebral palsy and severe hypotonia/hypertonia, between two periods: 1990 to 1999 (n=83) and 2000 to 2005 (n=34). Measures of function at 20 months corrected age included the Mental and Psychomotor Developmental Indexes of the Bayley Scales of Infant Development and the Gross Motor Functional Classification System as primary outcomes and individual motor function items as secondary outcomes. Analysis failed to reveal significant differences for the primary outcomes, although during 2000 to 2005, sitting significantly improved in children with neurological impairment (P=0.003). Decreases in rates of neurological impairment among ELBW children have been accompanied by a suggestion of improved motor function, although cognitive function has not changed.

A study of the relation between the sCD40-sCD40L system and the course of multiple sclerosis

To determine the relationship between the level of soluble CD40 and CD40L (sCD40, sCD40L) and key characteristics of the course of multiple sclerosis. A comparative cross-sectional study covered 80 patients with multiple sclerosis diagnosed according to 2005 McDonald criteria. Enzyme immunoassay method was applied to measure the concentration of sCD40 and sCD40L in venous blood serum. No significant changes in sCDL or sСD levels were found during acute MS periods in comparison to remission periods. The positive correlation between the frequency of exacerbations and the level of sCDL was shown. No evidence for the association between indexes of activity of the sCD40-sCD40L system in blood and both exacerbation of MS, severity and rate of neurological impairment in this disease was demonstrated.

Editorial Comment: Total aortic arch replacement in Marfan patients: caution or boldness?

In their article titled ‘Should aortic arch replacement be performed during initial surgery for aortic root aneurysm in patients with Marfan syndrome?’ Schoenhoff et al. raise again a very important question which, after several decades of aortic surgery in this particular group of patients, still remains unresolved. They have operated on 94 patients who underwent 148 procedures. About two-thirds of the patients were first operated on for elective aortic root replacement and one-third, for acute type A dissection. As could be expected from this surgical group that has a very large experience with aortic surgery, the reported results are outstanding and among the best published in this matter [1]. By analysing their experience and comparing the rate of primary and secondary total aortic arch replacement in those various groups, the authors came to the conclusion that replacing such an aortic segment during elective surgery is not necessary. Conversely extending the aortic replacement to the arch during surgery of acute type A dissection may dramatically reduce the rate of further reoperations and, in particular, the number of secondary arch replacements. This confirms what many groups dealing with Marfan patients have intuitively considered for years. It also confirms our own work published a few years ago and in which we came to the same conclusion. Indeed, in our experience, the transverse arch was replaced only once in 44 patients (2.2%) operated on either electively for aortic root aneurysm (25 cases) or in emergency for acute type A dissection (19 cases). Four (16%) secondary arch replacements were required after elective complete aortic root replacement. These were mandated at a second and a third reoperation in 1 patient by the presence of a false aneurysm, and in 1 patient by the occurrence and evolution, 9 years after initial elective surgery, of an acute type B dissection initially treated conservatively. In the remaining patients, the arch replacement was the surgeon’s choice as the patients needed a reoperation of the ascending aorta and aortic root. In contrast, a subsequent arch replacement was required in 14 of the 19 patients (73%) operated initially for acute type A dissection because of the further evolution of a persistent false lumen in the aortic arch and distal aorta [2]. Nevertheless, despite this sort of intuitive knowledge about what should be done, very few groups (if any) have yet published any experience of systematic arch replacement in Marfan patients suffering from acute type A dissection. Therefore, the article by the Bern group is quite important. It is indeed a critical step forward to the transformation of this silent but, so far, unproductive agreement into an open one and towards a sort of recommendation to the whole surgical community when performing surgery in Marfan patients. However, a few points in the present article may be questioned. The authors state that ‘there was no patient that suffered from persistent neurological impairment after primary or secondary Total Arch Replacement in our institution’. This could leave the reader with the feeling that such procedures encompass a very low neurological risk. Yet, there were neurological complications in 6 (4%) of all the procedures, either primary or secondary, with or without TAR. This is, indeed, quite low a rate. However, since Marfan patients operated on electively for aortic root replacement very seldom experience any neurological complication, we may suppose that most of the reported neurological complications occurred in patients operated on for acute type A dissection or during a reoperation. Then, the rate of neurological impairment would be much higher and closer to what we had observed in our own experience. Another interesting and somewhat intriguing point is that, whether or not the patient underwent a total arch replacement, the rates of late reoperations on the distal thoracic and thoracoabdominal aorta were not significantly different. Therefore, one might wonder ‘why then complicate an already difficult emergency operation with Total Arch Replacement?’ It seems that this was the conclusion of the authors as they state ‘In (Marfan) patients with acute type A dissection, the need for reintervention is precipitated by the dissection itself and not by limitating the procedure to a hemiarch replacement in the emergency setting’. This is a cautious statement, and possibly a too-cautious one. First, because the number of patients at risk was too low to reach any statistical significance that would have been reached with a larger cohort as the trend seems to indicate, and secondly, because in their and our experiences, 33 and 73% patients, respectively, required a secondary total arch replacement. Having replaced the arch during the first emergency

