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In Reply: - The most important part of the letter by Drs. Price and Carpenter begins shortly before the paragraph that introduces their Table 1. Before that, the letter reviews the caveats presented in the original article, or in the two editorials that accompanied it. These clearly stated and discussed interpretative limitations imposed by not knowing how many spinals were performed using lidocaine or how many were performed using bupivacaine.
With respect to whether the study was prospective, we also note the "ideal" concern of R. Smith's editorial that data for the "relevant prognostic and outcome variables are collected from patients as they are treated.
As explained in the original article, all participants knew they were participating before the study took place, before regional anesthesia was administered, and before data were entered in the anesthetic record or on the questionnaires. Also, all physicians knew there would be follow-up inquiries about the cases.
The questionnaire procedure was very different from a retrospective approach, in which unexpected inquiries are made to surprised individuals, asking them whether they recall various procedural events. Coincidentally, the thoughts cited by Drs.
Price and Carpenter are addressed in a more recent editorial by Dr. Table 1. Price and Carpenter state that our data "suggest a recall bias in reporting for patients with neurological deficits. We are concerned that their Table reflectsa superficial assessment.
If paresthesia or pain were totally independent of the agent used, i. Because one starts with the group that had deficits, there is no a priori reason why the incidence of paresthesias and pain must be the same in both drug groups.
The text of our article clearly refers to pain during injection, which might be agent dependent. It is possible that "no pain" during injection occurs less frequently during injections of a particular toxic substance than during injection of another less-toxic substance. Thus, the numbers in their Table 1 do not form the basis for their subsequent reasoning that we have proven an obviously absurd hypotheses i. In the next to last paragraph or their article, Drs. Price and Carpenter need to change "paresthesia during needle insertion to "paresthesia during needle insertion or pain during injection.
After constructing Table 1 , Drs. Price and Carpenter ask, "are these data sufficient to support speculation regarding risk for nerve injury? We are concerned about the intensity with which Drs. Price and Carpenter seek to counter this important message of our study: that lidocaine toxicity might exist.
They state that "it is certainly possible that lidocaine was chosen more frequently. Although it is mathematically possible, it has no factual basis. Price and Carpenter essentially congratulate us for gathering enormous amounts of uninterpretable data. However, we believe it is important to note that both of these people represent Astra USA, which manufactures lidocaine, Dr.
He wrote, criticizing an earlier study by others that 1 "This study. Price and Carpenter clearly believe that the available information is insufficient, a logical final question is whether Astra, which funds expensive studies of new molecules, is also willing to fund the extraordinarily expensive, "high-quality" clinical studies that they seem to believe are needed to address a problem with an "old molecule" such as lidocaine?
Patrick Narchi, M. Antoine Messiah, M. Kamran Samii, M. Lawrence Litt, Ph. Bernard Rouvier, M. Accepted for publication May 4, Smith RL: Observational studies and predictive models.
Anesth Analg ; Duncan PG: That was then, this is now! Results of a prospective survey in France. Anesthesiology ; Carpenter RL: Hyperbaric lidocaine spinal anesthesia: Do we need an alternative?
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