I was in a lingerie shop, trying on bras. I was chatting with the shop assistant, trying to explain that no, indeed, going one size larger on the strap and a size smaller on the cup didn’t make the bras “the same size.”

But hey, what do you expect for $10 an hour plus commission?

I was pulling my shirt over my head when I felt a most excruciating *crunch* in my right shoulder.

Apparently I let out a very impressive shriek.

I knelt on the floor for a minute, realising that my shoulder had subluxed out (hazards of an old traumatic dislocation and not lifting weights much lately-lazy girl).

And all I could think was, how do I ask the shop assistant to come in and help me relocate my shoulder?

Reading on The Happy Hospitalist re: his take on what Obama’s plan would mean in terms of cost per QALY, I noticed something: his stats were appalling. When called on it gently, he confidently reiterated his error, and the commenter backed down.

Clearly, we as doctors need more training in statistics so we can a. spot these sorts of errors and b. be confident in correcting them.

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So what’s my issue with Happy’s math? Here’s a quote from his post:

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Let’s look at the numbers. Let’s round up for easy numbers. 20,000 deaths a year are attributed to lack of insurance. Obama is trying to brainwash the public into believing we need to spend one trillion dollars in public money over the next 10 years to cover everyone. Let us use easy math and assume a linear function over time. That means an additional 100 billion dollars a year are required to insure the entire nation.

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And in the process we will save 20,000 lives a year. That’s 100 billion dollars a year to save 20 thousand lives. That means Obama wants to spend 5 million dollars to save one life for one year. That’s a Quality-adjusted Life Year of 5 million dollars.

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Error #1: Comparing apples to apple trees. Initially he’s talking about lives saved, then suddenly he starts talking about QALYs. He’s linked to the Wiki article, but apparently he didn’t bother to read it.

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Here’s an excerpt:

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The QALY is based on the number of years of life that would be added by the intervention. Each year in perfect health is assigned the value of 1.0 down to a value of 0.0 for death. If the extra years would not be lived in full health, for example if the patient would lose a limb, or be blind or be confined to a wheelchair, then the extra life-years are given a value between 0 and 1 to account for this.

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Clearly, one life saved is going to impact on the total number of QALYs for the duration of the time this person remains alive. The number of QALYs is not necessarily equal to the number of years that person lives, due to the adjustment factor for quality of life. That’s an insurance thing, and if we disregard the quality adjustment, we can call the measure “person-years,” which takes into account both the number of people (multiplied by) and  the number of years each person lives.

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For example, if I live to be eighty, that’s eighty person-years. If my husband lives to be ninety, we live a total of 170 person-years.

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QALYs are different in that, if he spends the last ten years of his life in a wheelchair, some arbiter somewhere might decide that means his life is 50% quality, so, the last ten years might be worth only 50%, so 5 QALYs.

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Presuming we have both been 100% healthy until that point (we had a car crash on the speedway at the age of 80, which killed me and put him in a wheelchair, lolz), we lived a total of 165 QALYs.

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I can’t calculate QALYs based on an estimated number in an article for future deaths based on lack of insurance, due to not having health data on the people involved.

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Error #2: Deny that lives saved are people who will continue to survive. A refutation from Happy when nudged on the person-year aspect:

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Let’s assume every year 20K lives are saved. And each year you just add another 20K lives. [...] And at the end of 10 years, using your logic (which does make sense in theory) 200K lives would have been saved if everyone had insurance for 10 years.

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Okay, so he’s got the number of lives saved. But he’s not looked at person-years and not even hinted at QALYs, which are, after all, his original measuring post. And then things get quite fuzzy indeed:

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Now, lets do a back track. Lets take away the insurance that all these people had for the last 10 years and lets look at year 11

Using your logic, all 200K people + an additional 20K people would die if you took away their insurance to the level 11 years prior.[...]

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Pardon me? Why? How? Are you going to go around and shoot them all?