Are we improving long-term outcomes for extremely preterm babies?

Survival rates for extremely preterm or tiny babies have increased dramatically with advances in perinatal and neonatal intensive care. However, the rates of neurological impairments and disabilities are too high in survivors relative to term controls; major neurological disability rates in those <1000 g or <28 weeks are four to five times higher than in term controls. There are some recent advances, however, that improve the outcome, both short and long term, for extremely preterm or tiny babies. Magnesium sulphate given to the mother just prior to very preterm birth reduces the rate of cerebral palsy in survivors. Caffeine given to very tiny babies not only reduces several short-term morbidities, such as patent ductus arteriosus and bronchopulmonary dysplasia, but also reduces the rates of death or disability, cerebral palsy and cognitive delay. Docosahexanoic acid, an omega-3 fatty acid important in brain function, given as a supplement to feeds in very preterm babies, improves cognitive function, but mostly in females and in those <1250 g birthweight. Developmental interventions after discharge home designed to improve baby cognitive and motor development have been shown to increase cognitive development over the preschool years; however, the effect is no longer evident after the patients start school. In summary, several recent interventions look promising in improving long-term outcomes for very preterm infants; however, their effects when implemented into usual clinical practice must be determined.

Management of brain abscess in children

Brain abscesses continue to pose a problem in paediatric neurosurgery because the associated morbidity and mortality have remained significant throughout the antibiotic and CT era. The objective of this paper is to report the treatment of 28 children with the diagnosis of brain abscess. We report our experience with the surgical management of brain abscesses in 28 paediatric patients between 1981 and 2005. The following parameters were assessed: age, gender, clinical manifestations, physical examination, radiological data, aetiological agent, treatment and clinical evolution of the patients. Patients' age varied from 2 weeks to 16 years (mean 8.6 years); 17 were male. The most notable predisposing factor was contiguous infection in 11 cases, of which six were chronic otitis media. The abscess was supratentorial in 27 children with only one infratentorial case. In all patients, treatment consisted of a combination of surgical evacuation and antibiotics. In two children, the evacuation of pus was via transfontanelar puncture. Positive abscess cultures were obtained from 15 abscesses, and gram-negative were the main bacteria involved. Nine patients had neurological sequelae (seizure, cognitive impairment and paresis); two deaths occurred. Brain abscess in children continues to be associated with high rates of neurological impairment and death.

Antenatal magnesium sulphate neuroprotection in the preterm infant

Very preterm infants have high rates of neurological impairments and disabilities. These rates have not diminished as the survival rates have improved. Basic science research suggests that magnesium sulphate before birth can be neuroprotective for the preterm fetus. Some, but not all, observational studies in humans also suggest a protective effect of antenatal magnesium sulphate on cerebral palsy. Four randomised controlled trials of antenatal magnesium sulphate have reported long-term neurological effects in surviving infants, but only one of these was designed specifically to evaluate the long-term effects of treatment. These studies found that, overall, antenatal magnesium sulphate therapy had no significant effect on paediatric mortality or neurological outcomes in the first few years of life, including cerebral palsy, but it was found to lower the rate of motor problems at 2 years of age in one study. The role for antenatal magnesium sulphate therapy as a neuroprotective agent for the preterm fetus is not yet established.

