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Archive for the ‘ethics’ Category

The Cardiometabolic Risk Working Group: Another Coven Practising Drug-Induced Magical Thinking

Posted by Colin Rose on April 14, 2011

The latest issue of the Canadian Journal of Cardiology, published by the Canadian Cardiovascular Society (CCS), both of which are largely funded by the drug industry has shamelessly published a “Position Statement by the Cardiometabolic Risk Working Group” (see highlights below). We have previously blogged about the American “Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults” and the Canadian “Working Group on Hypercholesterolemia and Other Dyslipidemias”. Now that the ability of “cholesterol” to induce terror in doctors and patients has become a little worn and less profitable, drug dealers have invented a new disease, “cardiometabolic risk” with which to terrorize asymptomatic people into demanding even more drugs and doctors into prescribing them. Many of the members of the previous covens have migrated to the new one.

These medical covens take it upon themselves to dictate to the rest of the medical profession what drugs should be prescribed to prevent diseases of lifestyle in the otherwise “normal” population, so-called primary prevention. How are these covens assembled and what gives them the authority to establish norms for other doctors? This paper reveals in stunning clarity the answers to these questions. As we can see from the Acknowledgements and Disclosures sections, most of the authors of this Position Statement have many long-term financial relations with many drug dealers. Of the ten members of the executive committee of the Cardiometabolic Risk Working Group, nine have multiple financial relations with drug dealers and of the whole Working Group 19 out of 21 have similar relations. Clearly, drug dealers have distributed tens, if not hundreds, of millions of dollars to these doctors, justified under various guises, to facilitate a culture of drug dependency. Drug dealers choose members of  the Working Group, pay them to be “authors”, pay a medical writer to compose the Position Statement and get it published in a journal which would not exist without the financial support of the same drug dealers. Why am I not impressed and why would any other doctor follow the advice of this coven? But most family physicians and many cardiologists treat this sort of statement, endorsed by presumably unassailable organizations like the CCS, as revealed truth by a mysterious higher authority in possession of occult knowledge that must be accepted or suffer ostracism by one’s colleagues. Of course it doesn’t hurt that a 30-second drug prescription for numerical symptoms of junk food addiction is much easier that spending many unpaid hours reducing the addiction, the only real way to prevent its consequences.

Here is an example of the occult numerological incantations of the Working Group. Compare this with the occult number philosophy of Agrippa based on the pentacle below.

Optimize lipid levels. In patients with cardiometabolic risk with a moderate or high Framingham Risk Score, treatment should be initiated with a statin to reduce low-density lipoprotein cholesterol (LDL-C) by at least 50% and to 2.0 mmol/L. Apo B levels are a better measurement of lipid-related risk in these patients, and the target level for treatment is 0.8 g/L in high-risk and moderate-risk individuals. There is a large residual risk for patients at high risk for CVD, despite LDL-C reduction with high-dose statins. Many patients with cardio- metabolic risk may also have an acquired combined hyperlipidemia, associated with increased triglycerides (TGs), a modest increase in LDL-C, and low high-density lipoprotein cholesterol (HDL-C). LDL particle numbers are increased, as reflected by the increased levels of apo B100. Beyond LDL-C lowering, strategies that might reduce the residual risk include reducing the total cholesterol (TC) to HDL-C ratio, high-sensitivity C-reactive protein, and TG, although there are no clinical trial data to date to support such strategies. In the patient with diabetes, glycemic control optimization and health behaviour modification should be attempted prior to the addition of another agent, such as a fibrate. In the Action to Control Cardiovascular Risk in Diabetes trial the addition of fenofibrate to simvastatin in patients with type 2 diabetes failed to show any reduction of CV events, although there may have been benefit in the subset of individuals with high TG/low HDL-C.

The deliberations of the Cardiometabolic Risk Working Group have much in common with pagan covens with occult rituals and symbols like the pentacle which when worn will drive out evil numbers such as “cholesterol”. Expensive statins for “cholesterol” and ARBs for high blood pressure are the new pentacle. The significance of the pentacle, as described by Heinrich Cornelius Agrippa in his Three Books of Occult Philosophy, makes as much sense as the Position Statement of the Working Group.  “A Pentangle also, as with the vertue of the number five hath a very great command over evil spirits, so by its lineature, by which it hath within five obtuse angles, and without five acutes, five double triangles by which it is surrounded. The interior pentangle containes in it great mysteries, which also is so to be enquired after, and understood; of the other figures, viz. triangle, quadrangle, sexangle, septangle, octangle, and the rest, of which many, as they are made of many and divers intersections…

