Attitudes Toward the Adoption of Remote Patient Monitoring and Artificial Intelligence in Parkinson's Disease Management: Perspectives of Patients and Neurologists

OBJECTIVE

Early detection of Parkinson's Disease (PD) progression remains a challenge. As remote patient monitoring solutions (RMS) and artificial intelligence (AI) technologies emerge as potential aids for PD management, there's a gap in understanding how end users view these technologies. This research explores patient and neurologist perspectives on AI-assisted RMS.

METHODS

Qualitative interviews and focus-groups were conducted with 27 persons with PD (PwPD) and six neurologists from Finland and Italy. The discussions covered traditional disease progression detection and the prospects of integrating AI and RMS. Sessions were recorded, transcribed, and underwent thematic analysis.

RESULTS

The study involved five individual interviews (four Italian participants and one Finnish) and six focus-groups (four Finnish and two Italian) with PwPD. Additionally, six neurologists (three from each country) were interviewed. Both cohorts voiced frustration with current monitoring methods due to their limited real-time detection capabilities. However, there was enthusiasm for AI-assisted RMS, contingent upon its value addition, user-friendliness, and preservation of the doctor-patient bond. While some PwPD had privacy and trust concerns, the anticipated advantages in symptom regulation seemed to outweigh these apprehensions.

DISCUSSION

The study reveals a willingness among PwPD and neurologists to integrate RMS and AI into PD management. Widespread adoption requires these technologies to provide tangible clinical benefits, remain user-friendly, and uphold trust within the physician-patient relationship.

CONCLUSION

This study offers insights into the potential drivers and barriers for adopting AI-assisted RMS in PD care. Recognizing these factors is pivotal for the successful integration of these digital health tools in PD management.

Clinical and Brain Morphometry Predictors of Deep Brain Stimulation Outcome in Parkinson's Disease

Subthalamic deep brain stimulation (STN-DBS) is known to improve motor function in advanced Parkinson's disease (PD) and to enable a reduction of anti-parkinsonian medication. While the levodopa challenge test and disease duration are considered good predictors of STN-DBS outcome, other clinical and neuroanatomical predictors are less established. This study aimed to evaluate, in addition to clinical predictors, the effect of patients' individual brain topography on DBS outcome. The medical records of 35 PD patients were used to analyze DBS outcomes measured with the following scales: Part III of the Unified Parkinson's Disease Rating Scale (UPDRS-III) off medication at baseline, and at 6-months during medication off and stimulation on, use of anti-parkinsonian medication (LED), Abnormal Involuntary Movement Scale (AIMS) and Non-Motor Symptoms Questionnaire (NMS-Quest). Furthermore, preoperative brain MRI images were utilized to analyze the brain morphology in relation to STN-DBS outcome. With STN-DBS, a 44% reduction in the UPDRS-III score and a 43% decrease in the LED were observed (p<0.001). Dyskinesia and non-motor symptoms decreased significantly [median reductions of 78,6% (IQR 45,5%) and 18,4% (IQR 32,2%) respectively, p=0.001 - 0.047]. Along with the levodopa challenge test, patients' age correlated with the observed DBS outcome measured as UPDRS-III improvement (ρ= -0.466 - -0.521, p<0.005). Patients with greater LED decline had lower grey matter volumes in left superior medial frontal gyrus, in supplementary motor area and cingulum bilaterally. Additionally, patients with greater UPDRS-III score improvement had lower grey matter volume in similar grey matter areas. These findings remained significant when adjusted for sex, age, baseline LED and UPDRS scores respectively and for total intracranial volume (p=0.0041- 0.001). However, only the LED decrease finding remained significant when the analyses were further controlled for stimulation amplitude. It appears that along with the clinical predictors of STN-DBS outcome, individual patient topographic differences may influence DBS outcome. Clinical Trial Registration Number: NCT06095245, registration date October 23, 2023, retrospectively registered.

GPi-DBS-induced brain metabolic activation in cervical dystonia

BACKGROUND

Deep brain stimulation (DBS) of the globus pallidus interna (GPi) is a highly efficacious treatment for cervical dystonia, but its mechanism of action is not fully understood. Here, we investigate the brain metabolic effects of GPi-DBS in cervical dystonia.

METHODS

Eleven patients with GPi-DBS underwent brain 18F-fluorodeoxyglucose positron emission tomography imaging during stimulation on and off. Changes in regional brain glucose metabolism were investigated at the active contact location and across the whole brain. Changes in motor symptom severity were quantified using the Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS), executive function using trail making test (TMT) and parkinsonism using Unified Parkinson's Disease Rating Scale (UPDRS).