Here’s my reply:

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But if you save a life, you MUST add that person-year to each year.[....] If you take away the insurance at the end of ten years, you really do still have the accumulated person-years saved, which incidentally works out to (using your 20K for easier math) 200K (the people saved in the first year who live 10 years) plus 180K (saved in the second year who live nine years) plus… you get the idea, working out to 1.1M person years. Then people start dying again, but more slowly, because they have had ten whole years of extra care.

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And here’s Happy’s:

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redrabbit, let’s just assume lives saved. Even better. 5 million dollars to save one life. Same conclusion.Your conclusion would assume after 10 years that removing insurance would kill 200K lives. That’s not what the statistic says. It says 20K lives.

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Error #3: Look for common ground where there isn’t any.

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Oh dear. I think he really sucks at math. Or reading comprehension. Or something. What is a life worth? Even insurance companies baulk at that one. Certainly, a “life saved” is worth more than a QALY, insofar as the person is likely to live more than a year.

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No, Happy, that was your conclusion. My conclusion was that 1.1 million person-years would be saved over ten years, in this case equal to about 200 thousand people. I also stated that people would again begin dying once insurance was taken away, but not all at once.Maybe at a rate of about the same or less than previously, so these people keep on living, and maybe 20 thousand die (assuming same as before insurance, right?), but you still have an accumulated group of live people who continue to be alive. So the savings of people and person-years actually will continue to accumulate.

I thought that was clear from my math, but I guess not.

So, at 11 years, having cancelled the whole programme at 10, because Happy was elected POTUS, we still have a savings of 1.28 million person-years. At 12 years, even with the 20 thousand people a year dying again, still saving 1.44 million person-years, at 13 years still benefitting by lessee 1.56 million person-years. Still 120 thousand people alive who would have died otherwise.

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I didn’t do the QALY numbers here, but you can see that $5 million per QALY price tag he quotes is something of an exaggeration. In terms of person-years, at 20 years, assuming the programme is cancelled and people are dying off at the same rate, this would mean that all 200 thousand people die. We still had a savings of 2.2 million person years, with a cost of about $50 thousand per person-year saved.

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Now, to be fair, it probably will be more per QALY. But if I was Happy, I might not have pointed that out.

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Let’s just hope Happy stays in the hospital and out of policy, because he sure doesn’t seem to get it.

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Ah, I see what Happy’s problem is. He wants to credit the insurance for not only saving a life, but for keeping that person alive, so each life saved in the first year is a person who will die in the second year without insurance.

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For some people/situations, I can see his point. A heart failure patient who has an acute event might not live very long without recurrent intervention, etc. However, the estimates he uses are based on the current situation in the USA, and represent actual lives lost due to lack of intervention due to lack of insurance. Meaning, people who died in the first year didn’t survive to get counted in the group that died in the second year. Meaning, there’s one hell of a burden of disease out there.

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So the meaning of all this is: you can use my calculations to look at lives lost in the past 10 years due to lack of insurance. The truth about the future is probably not as cut-and-dried, as he has a point, many of the people “saved” will not live the full 10 or 20 or however many years.

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But many will. Acute trauma patients. Patients suffering acute events such as DVT, PE, pneumonia. People diagnosed with cancers, diagnosed early and treated appropriately. Some people will get many more years, and many more QALYs.

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He’s right on one thing: it’s wrong to think every person “saved” in the first year will survive right on through. But he’s really pushing it to say every person (or even a majority) saved by medicine this year would die next year without it.

One of the top google search terms for this blog is: “What do atheists believe about how life started?”

I have a post on what atheists in general believe (summary: they don’t like the word believe), but I figure, I can pander and answer the question.

Atheists are not a uniform group, but their (our) usual unifier is an inquiring mind that looks for evidence behind a statement. Scientists are often atheists, but atheists are not always scientists.

Science is the means people have used to look for answers in a verifiable fashion. Science has any number of theories for how life on earth began, and all are equally wild.