When one manages to decode the occult numerology of the Statement one can see that the goal of the Working Group is to have every overweight junk-food addict in Canada, the typical “high-risk” patient, on some combination of pills for “high” blood pressure and “high” cholesterol. The “targets” for blood pressure and cholesterol are set low and arbitrarily to guarantee that most of the Canadian population would be on some drug. The drug dealers can be assured that doctors will prescribe the newest, most expensive patented drug rather than a cheaper generic alternative because they have already spend hundreds of millions of dollars in advertising the advantages of the patented drugs. This is called clever marketing but it has nothing to do with the health of the population. The consequences of self-destructive lifestyles will not be lessened by any number of drugs which will have the unintended consequence of worsening those lifestyles when people are convinced they can continue those lifestyles with impunity under the “protection” of drugs that make the numerical symptoms of those lifestyles look better. While the Position Statement gives lip service to the necessity of “health behaviour interventions” it insists also on the necessity of “vascular protective measures”, code for expensive drug prescription.

Canada is currently in the middle of a federal election campaign in which the most important issue for voters is “health care”. All parties are promising to increase “health care” spending by 6% a year indefinitely. With an inflation rate of only 2%, a PhD in mathematics is not required to see that in the not too distant future “health care” will consume the entire tax revenue of federal and provincial governments. The increase in “health care” spending is driven by the sort of activities represented by this Position Statement but no candidate dares to mention drug-induced magical thinking in their campaign speeches or platforms. The electorate loves its addictions and demands infinite “health care” to provide the mirage of protection from the consequences of those addictions and any candidate who points out the obvious absurdity of this belief is dead electoral meat.

How can we exorcise the myths promoted by these venal covens? There at two excellent drug review publications written by authors with absolutely no connection to drug dealers that should be required reading for every doctor: Prescrire, a French publication available in English, which is expensive but is the gold standard in independent thinking about drugs and the Drug and Therapeutics Bulletin of Navarre, a Spanish publication, available in English, which is free but covers a limited range of drugs. A recent excellent article from the latter, “Magical numbers in pharmacological prevention of cardiovascular disease and fractures: a critical appraisal“, analyzed in detail the occult numerology of the drug-funded covens’ pontifications on “primary prevention” and concludes,

A considerable part of the pharmacological recommendations to prevent cardiovascular events and fractures in healthy persons lack any solid justification. No clear efficacy, nor the size of the effect of these agents or a clear balance between risk and benefit make the intervention clinically and socially worthwhile. The “therapeutic targets” and the “operative definition” of disease or risk factor that include instruments or tables to calculate risk are new gateways to unnecessary medicalization. In the context of modern medicine, immersed in conflicts of interest, the physician is obliged to interpret the results of trials and the recommendations from guidelines and consensus at a critical distance, and to place emphasis on the development of clinical prudence as a desired skill.

In other words a truly professional doctor will ignore any advice from the drug dealer funded covens and use his or her own best judgement.

Lawrence A. Leiter, David H. Fitchett, Richard E. Gilbert, Milan Gupta, G. B. John Mancini, Philip A. McFarlane, Robert Ross, Hwee Teoh, Subodh Verma,  Sonia Anand, Kathryn Camelon, Chi-Ming Chow, Jafna L. Cox, Jean-Pierre Després, Jacques Genest, Stewart B. Harris, David C. W. Lau, Richard Lewanczuk, Peter P. Liu, Eva M. Lonn, MD, Ruth McPherson, Paul Poirier, Shafiq Qaadri, Rémi Rabasa-Lhoret, Simon W. Rabkin, Arya M. Sharma, Andrew W. Steele, James A. Stone, Jean-Claude Tardif, Sheldon Tobe, Ehud Ur

Posted in Canada, cardiology, cholesterol, cme, continuing medical education, diabetes, diabetes, Type 2, diet, drug marketing, drugs, election, ethics, health care, junk food, medical terrorism, obesity, professionalism, statins | 5 Comments »

Zivadinov proves Zamboni’s “CCSVI” does not exist

Posted by Colin Rose on January 15, 2011

Almost a year ago at a much heralded news conference Dr. Robert Zivadinov, a Buffalo-based early disciple of Paolo Zamboni, claimed to show some difference in the presence of venous flow patterns in the heads of MS patients compared to controls using special Doppler ultrasound techniques that had never been validated. He never published the details of this study and has apparently abandoned ultrasound in favour of MRI venography which gives an overall picture of venous flow patterns in all head and neck veins. Zivadinov has now published a well-blinded study using MRV in MS patients and healthy controls which shows no difference in venous flow patterns in the two groups. There are almost blocked internal jugular veins in some MS patients and some normal people. But such blockages are insignificant because of the extensive collateral veins and the emissary veins connecting intra- and extra-cerebral venous circulations, as I described in my original response the Zamboni hypothesis.