RESULTS

The mean (SD) best therapeutic response to DBS during the treatment was 81 (22)%. The TWSTRS score was 3.2 (3.9) points lower DBS on compared with off (p=0.02). At the stimulation site, stimulation was associated with increased metabolism, which correlated with DBS stimulation amplitude (r=0.70, p=0.03) but not with changes in motor symptom severity (p>0.9). In the whole brain analysis, stimulation increased metabolism in the GPi, subthalamic nucleus, putamen, primary sensorimotor cortex (PFDR<0.05). Acute improvement in TWSTRS correlated with metabolic activation in the sensorimotor cortex and overall treatment response in the supplementary motor area. Worsening of TMT-B score was associated with activation of the anterior cingulate cortex and parkinsonism with activation in the putamen.

CONCLUSIONS

GPi-DBS increases metabolic activity at the stimulation site and sensorimotor network. The clinical benefit and adverse effects are mediated by modulation of specific networks.

Levodopa-Entacapone-Carbidopa Intestinal Gel Treatment in Advanced Parkinson's Disease: A Single-Center Study of 30 Patients

BACKGROUND

Levodopa-entacapone-carbidopa intestinal gel (LECIG) is a novel device assisted treatment option for advanced Parkinson's disease (PD). It has been available in Finland since 2020. There is paucity of scientific studies considering LECIG treatment in clinical practice.

OBJECTIVES

Objectives of this study were to evaluate the changes in medication, adverse events and early discontinuations of LECIG treatment in real life clinical practice.

METHODS

The records of 30 consecutive patients, who received LECIG between years 2020 and 2022 in Helsinki University Hospital, were retrospectively analyzed. Data considering changes in medication, discontinuations, and adverse events during the first six months of LECIG treatment was collected.

RESULTS

Mean levodopa equivalent daily dose (LEDD) rose significantly between baseline before LECIG and six months with treatment (1230 mg vs. 1570 mg, P = 0.001). Three patients were discarded during nasojejunal tube test phase and seven discontinued the treatment during six-month follow-up. Most common reasons for discontinuation were difficulty in finding suitable infusion rate and neuropsychiatric problems. Safety issues encountered were similar to those reported with levodopa-carbidopa intestinal gel (LCIG) treatment. One case of rhabdomyolysis due to severe dyskinesia during LECIG treatment was observed. Patients were satisfied with the small size of the pump system.

CONCLUSIONS

LEDD seems to increase during the first months of LECIG treatment. When compared to studies on LCIG, safety profile of LECIG appears similar, but early discontinuation rate is higher than expected. However, long-term studies are lacking. Only clear advantage to LCIG appears to be the smaller LECIG pump size.

Real-Life Experience on Directional Deep Brain Stimulation in Patients with Advanced Parkinson’s Disease

Directional deep brain stimulation (dDBS) is preferred by patients with advanced Parkinson’s disease (PD) and by programming neurologists. However, real-life data of dDBS use is still scarce. We reviewed the clinical data of 53 PD patients with dDBS to 18 months of follow-up. Directional stimulation was favored in 70.5% of dDBS leads, and single segment activation (SSA) was used in 60% of dDBS leads. Current with SSA was significantly lower than with other stimulation types. During the 6-month follow-up, a 44% improvement in the Unified Parkinson’s Disease Rating Scale (UPDRS-III) points and a 43% decline in the levodopa equivalent daily dosage (LEDD) was observed. After 18 months of follow-up, a 35% LEDD decrease was still noted. The Hoehn and Yahr (H&Y) stages and scores on item no 30 “postural stability” in UPDRS-III remained lower throughout the follow-up compared to baseline. Additionally, dDBS relieved non-motor symptoms during the 6 months of follow-up. Patients with bilateral SSA had similar clinical outcomes to those with other stimulation types. Directional stimulation appears to effectively reduce both motor and non-motor symptoms in advanced PD with minimal adverse effects in real-life clinical care.

Single-Center Study of 103 Consecutive Parkinson's Disease Patients with Levodopa-Carbidopa Intestinal Gel

Background

Levodopa-carbidopa intestinal gel (LCIG) effectively reduces off time and dyskinesia and increases on time in advanced Parkinson's disease (PD). However, patients with LCIG-infusion experience frequent complications and some discontinue treatment early on.