Did lighting get bunged through a load of organic molecules which had been forming and forming based on the conditions of earth a some time several gazillion years ago, and BOOM, alive?

Did a self-replicating form arise and simply evolve to become more and more efficient, eventually giving rise to life?

Did a meteorite strike contain life forms from another planet (which doesn’t answer the whole “how did life get started?” question, but cleverly avoids it)?

Did goddidit?

The issue, of course, is falsifiability. People are trying to replicate the conditions of the time in question, in order to see if they can make something happen in terms of creating life from not-life. They are looking for evidence for one pathway or another.

Right now, there isn’t much evidence one way or another, so most atheists are happy to pick a favourite theory and go with it until it gets proven wrong. I quite like the alien bacteria theory myself, though as I say, it doesn’t answer the central question.

This is the issue atheists have with goddidit: people who take the word of the bible as literal truth cannot help us find evidence. They refuse to conduct experiments to look for the conditions under which goddidit. They just say, look, someone wrote it down, so it must be true.

Yeah, well. I won the lotto. See, written down; still, sadly, no evidence for that.

During my undergraduate medical training, we had a section on end-of-life care, also known as palliative care. This section was led by a sensitive and caring physician, who had himself been to the brink of death.

He talked to us about such broad concepts as medical futility, acceptance, “total pain,” and oneness.

We were a group of medical students, mostly in our early 20’s. We believed that the function of medicine was to save lives. The people we couldn’t save would represent our failures. His talk frightened and embarrassed us.

We were terrified on our actual first visit to see his patients.

In a palliative care ward, I expected to see old people, crying people, sad people, people in wretched pain, people drugged to unconsciousness, people who were depressed and suicidal, people vomiting and retching. I was expecting to see the people medicine was giving up on.

My professor introduced me to a young man of 23 in a hospital gown. This young man smiled and shook my hand. His mother and grandmother were present, in street clothes. They were smiling as well.

This young man explained to me that he had had cancer as a young child, had been successfully treated, and had been many years cancer free. He now had lymphoma, and had had it for five or six years. He had exhausted several treatments, but secondary lymphomas, he explained, were harder to cure than ones with no known cause.

He was in the palliative care ward because he had chosen not to have surgery for a complication of his lymphoma, and this had been expected to end his life. They had tried a new drug, however, which had worked for the time being, “So, actually, I’m going home today for a while. We’ll see where things go from here.”

I was surprised: I know this isn’t the usual outcome. But what surprised me more was how serene and accepting he and his family were.

My professor had some thoughts about this young man. His life was in order. He knew the end was coming. Every day for him was a gift, and he was pleased to have it to spend with his mother and grandmother. He had expressed regrets- having been too ill to date and have a proper girlfriend was chief among them- but he chose not to dwell on this as he neared the end.

The professor was an sweet man, with many theories. He said the human animal had the capability to find peace and acceptance almost anywhere. He told one story to illustrate: Once, he was at a concert downtown. The music was exceptionally fine, the audience was entirely in tune with the musicians. The hall was suffused with light. At one point, the entire audience was singing, and my professor said he felt a profound sense of oneness, a tingling to his fingertips.

And that was when he realised they were singing about Saturday night being Alright for Fighting…

Death squads? Oh, I must have missed those. End-of-life care is one of the most important parts of primary care medicine. Do they really think if they take out end-of-life care wording, people will stop dying?

Some recent lunatic ramblings from everyone’s favourite wild-eyed Alaskan scaremonger:

The America I know and love is not one in which my parents or my baby with Down Syndrome will have to stand in front of Obama’s “death panel” so his bureaucrats can decide, based on a subjective judgment of their “level of productivity in society,” whether they are worthy of health care. Such a system is downright evil.

OH NOES!!!1!

I have been living with public healthcare my whole life. So has the rest of my family.

I wonder how my 57-year old auntie with Down Syndrome has managed to escape these “death squads.” She is pretty clever.

Maybe when she was getting her pacemaker put in, she wore a mask.