I quote from the Discussion section of the paper: “We did not find significant differences between MS patients and HC subjects or between RR and SP MS patients in regard to collateral circulation. This is indeed an important finding because it does not support collateral circulation as a compensatory mechanism of CCSVI.” Such “abnormal” collateral flow was a crucial part of the Zamboni hypothesis.

As I said in response to Zivadinov’s first “study” of “CCSVI”, real scientific discussion is not conducted by news conference. Those who thought otherwise should now be convinced that only publications in respected journals following the time-honoured format for scientific communication are worthy of consideration.

With this paper and at least three others showing the same result, we now have overwhelming evidence that “CCSVI” is a fantasy, concocted by Paolo Zamboni, a varicose vein surgeon who convinced himself that he could “liberate” his wife from MS by dilating her neck veins. To date, at least $one billion has been wasted on this myth by desperate patients, granting agencies and governments. No further attention or money should be directed at this farce. All MS patients should refrain from paying for “liberation”, a very profitable scam based on the “CCSVI” myth.

Posted in ccsvi, ethics, liberation, multiple sclerosis, professionalism, randomized trial, Zamboni, Zivadinov | 12 Comments »

“Low risk” nurse with normal cholesterol but self-destructive lifestyle ends up with heart transplant after CCTA

Posted by Colin Rose on December 20, 2010

Here in a nutshell is a demonstration of the problem with expecting technology to substitute for good clinical medicine and save us from our self-destructive addictions. If anyone is puzzled about the dichotomy between the exorbitant cost of the US medical system and its relative lack of effect on any measure of health here is the reason.

Below is a story from followed by the actual paper in the Archives of Internal Medicine minus the references.

In the absence of any symptoms attributable to coronary artery disease there was no reason to do any more testing but the temptation to use high tech tools without good indication is irresistible to many doctors. CCTA is the latest expensive test to detect coronary atherosclerosis. Patients think that they will never have a heart attack and live longer if the disease is detected and some surgical procedure, like an angioplasty or bypass is done and doctors making $millions from doing them are not about to discourage them and point out the total lack of evidence for any significant benefit from angiography or the surgical procedures in patients with chronic coronary disease.

The authors have labelled this patient “low risk” because her “cholesterol” was normal but clearly she was at high risk based on her obesity and hypertension, both indices generally of  junk food addiction, in spite of her being a nurse.  When she started new exercises she probably got muscle pain from weight lifting. With an obvious self-destructive lifestyle, she should not have been “simply reassured” as recommended by the editors. But instead of encouraging her to make meaningful lifestyle change her doctors ordered tests with no clinical indication.

Framingham scores, lipid profiles and CRPs can be very deceptive because they do not assess LDL modification in the arterial wall, essential to the formation of atherosclerotic plaque. In spite of having “normal” numbers for all the usual “risk factors” she had advanced atherosclerosis in her coronary arteries. Apparently no dietary history was taken and no attempt was made to encourage her to change her lifestyle, an example of gross diagnostic and therapeutic incompetence, all too common in an era of absolute faith in the power of technology to protect us from our self-destructive addictions. Doctors abdicate professionalism by ordering tests instead of dealing with the real problems, like junk food addiction, which take much time for which they are not compensated and risk alienating patients who demand a high-tech fix or reassurance so that they can continue their risky behaviour.


Case study shows how “just-in-case” CCTA in a low-risk patient may spectacularly backfire

DECEMBER 17, 2010 | Reed Miller

San Francisco, CA – Coronary computed tomographic angiography (CCTA) in patients with a low pretest risk of coronary disease wastes resources and can even lead to horrendous outcomes, a case study published December 13, 2010 in the Archives of Internal Medicine shows. The report tells the story of a 52-year-old white female who initially presented with chest pain and had a CCTA; this was followed by an unfortunate chain of events in which she suffered an aortic dissection during cardiac catheterization and that culminated in her having a heart transplant.

Part of its ongoing “Less is More” series begun last April, the latest case, reviewed by Dr Matthew Becker (St Vincent’s Heart and Vascular Institute, Erie, PA), Dr John Galla (Providence Hospital, Mobile, AL), and Dr Steven Nissen (Cleveland Clinic, OH), describes how the well-meaning attempt to reassure a patient with a low risk of coronary disease backfired spectacularly.

