To the Editor:
First of all, we would like to thank Lim et al for their valuable comments. We do of course agree that the setting – and often the group of patients – would be different between single cases and outbreaks. However, we disagree that the patients are fundamentally different. Second, the present study looks at prognostic parameters on admission based on their actual status, regardless of the potential ethanol contents of the mixture, and regardless of their intention and way of presentation, being it single cases or outbreaks:
If the patients have ethanol above a certain level on admission, they would not be acidotic on admission and hence classified as such, and vice versa. The present study, and the risk assessment scheme, is meant as a tool to evaluate their prognosis based on their status on admission. Their pre-admission history would in many cases be difficult to acquire, and the important aspects for the clinician treating the patient is the present status.
Regarding the difficulties of generalizing the results, we disagree: These are solely strong, independent parameters that are largely in compliance with earlier findings, whereas it is now put into a larger context. However, prioritizing or triaging based on these parameters, will definitely depend on the practicalities, resources, number of patients, and even local preferences or traditions.
The majority of the patients in the study have received hemodialysis, especially the acidotic patients: Some may have received it for a shorter period of time, but these are not overrepresented in any of the groups in Fig. 2, and so should not bias the results.
Finally, it should be noticed that the patients in the present study are not only from varying countries, but also from various circumstances: The patients from the Estonian outbreak and the first Norwegian outbreak (1979) are typical short-time outbreaks with a large number of patients being admitted over a short time, whereas the second Norwegian group of patients (2002–2005) were admitted over more than two and a half years, and to various hospitals, comparable to the situation of single cases often seen in the developed part of the world. The patients from Iran (both Mashhad and Teheran) are not even clusters: They consist of a regular flow of patients to two different centers treating a large number of tox-patients every year, including suicidal attempts: Loghman-Hakim hospital in Teheran is the largest toxicology unit in the world, with 25,000 poisoned patients admitted to the Emergency Dept. every year, of whom 12,000–13,000 patients are hospitalized. Of these, methanol-poisoned patients represent a small, but notable number of patients, regularly being admitted in a non-outbreak manner. Thus, the present study covers a wide variety of patients, including non-outbreak methanol-poisoned victims.
We do therefore support the comment of the various natures of the patients, whereas the simple, yet strong prognostic parameters to our opinion stand tall regardless of the patient's intention. The exact share of fatalities (as presented in Fig. 2) would of course vary also based on the nature of the patient population, their age, their pre-morbidity etc., but the final triage and decision on how to handle the patients based on these factors are not within the scope of this paper, nor in our intention to comment on.
Declaration of interest
The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.