Objectives

The objectives of this study were to find predictive factors for early dropout from the LCIG infusion, analyze the treatment burden on the tertiary health care system, and explore changes in medication during the LCIG treatment.

Methods

LCIG-infusion was administrated to 103 patients between July 2006 and May 2020 at the Helsinki University Hospital, accumulating 350 years of follow-up data. We evaluated, retrospectively, changes in medication during treatment, discontinuation of the infusion, and adverse events from the patient records.

Results

Living alone was a predictive factor for early dropout (OR = 3.88; 95% CI = 1.03-14.66; P = 0.045). The treatment burden on the tertiary health care system increased after the initiation of LCIG infusion mostly because of common complications related to the infusion system (median change of in- and out-patient visits +1, P = 0.03). Mean levodopa equivalent daily dose (LEDD) rose from baseline to 6 months (1246.7 vs. 1684.9, P = 0.001) and stabilized thereafter. Patients commonly switched from "polypharmacy" to "LCIG-only" or "LCIG + oral levodopa" medication-groups during long-term treatment.

Conclusions

Recurrent complications related to the infusion system increase the treatment burden on tertiary healthcare system after the initiation of LCIG-infusion. Most patients continue long-term with the infusion. Few patients discontinue infusion during the first year after initiation and living alone appears to be a risk factor for this outcome.

Polyneuropathy monitoring in Parkinson's disease patients treated with levodopa/carbidopa intestinal gel

OBJECTIVES

Levodopa-carbidopa-intestinal-gel (LCIG) infusion is an effective treatment for advanced PD with motor fluctuations. Polyneuropathy occurs as a complication in 10-15% of patients. We wanted to assess the frequency of polyneuropathy in Finnish advanced Parkinson's disease (PD) patients with continuous LCIG infusion, and the value of different clinical monitoring parameters during follow-up.

MATERIALS AND METHODS

Patient records of PD patients started on LCIG infusion at Helsinki University Hospital who received nerve conduction studies at baseline and 6 months after treatment initiation were reviewed for epidemiological information, mini mental state examination, baseline and 6 months' UPRDS-III, weight, body mass index, levodopa dose (LD), plasma homocysteine levels, folate, vitamin B6 and B12.

RESULTS

Out of 19 patients (n = 6 on B-vitamin substitution), two (10.5%) developed new-onset polyneuropathy after initiation of LCIG therapy (n = 0 with vitamin substitution). Neuropathy was associated with significant weight loss (BMI reduction > 1.5), but not with other monitoring parameters. Homocysteine rose significantly in patients not substituted with B-vitamin complex, but not in patients with B-vitamin substitution. Homocysteine changes correlated with LD changes in the absence of vitamin B substitution. After oral B-vitamin substitution, both patients' polyneuropathy remained electrophysiologically and clinically stable.

CONCLUSIONS

Rates of polyneuropathy in Finnish PD patients with LCIG treatment are comparable to previous studies. Patients' weight should be included in regular follow up monitoring and can be used for patient self-monitoring. Vitamin B substitution appears to reduce coupling between levodopa dose and homocysteine and may be useful to prevent polyneuropathy related to LCIG.

Ambulatory surface electromyography with accelerometry for evaluating daily motor fluctuations in Parkinson's disease

OBJECTIVE

To evaluate motor fluctuations in patients with advanced Parkinson's disease (PD) using a small-sized wearable device for surface electromyography (EMG) with accelerometry (ACC) for 24 hours.

METHODS

Seven PD patients with medication were measured once, and nine patients with directional deep brain stimulation (dDBS) twice: before and after the dDBS reprogramming. EMG and ACC parameters were compared with clinical rating scores and patients' home diaries.

RESULTS

The combination of EMG and ACC parameters (first principal component PC₁) correlated significantly with patient's condition as quantified by the motor score of Unified Parkinson's Disease Rating Scale and it changed significantly with dDBS reprogramming in line with decreased PD symptoms. Monitoring data detected in comparison with the home diaries: 91 % concordance with tremor, 76 % with rigidity, and 74 % with dyskinesia. In the DBS group, the wake-up time with abnormal neuromuscular function was reduced with reprogramming in all except one patient based on measurements.

CONCLUSIONS

A wearable device measuring simultaneously both muscle activity and motion can provide continuous and dynamic information about patient's condition and motor fluctuations at home.

SIGNIFICANCE

The present method may help to modify pharmacologic management and DBS treatment in advanced PD.