“Perhaps the most important point to be learned from the case described by Becker and colleagues is that there are safer ways to reassure patients,” say journal editors Drs Rita RedbergMitchell Katz, and Deborah Grady (University of California, San Francisco) in an accompanying editorial. “Patients value our advice. Talking with our patients should be our first choice for reassurance.” They add that “applying the ‘less-is-more’ principles prospectively could have avoided this unfortunate case.”

From diagnostic uncertainty to disaster
The 52-year-old nurse had hypertension and mild obesity and had recently begun an exercise and diet regimen to control her weight and blood pressure. She presented to her primary physician with chest pain, but no other symptoms: she had a normal ECG with a normal lipid profile and normal C-reactive-protein level. Her doctor attributed the chest pain to a musculoskeletal cause but performed a CCTA to reassure her that she was not at risk for a coronary event.

The CCTA showed discrete, noncalcified, nonobstructive plaque in the mid and distal segments of the left circumflex and dominant right coronary arteries and diffuse, complex calcification in the proximal left anterior descending (LAD) coronary artery. Because that calcification was difficult to quantify, the physician recommended that she undergo cardiac catheterization to get a clearer look at the LAD.

This exam, performed at the local community hospital, revealed only a mild irregularity in the LAD, but during the procedure, the patient complained of chest pressure, which prompted an aortogram that revealed an aortic root dissection that was compromising the left main coronary artery.

So the patient underwent urgent coronary artery bypass graft (CABG) surgery and stayed in the hospital for two weeks with a residual left ventricular ejection fraction of 35%. The bypass graft soon failed and was treated with multiple drug-eluting stents, but despite her compliance with dual antiplatelet medical therapy, a stent in the vein graft supplying the circumflex artery developed a thrombosis, causing an ST-segment-elevation MI complicated by cardiogenic shock. The thrombosis was successfully treated, but the patient remained in refractory cardiogenic shock and ultimately underwent orthotopic heart transplantation.

Unnecessary testing happening every day
“With few cardiac risk factors and an atypical chest pain presentation, this patient had a low pretest probability for coronary artery disease and should have been reassured and not undergone any further risk stratification,” say the authors. “Lacking randomized data suggesting improvement in clinical outcomes and with clear risks, including contrast load, radiation exposure, and suboptimal diagnostic specificity, CCTA should have a very limited role in the evaluation of patients who present with chest pain.”

They acknowledge the risk of complications associated with cardiac catheterization is low, but catastrophic events are always a possibility. They believe the physicians in this case overestimated the stenosis in this patient’s coronaries because they did not fully appreciate the CCTA’s potential for false-positive findings. Complete visualization of all segments of the coronary tree with CCTA is often hindered by cardiac motion, which can lead to the appearance of “blooming artifacts” of coronary calcification that may cause the observer to overestimate the extent of stenosis.

Becker et al point out that previous studies comparing CCTA with conventional coronary angiography in diverse patient populations show CCTA’s sensitivity is between 79% and 100% for the detection of obstructive coronary disease, but its specificity is only 64% to 85%, corresponding to “an unacceptably high false-positive rate” of up to 81% in some populations.

As reported by heartwire, the recently released professional guidelines on Appropriate Use Criteria for Cardiac Computed Tomography list CCTA as “inappropriate” for detection of CAD patients with a low risk of heart disease, ability to exercise, nonacute symptoms that may be an “ischemic equivalent,” and an interpretable ECG.

Patient could have been simply reassured
“If a test is not sufficiently accurate to change clinical management in a particular setting, it should not be done,” but according to Redberg et al, often these tests are done anyway—sometimes even before the patient sees a physician—because nobody has assessed the patient’s pretest probability of the disease or properly considered how the test result will change the clinical management of the patient.

“There are cases where [the test presents] more risks than benefits, and you really need to consider the risks and benefits and not [assume that] just because you can do the test, you should do the test. And this case highlights that,” Redberg told heartwire.

Cases like this where an inappropriate test leads to many complications and near catastrophe are rare, “but to have a CT or another test that was just done for reassurance, when you could have just told the patient ‘You’re fine,’—I think that’s done every day lots of times.

“You don’t know which [tests] are going to lead to that kind of problem, but you do know which of those is not going to give you any benefit, so if there is no benefit, it’s better not to be taking any risk, even a small one.”


