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The definition of disability in the whole body cooling trial by Shankaran et al is quite different from that in the selective head cooling trials by Gluckman et al and Gunn et al (moderate/severe vs. only severe disability).
One infant with a Thompson score < 7 was cooled, but data from a secondary analysis of the CoolCap cooling trial data suggest that the hypothermia is unlikely to have influenced the improvement in grade of encephalopathy in this infant [ 26].
Thirdly, palliation bias in the form of a higher rate of withdrawal of treatment (27 vs. 12) in the control group may also have played a role in the significant benefit reported in the whole body cooling trial by Shankaran et al [ 32].
The exact timing of mortality was not known; during a cooling trial, larvae entered chill coma and ceased moving, and we were thus unable to determine mortality due to beam exposure from our x-ray imaging alone.
Infants ≥ 36 weeks gestation and birth weight ≥ 2000 g, with signs of encephalopathy after age 10 minutes but before age 5 hours were consecutively recruited using similar criteria for intrapartum hypoxia to those described in the cooling trial by Shankaran et al. [ 19].
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Subgroup analysis seems to suggest that the results of the selective head cooling trials are not as convincing as those of the whole body cooling trials.
The specific clinical signs we analyzed were those used as entry criteria in the cooling trials with abnormal aEEG as an additional criterion [ 15- 17].
It is notable that the PPV for adverse outcome in this randomised study is lower than previously reported from observational studies carried out in the precooling era and from the study from one centre that included subjects in cooling trials.
Finally, the intervention and the outcome measures of these neuroprotectants are likely to be highly heterogeneous (eg, different protocols, dosage and timing of the intervention) unlike the three major cooling trials, thus reducing the chances of robust meta-analysis.
Our cohort of cooled infants had lower mortality (14%) than in previous cooling trials.
The specific clinical signs utilized in the cooling trials were analyzed using the same method.
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