Maybe when she was being treated for Addison’s disease, she had someone else go.

Death squads! Boohoo!

Maybe now that she is being treated for Alzheimer’s, as anyone who reaches the ripe old age of 57 with three copies of chromosome 21 will need to be, she might be in more danger.

Watch out, Minnie, the “death squads” are after you.

Or, wait, are those the ramblings of a lying rich woman who doesn’t want others to benefit? “I paid for mine, you can pay for yours and I’M NOT SHARING!”

Surely nobody could be that petulant and downright selfish?

Tommy Douglas is widely hailed as the founder of public health in Canada. Premier of Saskatchewan for more than 20 years, he was voted “Greatest Canadian” of all time by the Canadian TV-viewing public, beating out Alexander Graham Bell (inventor of the telephone), Banting and Best (discoverers of insulin), and of course Jim Carrey (vaccine-fearing nutjob and actor).

Canadian physicians were initially unimpressed and downright mistrustful of the overarching changes Douglas proposed, and indeed, in his own province launched a campaign of misinformation and scare tactics to discredit the proposed programme.

Tommy Douglas was surely no paragon, being a bible-thumping Nazi sympathiser.

But he did help bring about something of which the vast majority of Canadians and Canadian physicians are exceedingly proud. We are a nation which believes that a child getting appendicitis should not mean a family becoming homeless. We are a nation which believes that hospitals trump highways (and it shows). We value this about ourselves and about our country.

Obama is facing a massive amount of criticism from the right wing for trying to introduce universal medical insurance. The Canadian example isn’t the only way: the Dutch are universally covered, as are the British, the Australians, the French….

No system is perfect. But I like ours.

To Mr. Obama: keep pushing. History will remember you well.

Reprinted in full from the Committee for Skeptical Inquiry.

Some practitioners claim it is a cure-all, but the research suggests chiropractic therapy has mixed results – and can even be lethal, says Simon Singh.

On 29th July a number of magazines and websites are going to be publishing Simon Singh’s Guardian article on chiropractic from April 2008, with the part the BCA [British Chiropractic Association] sued him for removed.

They are reprinting it, following the lead of Wilson da Silva at COSMOS magazine, because they think the public should have access to the evidence and the arguments in it that were lost when the Guardian withdrew the article after the British Chiropractic Association sued for libel.

We want as many people as possible around the world to print it or put it live on the internet at the same time to make an interesting story and prove that threatening libel or bringing a libel case against a science writer won’t necessarily shut down the debate.

You might be surprised to know that the founder of chiropractic therapy, Daniel David Palmer, wrote that “99% of all diseases are caused by displaced vertebrae”. In the 1860s, Palmer began to develop his theory that the spine was involved in almost every illness because the spinal cord connects the brain to the rest of the body. Therefore any misalignment could cause a problem in distant parts of the body.

In fact, Palmer’s first chiropractic intervention supposedly cured a man who had been profoundly deaf for 17 years. His second treatment was equally strange, because he claimed that he treated a patient with heart trouble by correcting a displaced vertebra.

You might think that modern chiropractors restrict themselves to treating back problems, but in fact some still possess quite wacky ideas. The fundamentalists argue that they can cure anything, including helping treat children with colic, sleeping and feeding problems, frequent ear infections, asthma and prolonged crying – even though there is not a jot of evidence.

I can confidently label these assertions as utter nonsense because I have co-authored a book about alternative medicine with the world’s first professor of complementary medicine, Edzard Ernst. He learned chiropractic techniques himself and used them as a doctor. This is when he began to see the need for some critical evaluation. Among other projects, he examined the evidence from 70 trials exploring the benefits of chiropractic therapy in conditions unrelated to the back. He found no evidence to suggest that chiropractors could treat any such conditions.

But what about chiropractic in the context of treating back problems? Manipulating the spine can cure some problems, but results are mixed. To be fair, conventional approaches, such as physiotherapy, also struggle to treat back problems with any consistency. Nevertheless, conventional therapy is still preferable because of the serious dangers associated with chiropractic.