Left Main Trunk Coronary Artery Dissection as a Consequence of Inaccurate Coronary Computed Tomographic Angiography

Matthew C. Becker, MD; John M. Galla, MD; Steven E. Nissen, MD

Arch Intern Med. Published online December 13, 2010. doi:10.1001/archinternmed.2010.464


A 52-year-old woman presented to a community hospital with atypical chest pain. Her low-density lipoprotein cholesterol and high-sensitivity C-reactive protein levels were not elevated. She underwent cardiac computed tomography angiography, which showed both calcified and noncalcified coronary plaques in several locations. Her physicians subsequently performed coronary angiography, which was complicated by dissection of the left main coronary artery, requiring emergency coronary artery bypass graft surgery. Her subsequent clinical course was complicated, but eventually she required orthotropic heart transplantation for refractory heart failure. This case illustrates the hazards of the inappropriate use of cardiac computed tomography angiography in low-risk patients and emphasizes the need for restraint in applying this new technology to the evaluation of patients with atypical chest pain.


A 52-year-old white female nurse with a medical history that was notable for hypertension and mild obesity presented to her local primary care physician with the recent onset of chest pain. Further investigation revealed that in an effort to lose weight and assist in the control of her hypertension, she had adopted a new diet and exercise program several weeks earlier. At her initial presentation, she described 48 hours of nonexertional, sharp chest pain that was aggravated by elevation of her right arm and deep inspiration. She denied associated symptoms of shortness of breath, nausea, vomiting, or diaphoresis, and her office electrocardiogram showed no abnormalities.Other than mild hypertension (blood pressure, 142/85 mm Hg), the results of her physical examination were unremarkable except that elevation of her right arm and palpation of the right chest wall reproduced the symptoms with which she presented. With a normal lipid profile and an ultrasensitive C-reactive protein level, she was diagnosed as having atypical chest pain most likely of musculoskeletal origin. Hydrochlorothiazide was used to treat her hypertension, and cardiac computed tomography angiography (CCTA) was performed to exclude the possibility of coronary artery stenosis and to reassure her. Interpretation of the CCTA findings suggested that both the left circumflex and the dominant right coronary arteries had discrete areas of mild, noncalcified, nonobstructive plaque in their mid and distal segments. The large-caliber left anterior descending coronary artery (LAD) was reported to have diffuse and complex calcification of the proximal segment, which made accurate quantification of the luminal stenosis challenging.

Subsequently, the patient’s physician recommended cardiac catheterization to enable more precise assessment of the LAD luminal stenosis. Selective coronary angiography was performed at the local community hospital and revealed only a mild luminal irregularity of the LAD. Shortly after the second injection of contrast, the patient complained of intense chest pressure and was noted to be hypotensive and tachycardic (blood pressure, 78/45 mm Hg; heart rate, 110/min). Mild “staining” of contrast was noted in the left coronary cusp of the aorta, and an ascending aortogram revealed a dissection of the aortic root extending into, and resulting in compromise of, the left main coronary artery. An intra-aortic balloon pump was placed, and the patient underwent urgent coronary arterybypass with saphenous vein grafting of both the LAD and the left circumflex coronary artery.

Following a prolonged, 14-day hospital course and a residual left ventricular ejection fraction of 35%, the patient was discharged home with intensive cardiac rehabilitation. Unfortunately, within 6 months of the bypass, she presented again with escalating chest pain and was noted have premature graft failure that was treated with percutaneous coronary intervention with multiple drug-eluting coronary stents. Despite her compliance with dual antiplatelet medical therapy (aspirin and clopidogrel daily), she presented 8 weeks later with an ST-segment elevation myocardial infarction complicated by cardiogenic shock. Emergent catheterization revealed thrombosis of the stent in the vein graft supplying the circumflex artery that was successfully treated with a catheter-based intervention. However, the patient remained in refractory cardiogenic shock and ultimately required urgent orthotopic heart transplantation.