Motor outcome and electrode location in deep brain stimulation in Parkinson's disease

OBJECTIVES

To evaluate the efficacy and adverse effects of subthalamic deep brain stimulation (STN-DBS) in patients with advanced Parkinson's disease (PD) and the possible correlation between electrode location and clinical outcome.

METHODS

We retrospectively reviewed 87 PD-related STN-DBS operations at Helsinki University Hospital (HUH) from 2007 to 2014. The changes of Unified Parkinson's Disease Rating Scale (UPDRS) part III score, Hoehn & Yahr stage, antiparkinson medication, and adverse effects were studied. We estimated the active electrode location in three different coordinate systems: direct visual analysis of MRI correlated to brain atlas, location in relation to the nucleus borders and location in relation to the midcommisural point.

RESULTS

At 6 months after operation, both levodopa equivalent doses (LEDs; 35%, Wilcoxon signed-rank test = 0.000) and UPDRS part III scores significantly decreased (38%, Wilcoxon signed-rank test = 0.000). Four patients (5%) suffered from moderate DBS-related dysarthria. The generator and electrodes had to be removed in one patient due to infection (1%). Electrode coordinates in the three coordinate systems correlated well with each other. On the left side, more ventral location of the active contact was associated with greater LED decrease.

CONCLUSIONS

STN-DBS improves motor function and enables the reduction in antiparkinson medication with an acceptable adverse effect profile. More ventral location of the active contact may allow stronger LED reduction. Further research on the correlation between contact location, clinical outcome, and LED reduction is warranted.

Serotonin receptor genes 5HT1A and 5HT2A modify the relation between childhood temperament and adulthood hostility

We examined a modifying role of 5HT1A and 5HT2A receptors in the relation between childhood difficult temperament and adulthood hostility in 729 subjects derived from a population-based sample. Subjects were 3-12 years when their childhood temperaments consisting of hyperactivity, low sociability and negative emotionality (i.e. the difficult temperament), were assessed by their mothers. Their adulthood hostility comprising anger, cynicism and paranoia, was measured twice, 17 and 21 years later. It was found that the 5HT1A and 5HT2A receptors were not related to childhood temperament or to adult hostility, but they modified the association between childhood hyperactivity and adult hostility in men. Male carriers of T/T genotype of 5HTR2A who were rated hyperactive by their mothers expressed a high level of hostility, especially that of cynicism, in adulthood. For men with other genetic variants, such an association was not seen. This finding was consistent across the two follow-ups 4 years apart. Further research is needed to clarify whether mother-related hyperactivity adequately describes the temperament of the child or is a reflection of mother's hostile child-rearing attitudes.

Risk factors for chronic otitis media with effusion in infancy. Each acute otitis media episode induces a high but transient risk

OBJECTIVE

To examine the effects of a history of acute otitis media and different extrinsic factors on the risk of chronic otitis media with effusion in infancy.

DESIGN

A retrospective birth cohort with a 2-year follow-up. Infection data were gathered from medical records and background information came from questionnaires. The monthly risk of chronic otitis media with effusion was dynamically modeled to control the confounding effects and time-dependency of the risk factors.

SETTING

Primary health care centers, hospitals, and private practices in 10 randomly selected local government districts in the two northern most provinces of Finland.

SUBJECTS

A random sample of 2512 children from the cohort.

MAIN OUTCOME MEASURES

Chronic otitis media with effusion, defined as a minimum of 2 months of middle-ear effusion, usually is disclosed by tympanocentesis and specific operative findings.

RESULTS

Previous acute otitis media episodes were the greatest risk factor. Each acute episode induced a highly increased risk (odds ratio, 11.9; 95% confidence interval, 5.7 to 24.9) that disappeared in 3 months. Successive episodes were risky, but this risk also decreased rapidly. Other significant risk variables were attendance at a day nursery (odds ratio, 2.56; confidence interval, 1.17 to 5.57), male sex (odds ratio, 2.17; confidence interval, 1.37 to 3.44), and autumn season (odds ratio, 1.99; confidence interval, 1.11 to 3.55).

CONCLUSIONS

Acute otitis media episodes constitute the greatest risk of chronic otitis media with effusion. Each episode has a high transient risk for 3 months but no further direct effect on the risk.

Chronic otitis media with effusion in infancy. How frequent is it? How does it develop?

OBJECTIVE

To study the occurrence and development of chronic otitis media with effusion in infancy.

DESIGN

A retrospective birth cohort with a 2-year follow-up. Infection data were gathered from medical records; background information came from questionnaires.

