To the Editor: In their meta-analysis, Dr Block and colleagues1 concluded that epidural analgesia provided improved postoperative pain control compared with parenteral opiates, as indicated by a summary difference of 10 mm on a 100-mm visual analogue scale (VAS). We have several concerns about their methods.
First, we question the clinical significance of a 10-mm difference in VAS, especially given the relatively low baseline values of the VAS.
Second, we disagree with the authors' strategy of computing a summary effect for all forms of parenteral opiate analgesia. In fact, intravenous patient-controlled analgesia (PCA) opiate analgesia is generally regarded as better than other forms of parenteral opiate analgesia.2 This, and the prevalence of PCA analgesia in current medical practice, would make comparisons involving this mode of parenteral opiate administration more relevant. Although the authors mentioned that they did perform this analysis and that the results were no different than the primary analysis, it would have been helpful to see these data presented in the article.
Third, although we agree with the authors that randomized controlled trials (RCTs) involving the use of epidural analgesia are not consistently double-blinded, we think that the authors significantly undermined the strength of their conclusions by including RCTs that were not adequately blinded. Indeed, the authors noted that when the meta-analysis was performed using only blinded trials, epidural analgesia appeared considerably less advantageous.
Finally, the authors appear to not have considered the aggressiveness of pain management in the parenteral opiate groups of the studies included in their analysis. In general, management of epidural catheters involves individuals whose purpose is to ensure a properly functioning catheter, a minimum of adverse effects, and appropriate analgesia. When parenteral opiates are managed with the same degree of vigilance, differences in pain scores disappear.3
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
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