Emergency department visits for chest pain syndromes represent a large and growing health care burden. Because patients with chest pain require urgent triage and timely management, there are great incentives for developing a new generation of novel, complementary diagnostic strategies. A recent addition to the diagnostic armamentarium, multidetector CCTA, can noninvasively generate reconstructed images of the coronary circulation. However, the brisk expansion and rapid adoption of CCTA over the past decade has outpaced supportive clinical data and has led to the referral of a much larger, and often lower-risk, segment of the population for coronary artery catheterization. We believe that in this case the unwarranted use of advanced diagnostic imaging (false-positive CCTA findings) directly contributed to unnecessary cardiac catheterization that resulted in a tragic complication and significant morbidity.Advanced diagnostic imaging technologies or the latest biomarker cannot, and should not, replace a thorough history and physical examination with subsequent decision making guided by the bestevidence-based practice. The need for testing in patients with chest pain is based on the clinician’s estimation of the pretest probability of coronary disease. In a patient with a low pretest probability (<10%) of having significant coronary disease, the preferred course is to reassure the individual and to focus the treatment plan on primary or secondary prevention strategies. Additional diagnostic testing rarely garners useful information and exposes the patient to unnecessary risk—both from the diagnostic test itself and from subsequent invasive testing because of false-positive results. While the risk of complications associated with cardiac catheterization is low, catastrophic events can occur. As opposed to CCTA, in appropriately selected patients coronary angiography allows the presence, location, and, most importantly, the functional significance (eg, fractional flow reserve, intravascular ultrasonography) of lesions to be determined. Because there is often discordance between luminal stenosis and the physiologic significance of lesions, functional testing has assumed critical importance in the assessment of patients with a moderate pretest probability (10%-90%) of coronary disease.

Therefore, given the possible adverse consequences of the overuse of diagnostic imaging in a broad and uncensored population of patients with chest pain, recent joint professional guidelines emphasize that ” . . . an appropriate imaging study is one in which the expected incremental information, combined with clinical judgment, exceeds the expected negative consequences by a sufficiently wide margin for a specific indication that the procedure is generally considered acceptable care and a reasonable approach for the indication. . . . “Furthermore, because of differences in body habitus, coronary physiology, exercise physiology, symptom presentation, and disease prevalence, the diagnostic accuracy of stress testing may be affected by the female sex. In addition to having a markedly different ST-segment response to exercise from a young age, data suggest that ST-segment depression tends to be less sensitive and specific for coronary artery disease in women. With normal electrocardiographic findings, negative cardiac biomarkers, and a classically atypical presentation, our patient had an age-specific risk level that was below average. She had a low pretest probability of coronary disease (<10% risk of myocardial infarction or death per 10 year interval), making further testing inappropriate and the chance of false-positive study results unacceptably high. However, in an era of rapid advancement in diagnostic imaging strategies, the savvy clinician must not forget the basic tenets of data-driven medicine, patient selection, and risk tolerance and ultimately realize when less may be more. Such is precisely the case with CCTA.

Because CCTA is rapid and noninvasive and has wide availability, it has increasingly been used to detect coronary atherosclerosis in a broad array of patient populations. However, the lack of randomized data suggesting clinical benefit, as well as technical and anatomical limitations, restricts its application in many patients. Studies comparing CCTA with conventional coronary angiography in diverse patient populations suggest that CCTA is highly sensitive (79%-100%) for the detection of obstructive coronary disease, with a positive predictive value ranging from 86% to 91%. However, these same studies report suboptimal specificity (64%-85%) and negative predictive values of 83% to 90% that correspond to an unacceptably high false-positive rate of up to 81% in selected subpopulations. Further limiting the diagnostic accuracy of CCTA is the fact that complete visualization of all segments of the coronary tree is hindered by cardiac motion (heart rate, >70/min), smaller vessel caliber (<2 mm), and tortuousity that may result in portions of a vessel moving in and out of an imaging plane. Furthermore, given its high attenuation coefficient, the presence of coronary calcification commonly produces a “blooming artifact” that makes accurate assessment of adjacent arterial luminal challenging and may result in overestimation of the degree of luminal stenosis, which is likely the case in the patient described herein. Therefore, CCTA often overestimates the presence and severity of coronary atherosclerosis to a degree that is dependent on the study population, the equipment used, and the experience of the interpreting physician, which may lead to unnecessary, higher-risk, and costly invasive procedures.

Nevertheless, the use of CCTA has increased dramatically over the past decade, with some estimates suggesting up to 26% per year. In an era in which comparative efficacy of therapies has assumed critical importance, the unchecked growth of CCTA seems not only unfounded but also irresponsible and unsustainable. Aside from its cost implications, CCTA also exposes the patient to substantial amounts of ionizing radiation. It is estimated that the collective dose received from medical radiation increased by more than 700% between 1980 and 2006, with increases in computed tomography accounting for more than 50%. Furthermore, 64-slice CCTA (without tube current modulation) exposes the patient to an average effective dose of 15 mSv of radiation compared with only 7 mSv for diagnostic coronary angiography. With recent data suggesting that 1.5% to 2.0% of all reported cancers in the United States may be linked to ionizing radiation from computed tomography, there is reason for pause.