SETTING

Primary health care centers, hospitals, and private practices in 10 randomly selected local government districts in the two northernmost provinces of Finland.

SUBJECTS

A random sample of 2512 children from the cohort.

MAIN OUTCOME MEASURES

Chronic otitis media with effusion determined as a minimum of 2 months of asymptomatic middle ear effusion revealed by tympanocentesis and specific operative findings.

RESULTS

The periodic prevalence rate of chronic otitis media with effusion up to the age of 24 months was 4.4% (95% confidence interval, 3.5 to 5.3). The maximum risk was at age 16 months. The number of acute otitis media episodes among children who developed chronic otitis media with effusion was more than double that of normal healthy children before the onset of chronic inflammation and about five times as high during prolonged mucous middle ear effusion. Inadequate treatment of prior acute otitis media was not the reason for the chronic inflammation, which was a direct continuation of an acute episode in only half of the cases and was otherwise preceded by a latent period of varying duration.

CONCLUSIONS

Chronic otitis media with effusion, which may cause adverse developmental effects such as delayed language development, is a fairly common disease in infancy and is closely related to acute otitis media episodes.

Which children are being operated on for recurrent acute otitis media?

OBJECTIVE

To examine at the population level which children were operated on for recurrent acute otitis media episodes, how ill they were, and what factors affected the operation rate.

DESIGN

A retrospective birth cohort with an approximate 2-year follow-up. Infection data were gathered from medical records, and background information was gathered from questionnaires.

SETTING

Primary health care centers, hospitals, and private practices in 10 randomly selected local government districts in the two northernmost provinces of Finland.

SUBJECTS

A random sample of 2512 children from the cohort.

OUTCOME MEASURES

Adenoidectomy and/or tympanostomy tube insertion.

RESULTS

Only one of 10 of those with actual recurrent disease (> or = 4 episodes) had been operated on, and three of every five children operated on, in fact, had rather few episodes. The operation rate among those children with only a few episodes was increased by factors such as consulting an ear, nose, and throat specialist (risk ratio [RR], 13.0; 95% confidence interval [CI], 7.6 to 22.2); parental exaggeration of the episodes (RR, 6.7; 95% CI, 3.8 to 11.9); having the first episode under 6 months of age (RR, 4.5; 95% CI, 2.5 to 7.9); recurrent respiratory tract infections (RR, 3.3; 95% CI, 1.9 to 5.7); male sex (RR, 2.6; 95% CI, 1.4 to 4.6); urban domicile (RR, 2.4; 95% CI, 1.1 to 4.9); and day care (RR, 2.1; 95% CI, 1.1 to 3.8). The decision to operate was more or less a random phenomenon among those children with numerous episodes.

CONCLUSIONS

Physicians at the primary care level should be familiar with these pitfalls concerning patient selection so that the operations are targeted at those children who are most seriously ill.

Control of the temporal aspect when considering risk factors for acute otitis media

A random sample of 2512 children was monitored to age 2 years to study the biologic effects of various risk variables on acute otitis media using a new dynamic modeling that controls both the confounding effects and time dependency. Dynamic modeling proved to be superior to conventional approaches, both the random and systematic error being much smaller and the effect estimates being biologically interpretable. The major risk factors were the existence of a previous episode of acute otitis media in general (odds ratio, 2.03; 95% confidence interval [Cl], 1.81 to 2.25) or particularly during the preceding 3 months (odds ratio, 3.74; 95% Cl, 3.40 to 4.10) and attending a day nursery (odds radio, 2.06; 95% Cl, 1.81 to 2.34). As the form of day care is the only modifiable risk variable of significant importance and previous episodes entail a risk of future ones, infants should be cared for at home, particularly after they have already experienced an episode of acute otitis media.

What is an 'otitis-prone' child?

The present report concerns a random sample of 2512 children monitored for acute otitis media up to the age of two years. The criteria given by previous surveys classified from 1.8 to 41.2% of the population as 'otitis-prone', at a mean age varying between 13.4 and 18.8 months. A criterion of at least 4 episodes of acute otitis media during the next 9 months with a 30-day borderline between two distinct episodes yielded 273 children (10.8% of the population) with an acceptable mean age of 15 months. Early onset of acute otitis media was only a weak predictor of susceptibility in either the individual child or the whole population, the sensitivity levels and predictive values being too low for accurate prediction.