In 2001, a systematic review of five studies revealed that roughly half of all chiropractic patients experience temporary adverse effects, such as pain, numbness, stiffness, dizziness and headaches. These are relatively minor effects, but the frequency is very high, and this has to be weighed against the limited benefit offered by chiropractors.

More worryingly, the hallmark technique of the chiropractor, known as high-velocity, low-amplitude thrust, carries much more significant risks. This involves pushing joints beyond their natural range of motion by applying a short, sharp force. Although this is a safe procedure for most patients, others can suffer dislocations and fractures.

Worse still, manipulation of the neck can damage the vertebral arteries, which supply blood to the brain. So-called vertebral dissection can ultimately cut off the blood supply, which in turn can lead to a stroke and even death. Because there is usually a delay between the vertebral dissection and the blockage of blood to the brain, the link between chiropractic and strokes went unnoticed for many years. Recently, however, it has been possible to identify cases where spinal manipulation has certainly been the cause of vertebral dissection.

Laurie Mathiason was a 20-year-old Canadian waitress who visited a chiropractor 21 times between 1997 and 1998 to relieve her low-back pain. On her penultimate visit she complained of stiffness in her neck. That evening she began dropping plates at the restaurant, so she returned to the chiropractor. As the chiropractor manipulated her neck, Mathiason began to cry, her eyes started to roll, she foamed at the mouth and her body began to convulse. She was rushed to hospital, slipped into a coma and died three days later. At the inquest, the coroner declared: “Laurie died of a ruptured vertebral artery, which occurred in association with a chiropractic manipulation of the neck.”

This case is not unique. In Canada alone there have been several other women who have died after receiving chiropractic therapy, and Edzard Ernst has identified about 700 cases of serious complications among the medical literature. This should be a major concern for health officials, particularly as under-reporting will mean that the actual number of cases is much higher.

If spinal manipulation were a drug with such serious adverse effects and so little demonstrable benefit, then it would almost certainly have been taken off the market.

About the Author

Simon Singh is a science writer in London and the co-author, with Edzard Ernst, of Trick or Treatment? Alternative Medicine on Trial. This is an edited version of an article published in The Guardian for which Singh is being personally sued for libel by the British Chiropractic Association.

Did you know that taking aspirin immediately after getting home from the beach having forgotten your sunblock can prevent your sunburn from peeling?

Did you know that haloperidol (a powerful antipsychotic and sedative) can really help the nausea associated with various illnesses?

Did you know that several old-fashioned antidepressants are also excellent painkillers?

Traditional medicine, or for the granolas out there, “allopathic” medicine, prides itself on its use of evidence. The evidence in question has several levels, with the highest level of evidence, considered the most reliable, being meta-analysis of multiple randomised controlled trials (RCT). The next level is RCT itself. Then we get down to cohort studies and case-control studies. The final- and lowest- level of evidence is not evidence at all but “expert opinion,” often by consensus at a meeting.

Clinical trials start usually in animals, and once animal trials show some form of desireable effect and good safety, human trials can begin. Human trials have four phases: Phase I is absorption, elimination, tolerability, and safety. Phase II is dosing standards. Phase III are RCTs for efficacy.

Drugs are approved (or not) at Phase III, and can then be put on the market.

Phase IV trials are also known as post-marketing surveillance.

I was recently reading a commentary by Skepdude (of Skepfeeds) regarding the off-label use of antidepressants for behavioural control in autistic youngsters. He (she? it?-ed note- no offense, just don’t know if you are a boy or a girl) was quite upset at the idea that physicians, who talk a good talk about evidence, would merrily go about prescribing drugs for things other than those for which they underwent clinical trials.

Here’s the thing: Phase IV clinical trials often give more information that all of the previous steps combined.

