Predicting Outcome From Hypoxic-Ischemic Coma

To the Editor.—  Levy and colleagues¹ provide very helpful information about the prognosis of hypoxicischemic coma. While we fully agree that their data "provide a more rational approach for managing patients who sustain hypoxic-ischemic coma," we wonder about the possibility of a self-fulfilling prophecy that potentially confounds these data.In this study, these investigators "refrained from any involvement in [the patients'] care." However, during the period of the study, it was the conventional wisdom that certain clinical features (eg, unreactive pupils) predicated poor recovery. If patients with a preconceived poor prognosis received less than maximal sustained supportive care, the outcome may have been influenced by these preconceptions. This potentially confounding factor is inevitable in a study in which all patients were not known to have received the same level of sustained care.This is only a potential problem with these data, and of uncertain magnitude. The