Influence of Maternal, Obstetric and Fetal Risk Factors on the Prevalence of Birth Asphyxia at Term in a Swedish Urban Population

Birth asphyxia is a perinatal occurrence that, in serious cases, may lead to permanent adverse consequences or death. This retrospective case-control study of term neonates with birth asphyxia, defined as a 5-minute Apgarscore less than 7, had as its goal to explore risk factors for birth asphyxia itself, related hypoxic-ischemic encephalopathy (HIE), and asphyxia-related disability and death. Infants who died of nonasphyxial causes, such as infection or maternal sedation, were not included. Among more than 42,000 live births reviewed for the years 1985 through 1991 in an urban Swedish population were 225 cases of birth asphyxia that were matched with nonasphyxial control cases. The study group included 75 infants with both asphyxia and HIE. Surviving infants were followed for 18 months or longer, and those viewed as neurologically disabled were followed for 1.5 to 3 years longer. Twenty-two infants in the asphyxia group died or developed asphyxia-related neurological disability. Rates of birth asphyxia, pure birth asphyxia, and asphyxia-related HIE during the 7-year review period were, respectively, 6.9, 5.4, and 1.9 per 1000 live births. The asphyxia-related mortality rate was 0.26 per 1000 live births, and the rate of neurological impairment at the 18-month follow-up was 0.2 per 1000. Factors associated with birth asphyxia included single marital status (odds ratio [OR] = 7.1), intrauterine meconium release (OR = 4.1), operative delivery (OR = 8.7), breech delivery (OR = 20.3), and oxytocin augmentation (OR = 2.9). Other associated parameters were cord complications (OR = 15.8) and external compression to aid delivery (OR = 6.2). Significant cardiotocographic (CTG) correlates included repeated late decelerations (OR = 29.4), occasional late or variable decelerations (OR = 2.2), and a lack of accelerations (OR = 5.2). All groups of infants with asphyxia were delivered operatively or instrumentally more often than were the matched control infants. No association was evident between asphyxia and maternal age, smoking, illnesses, time of delivery (day vs. night or seasonal), or previous cesarean delivery. Independent risk factors for HIE included intrauterine meconium release, CTG score, and operative delivery. This is one of the few population-based studies of risk factors for asphyxia and perhaps the first to separately examine risk factors for pure asphyxia, HIE, and asphyxia-related death and disability. Asphyxia was strongly associated with CTG abnormalities, particularly the absence of baseline variability. CTG monitoring definitely is indicated for women given oxytocin augmentation, one of the factors associated with asphyxia in this study.

The outcome of very low birth weight infants: past, present and future.

This article is an attempt to review the impact of neotnatal intensive care on mortality and child-hood morbidity of VLBW infants. The evidence suggests that in the last decade there has been a significant reduction in neonatal mortality, particularly of the very tiny infants. However, although the data on morbidity is more difficult to interpret, there does not seem to have been a parallel decline in the rate of neurological impairment in infants. The implication of this for the future is discussed.

Cerebral palsy and newborn care. III: Estimated prevalence rates of cerebral palsy under differing rates of mortality and impairment of low-birthweight infants.

To maintain a stable over-all prevalence of handicap, the rate of handicap among survivors must decline in parallel to the decline in mortality among live births. The 24 per cent decline in mortality among low-birthweight infants in New York City between 1962 and 1976 requires a 35 to 39 per cent decline in the rate of neurological impairment among low-birthweight survivors simply to avoid the production of an increased number of handicapped children in the population as a whole. Such evidence as we have suggests that the declining morbidity may not be keeping pace with the recent declines in mortality: thus, although more healthy survivors will result from newborn intensive care, a modest increase in the prevalence of handicap may also ensue.