Witness the statins, wherein a lowering of the patient’s cholesterol was used as a surrogate for improving cardiovascular outcomes. If one follows the developments with the statins since the start of the phase IV trials, along with comparisons with fibrates, niacin, and other lipid-lowering drugs, one finds that following the cholesterol as a marker using a statin does correlate with cardiovascular outcomes, but using other drugs, not so much. More recent postmarketing research points to an anti-inflammatory effect from statins, now postulated to be more important than the lipid-lowering effect.

The point here is that all research is based on hypothesis, and hypothesis testing in humans is imperfect at best. Surrogate endpoints are the usual, and are often only associated, not causative, phenomena.

Ranitidine is an antacid, but we use it in treatment of anaphylaxis. Why? Because it is an antihistamine which acts on the digestive tract. It has not been tested for anaphylaxis, nor is it likely to be. It is a reasonable use based on mechanism of action for a known safe drug.

Propranolol is a blood-pressure medication which is also used for migraine prevention, and treatment of benign essential tremor. Again, reasonable uses based on mechanism of action for a known safe drug.

Back to the children with autism. Autism is difficult. It is incredibly stressful to be a parent and caregiver to a child with whom communication is difficult. It can be hard to know the state of mind of children with autism.

The hypothesis: If anxiety causes increased behavioural problems in kids with autism, and antidepressants have been shown to be effective in children with anxiety disorders, antidepressants are likely to help manage behavioural problems in children with autism.

Many behavioural problems of people with autism are attributed to increasing stress levels, as they are seen with changes in the person’s body (ie. adolescence), with illness, or with changes in routine. This may and incorrect assumption.

Certainly, antidepressants can be helpful for children with anxiety disorders who are not autistic. They have risks, but overall, the risk-benefit ratio is quite favourable. The kids are able to express that they feel better, and school grades and participation in fun activities often improve.

Kids with autism are still kids. They may be misinterpreting sensory stimuli. They may have difficulty expressing their needs. They are still people, and one way or another, they do let their caregivers know when they are stressed or anxious. They act out for a variety of reasons.

IMHO, it is reasonable then to consider antidepressant use to reduce anxiety levels in kids with autism, with the aim (for the parents) of making their behaviour more manageable. We don’t know what they are experiencing, but we can reasonably suspect that things that make life easier for other kids may be helpful for them.

Do we know this to be true? Certainly not. But if we do not use drugs off-label, we can never discover if it might be.

It is important that we discuss with patients, caregivers, and parents when a drug is being used off-label. We also need to have the usual “these are the common side effects and these are the dangerous ones” discussion. Informed consent demands no less.

Sometimes a new population can have unforseen risks. This can be the case with any drug: trials are done on very defined subpopulations which may or may not represent the actual population who will eventually get the drug in question. Jupiter, for example, measures statin effect on CRP in patients with no inflammatory comorbidities. Not exactly target market, really.

Phase IV clinical trials, or post-marketing research, gather information on off-label use for potential further RCTs (can you say possible patent extension and an excuse for rebranding?), as well as information regarding heretofore unknown side effects (I won’t say Vioxx, but the phase IV trials made it impossible to keep a lid on that). You can call it “experimenting on kids,” but that’s an oversimplification.

For some populations, all medication use is off-label. Morphine is a great painkiller, but small doses also relieve the air-hungry feeling of people dying of lung disease. Remeron increases the appetite in patients with AIDS cachexia, and gives them a chance to put a little weight back on. There is no impetus to do research on such effects, so these uses, though well-known, remain off-label.

Off-label use is a part of the art of medicine. Evidence-based medicine is powerful, but should not turn us into protocol-driven automatons. Clinical judgement and an understanding of physiology, pharmacology, and common sense are part of who we are as physicians.

Deer are a major road hazard around here. One of the local body shops apparently sees the results of a number of car vs deer incidents. They have an ad that plays out a scenario complete  with *crash* bang* smash* noises.

It ends with: “And remember, venison goes best with a nice baked potato.”

For my local radio station.

Like your mother always said, if you play with your knob too much, it’ll fall off.