Authors' replyVS Natu1, SB Kamerkar2, K Geeta2, K Vidya2, V Natu3, S Sane4, R Kushte5, S Thatte6, DA Uchil7, NN Rege7, RD Bapat7
1 Vijayashree Hospital, Umroli, Chiplun, India
2 Mangaon Cottage Hospital, Mangaon, India
3 Natu Hospital, Chiplun, India
4 Sane Hospital, Chiplun, India
5 Kushte Hospital, Chiplun, India
6 Natu Sane and Kushte Hospitals, Chiplun, India
7 Ayurveda Research Center, Seth GS Medical College and KEM Hospital, Parel, Mumbai, India
We thank the authors for their letter  and interest in our article.  We have suggested that neutralization of the venom by anti-scorpion venom serum is the most scientific line of treatment. The radical change is in the scoring system, the dosage schedule and the rapid recovery time (4 h against 19 h), which is highly significant. The anti-scorpion venom serum was blamed unnecessarily after giving inadequate doses to scorpion-stung victims. Mahadevan  has mentioned that anti-scorpion venom serum is not available in India. Doses of anti-venin used by Bawaskar  were very minute, and were one vial in 15 patients, two vials in nine patients and three vials in one patient, respectively.
The limitation of our study included lack of randomization because of problems in the rural settings, as mentioned in the article.
When the recovery is very fast, the patient states that there is no complaint except pain. This is not seen with prazosin, as the recovery time is much longer, the pain factor being diminished by that time. When there are no systemic manifestations in the scorpion-stung victim, severe pain is the only symptom.
A composite scoring system takes into consideration all the signs and symptoms of the stimulated autonomic nervous system. Severe sweating in females and sweating and priapism in males are important cholinergic signs that are usually associated with other severe systemic manifestations.
Our findings confirm the observations made by Dr. Bawaskar  that there was a positive correlation between occurrence of priapism in a male and the later development of cardiac manifestations after a scorpion sting. Priapism was also the most common important predictor factor for hospital admission in the study by Nouira et al. 
This is the main reason that sweating cannot be ignored in females. We will be proposing higher grades for females in the sweating category in the forthcoming study to compensate for the priapism. Inclusion of priapism caused slight difference and not a gross difference. Priapism has a maximum score of 3 as against the total score, which, as seen, is 25.
As for many disease therapies, composite scores are proposed based on original research and scientific wisdom. Further randomized controlled trials (RCTs) then validate the therapy. We have discussed in detail about the rationale behind the use of higher doses and intravenous doses.
A metaanalysis  in 2004 in fact stated that there was good evidence that intravenous administration of anti-venin reduces the serum venom concentration, and whether it was clinically relevant was open to question. Our data has now emphasized its efficacy. Further, in the metaanalysis of 69 studies scanned, there was only one eligible RCT that showed no improvement in symptoms. The weakness of that particular study was that it was found to be underpowered to show any difference in the morbidity as the mortality was low and a very low dose was used.
In the anti-venin group, two patients reported late and there was no previous treatment with prazosin. In fact, two patients from the prazosin group developed pulmonary edema. They were successfully treated with anti-venin.
Prazosin does not neutralize the venom; this is the main reason it cannot be used as a first-line treatment. The investigators questioning anti-venin have used anti-venin in very low doses. The half-life of venom is 24 h, and the patient treated with prazosin needs to be monitored in the Intensive Care Unit as development of pulmonary edema while on the way to recovery is known.