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Eric P. Batson, MD, PhD
JAMA. 1990;263(7):948-949. doi:10.1001/jama.1990.03440070034022.
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In Reply.—  The incidence of anaphylaxis during chemonucleolysis is difficult to quantify, with a wide range of values reported in the literature. The incidence of 0.46% cited by Dr Wright for 1982 through 1988 is within the range of 0.4% to 4.2% reported in the DATTA evaluation. The disparity in anaphylaxis rates between the United States and Europe is well known and is one piece of the supporting evidence that the ubiquitous presence of papain in the American diet contributes to the anaphylaxis rate in this country.The meta-analysis of the chemonucleolysis literature by Einarson et al1 relied on 33 published studies, only 2 of which were controlled, hence the observation that relatively few prospective, double-blind, placebo-controlled trials have been performed. The issue of what constitutes an appropriate placebo control for randomized trials of chymopapain chemonucleolysis is a complex one that could not be treated in detail. However,


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