The occurrence of acute otitis media in infants. A life-table analysis

A random sample of 2512 children were monitored to an average age of two years to determine the occurrence of acute otitis media (AOM). A life-table methodology was employed in the analysis. The cumulative incidence of the first episode of AOM up to 12 months of age was 42.4% (95% confidence interval 40.4-44.4) and the corresponding figure up to 24 months of age was 71.0% (68.9-73.1). The incidence rate for all acute otitis media episodes was 0.93 episodes per child per year (0.90-0.96) during the first 24 months of life increasing in the spring and autumn. The risk of experiencing an episode of acute otitis media increased at the age of 6-12 months and decreased slowly during the second year of life. The results confirm the frequent nature of acute otitis media and stress the necessity for clear, consistent definition of the criteria for acute otitis media in epidemiological research.

Is a child's history of acute otitis media and respiratory infection already determined in the antenatal and perinatal period?

A random sample of 2512 children were followed up from fetal period to the age of two years and the relation of various antenatal and perinatal factors to acute respiratory infection, wheezy bronchitis and otitis media was studied. A model containing the relationships between the variables was used as a basis for the analysis and the powerful confounding effects of postnatal factors were standardized. Acute otitis media with effusion (AOME) demonstrated by myringotomy was analyzed as a specific subgroup of acute otitis media (AOM). Low birth weight (less than or equal to 2500 g) and prematurity (birth before the 37th gestational week) did not influence either AOM or AOME. The odds ratio for low birth weight infants becoming 'otitis-prone' (greater than or equal to 3 episodes of AOME) was 1.5 (0.9-2.1, P greater than 0.1). The various neonatal ventilation therapies were not associated with either AOM or AOME, but intermittent positive pressure ventilation, low birth weight and prematurity were distinctly related to wheezy bronchitis. The odds ratio regarding intermittent positive pressure ventilation was 2.0 (1.0-3.0, P less than 0.05) and that regarding low birth weight 1.7 (1.0-2.3, P less than 0.05). Boys had a slightly increased risk with respect to all the infective parameters. Birth order was closely correlated with the infective parameters, but much of this correlation was due to the postnatal effect of siblings. Altogether the antenatal and perinatal factors had only a slight effect on the infective parameters studied.

Risk factors for recurrent acute otitis media and respiratory infection in infancy

Using a cohort-based design and random enrollment, the relation of various risk factors to acute otitis media, respiratory infection and wheezy bronchitis was studied in 2512 children from the fetal period to the age of two years. The complex interrelations of the risk factors with each other were separated out by multivariate analysis, and the confounding effects of antenatal parameters were also standardized. Acute otitis media with effusion (AOME), as demonstrated by myringotomy, was analyzed as a specific subgroup of acute otitis media (AOM). Day care in local authority nursery was the major risk factor for both types of acute otitis media. The odds ratio (OR) for such children becoming 'otitis-prone' (greater than or equal to 3 episodes of AOME) was 1.8 (95% confidence interval, 1.4-2.2). Short duration of breastfeeding involved another significant risk of recurrent respiratory infections and otitis media, the OR for AOME being 1.5 (1.1-2.0) and that for recurrent respiratory infection 1.3 (1.1-1.6). Allergy and family day care were also significantly associated with infective parameters, but to a lesser extent. The risk factors for wheezy bronchitis were the same as for infections, indicating that wheezy bronchitis is closely related to infections.

Prognosis of perinatal brain damage: a prospective study of a one year birth cohort of 12,000 children

The prognosis of perinatal brain damage was studied prospectively in a one year birth cohort of 12,000 children born in Northern Finland in 1966. Children were included in the study if they had an Apgar score of 0 at 1 min or less than 5 at 15 min, convulsions during the neonatal period, or a diagnosis of asphyxia, brain injury or intraventricular haemorrhage, but did not have CNS malformation, chromosomal aberrations or hereditary CNS degeneration. There were 233 children, 19.3 per thousand, of which 134, 58.0% were boys. Eighty-four, 36.4% died during the first 28 days and 7 children died before the age of 14 years, 6 of the latter group being handicapped. There were 44 children, 29.9% who had mental retardation, IQ less than 71, epilepsy or cerebral palsy. With regard to these children 13 had normal school performance, but there were 12 other children in the perinatal brain damage group who needed special education, two of them because of deafness. Perinatal brain damage accounted for 57.5% of all neonatal deaths, 30% of admissions to a special nursery and 12.5% of mental retardation (IQ less than 71), epilepsy and cerebral palsy at the age of 14.