In conclusion, our patient suffered a rare but devastating complication from an cardiac catheterization that was the direct result of unnecessary CCTA and false-positive findings. With few cardiac risk factors and an atypical chest pain presentation, this patient had a low pretest probability for coronary artery disease and should have been reassured and not undergone any further risk stratification. Lacking randomized data suggesting improvement in clinical outcomes and with clear risks including contrast load, radiation exposure, and suboptimal diagnostic specificity, CCTA should have a very limited role in the evaluation of patients who present with chest pain.

Posted in atherosclerosis, cardiology, CCTA, cholesterol, coronary artery disease, coronary computed tomographic angiography, diet, ethics, heart transplant, junk food, lifestyle, obesity, professionalism, surgery, technology, waist circumference | 1 Comment »

Zamboni is incapable of doing or unwilling to do legitimate research into his own “CCSVI” and “liberation” fantasy

Posted by Colin Rose on December 19, 2010

Dr. Alain Beaudet is President of the Canadian Institutes of Health Research and has been trying to navigate between the incessant demands of politicians pressured by desperate MS patients to authorize “liberation” on demand while doing “trials” and the scientific evidence to date showing that “CCSVI” doesn’t even exist.

Apart from exposing more of this political pressure in the Committee hearings, the testimony of  Dr. Beaudet revealed the true nature of Zamboni’s mentality. It is very interesting that Zamboni has effectively dissociated himself from large controlled studies of “CCSVI” diagnosis in Italy by demanding that only he can interpret the images and that he hasn’t received ethical approval or funding for a controlled trial of “liberation”. If Zamboni can’t get ethical approval for “liberation” now, why did the University of Ferrara approve the ethics of Zamboni’s initial testing of “liberation”, even on his wife?  It seems that Zamboni is incapable of writing a successful grant application and that even the Italians are getting a little suspicious of his hypothesis and techniques. I doubt that Zamboni himself will ever do a controlled trial of “liberation”. Why should he? He has gained transient fame and probably fortune by generating world wide hysteria with the tantalizing mirage of an instantaneous surgical cure for MS supported only by YouTube videos of anecdotal miracles. He was very fortunate that his only clinical publication on his hypothesis, an unscientific  concoction of hallucinations, was published, albeit in an obscure journal. He has indirectly compelled real scientists, like Dr. Beaudet and many other legitimate researchers to divert their time and money into dealing with the scientific absurdity of “CCSVI”. So why should Zamboni risk proving himself to be a fraud? When he is proven to be so he will be liable for compensation for the hundreds of millions of dollars wasted on his scam by patients, doctors and granting organizations. Zamboni will eventually  join the ranks of the great medical con men of history in the company of the likes of Dr. Walter Freeman, the ice pick lobotomist.


Subcommittee on Neurological Disease – Evidence from Alain Beaudet – December 7, 2010

Dr. Alain Beaudet:

I think this is an important point. First of all, Dr. Zamboni was originally part of the very large association studies that involved I think around 20 sites in Italy, and he withdrew from the study. The scientific director of the Italian MS Society told us that he withdrew because he asked that all the images from all the sites be vetted by his own laboratory, which obviously the committee didn’t feel was appropriate. Dr. Zamboni, however, is also applying for a therapeutic trial, a trial this time to investigate the treatment. As far as I know, the study doesn’t have all the funds necessary to be fully carried out. He did receive a bit of money from the province where his lab is, but I don’t know about the status of the ethical approval of this study. He was supposed to receive ethical approval at the beginning of December. I don’t know whether he did receive it.

Do you know? We don’t know.

The last time we spoke to Dr. Battaglia, the scientific director of the Italian MS Society, Dr. Zamboni still hadn’t received the ethical approval for his studies. It was pending, and we were told the beginning of December. What we know, however, is that right now the funding from the province that he’s receiving for that study is not sufficient to carry out the type of study that would be necessary to prove or disprove the efficacy of the treatment.

Posted in alain beaudet, ccsvi, ethics, junk science, liberation, multiple sclerosis, professionalism, randomized trial, Zamboni | Tagged: | 7 Comments »

University of Maryland solicits donations from desperate MS patients to support Zamboni’s “CCSVI” and “liberation” scam

