to the editor: Boyer et al. (May 14 issue) report that among children with neurotoxic effects of scorpion envenomation, scorpion-specific F(ab'))_2 antivenom resolved the clinical syndrome within 4 hours. In 1999, we published the results of a negative randomized, controlled trial of antivenom in patients with scorpion envenomation in southern Tunisia. Although neurotoxic effects are reported in up to 78% of patients with venomous scorpion stings in North Africa, we assessed the efficacy of scorpion antivenom on objective end points such as a change in severity grade. The 100% rate of resolution of neurotoxic symptoms with scorpion-specific antivenom in the study by Boyer et al. is ascribed to rapid neutralization of circulating scorpion venom; this finding has been previously reported, and its clinical relevance largely debated. The distribution range and the standard deviation around the mean of baseline plasma venom levels in the control group suggest, that some patients had no detectable levels of venom. Was the outcome for those patients the same as that of the active group or that of the control group? Midazolam infusion, which affected both the primary and secondary end points, was not standardized according to a validated grading system. Therefore, it is difficult to identify the precise moment that resolution of the neurotoxic syndrome occurred, and the decision to stop the midazolam infusion might have been delayed, since it was based on the observation of the patient's condition by the physician-investigator.
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