I clearly appreciate Dr. Robertson’s Mark Twain reference and his amplification of the limitations of case–control studies. However, I fear that his impressions of the article by Arbous et al.  1and my editorial2are based on isolated statements contained within them. The isolated quotation of statements without appreciation or notation of full context can be misleading. Indeed, my editorial notes that “. . . a case–control methodology can be used to seek possible  but not proven [emphasis added] risk factors.” Further, “… the findings in [the Arbous] study support many plausible assumptions.” Although I am likely biased, my statements do not seem to qualify as lies, much less as damn lies.

Drs. Avram and Krejcie are, as usual, absolutely correct that all statistical associations found using case–control methodology must be practically assessed in context and then subjected to more rigorous scrutiny in prospective studies to ascertain their validity. I thank Dr. Schmidt for supporting these contentions.

Finally, and to be perfectly candid, I do not know how to respond to Dr. Ivester’s comment on aircraft personnel. My editorial had nothing to do with distinctions between types of anesthesia personnel. Therefore, his comment does not seem pertinent to the current issues unless he disagrees with my statement that “… immediate availability of anesthesiologists to help when needed … should be seriously considered when seeking opportunities to improve the perioperative outcomes of anesthetized patients.” I personally believe that this statement is quite appropriate, important, and relevant to good patient care.

Mayo Clinic, Rochester, Minnesota. warner.mark@mayo.edu

Arbous MS, Meursing AEE, van Kleef JW, de Lange JJ, Spoormans HHAJM, Touw P, Werner FM, Grobbee DE: Impact of anesthesia management characteristics on severe morbidity and mortality. Anesthesiology 2005; 102:257–68
Warner MA: Perioperative mortality: Intraoperative anesthetic management matters. Anesthesiology 2005; 102:251–2