Posted by Colin Rose on December 5, 2010

A Toilet Money Award to the University of Maryland

The temptation was too great. American and Canadian professional fund raisers and catheter-wielding interventional radiologists around the world have been drooling over the ability of foreign clinics in places like India, Poland, Mexicao, Costa Rica, Bulgaria and Egypt to rake in hundreds of thousands of dollars per week flogging the Zamboni “CCSVI” and “liberation” scam for “treating” MS patients. So fund raisers at the University of Maryland, following the example of those at the University of British Columbia, convinced or, more likely, were convinced by Dr. Ziv Haskal, an interventional radiologist who stands to make many millions of dollars doing “liberation”, to ride Zamboni’s “CCSVI” hysteria to fatten the endowment of the University while giving legitimacy to the scam. UBC is using the scam to raise funds for a new MRI machine that will probably be used for other purposes than trying to diagnose “CCSVI”. But U of M is using the bait of implying that Haskal will actually be doing “liberation”. If so, this will be the first university-sanctioned use of “liberation” other than Zamboni’s University of Ferrara. Neither university is in the top 100 of the world’s universities. Ferrara isn’t even in the top 500.

Perhaps we should not be too surprised. After all, only 40% of the US population accepts the theory of evolution as the explanation for the variety of life on the planet, the most important scientific concept in history; presumably, the majority, 60%, believe in some form of creation or “intelligent design”. If one can believe the latter, one should have no reservations about accepting that internal jugular veins can cause damage to the brain without raising intracranial pressure and even if it did raise intracranial pressure could cause damage selectively to the  slowly-metabolizing, myelin-producing cell of the white matter BEFORE damaging the much more sensitive rapidly-metabolizing cells of the grey matter of the brain. Interventional radiology, while requiring a certain degree of manual dexterity, certainly doesn’t require more than a superficial knowledge of physiology and metabolism and doesn’t preclude a belief in creation.

“CCSVI” is junk science and its “treatment” by “liberation”, dilating presumably blocked neck veins to “cure” MS, is one of the greatest surgical hoaxes in medical history. Performing any medical procedure with no scientific evidence of benefit but with potential risk is grossly unprofessional and contrary to the Hippocratic Oath.

“CCSVI” is the crack cocaine of surgical scams. It has been estimated that at least three BILLION dollars will be spent next year by MS patients pursuing the Zamboni’s mirage, dwarfing other recent surgical scams like “bariatric” surgery.


Posted in ccsvi, ethics, liberation, multiple sclerosis, professionalism, surgery, Zamboni | Tagged: | 35 Comments »

MUHC Endorses Pfizer’s Products

Posted by Colin Rose on April 9, 2010

This is a back lit box on the first floor of the Montreal General Hospital, the “mountain campus” of the MUHC. This is how the McGill University Health Centre is caring for your health. Obviously Pfizer expects that the “professionels de la santé” at the MUHC would highly recommend Pfizer’s products and obviously the MUHC administration expects that they would. How many $millions is Pfizer paying the MUHC for this priceless endorsement of its products which directly benefit those “professionels de la santé?” What would happen to any of the “professionels de la santé” who gave “précieux conseils” that Lipitor was useless in the vast majority of people for whom it is prescribed as described in our blog page on statins? Do true professionals associate with organizations that take money from the profits of companies selling the products they recommend? In Quebec our taxes are about to increase dramatically to pay for a “health contribution” a lot of which will go to paying for expensive, mostly useless drugs like Lipitor. That’s good business if you are running a hospital but not if you are really caring for health. If you would like to protest this highly unprofessional behaviour  phone Rebecca Burns (MUHC media) at (514) 934-1934 Ext. 71443 or  email Dr. Arthur Porter, CEO of the MUHC.


Update, April 16, 2010

It seems the MUHC administration felt some heat. One week after posting this blog, the Pfizer ad had been removed. They reacted so fast that they had no replacement and had to leave only an embarrassing blank light box.

Thanks to all those who took the time to register their opinion of this example of grossly unprofessional behaviour.

One hopes that in the future McGill and the MUHC will think twice about prostituting themselves to the drug dealers.


Posted in cholesterol, drug marketing, drugs, ethics, professionalism, statins | Tagged: , , , | 2 Comments »

Getting more for less in health care (National Post, 06 Oct 2009)

Posted by Colin Rose on October 6, 2009

Esmail assumes that producing “health care” is analogous to producing widgets; the law of supply and demand applies to both. Not so. Demand for “health care”, really disease care, is infinite. Deluded inhabitants of developed societies believe that any money spent on doctors and hospitals will prolong their lives. But, there is no correlation between per capita expenditure on doctors and hospitals and any measure of health. The cost of disease care will continue to rise as long as demand is fueled by absurd expectations of a necessarily finite system, driven by the latest, doctor-self-aggrandizing story on some “life-saving” technology. The cost of disease care can only be contained if doctors are put on salaries and practice according to the Hippocratic Oath and the best evidence for effectiveness and safety of treatments. Only then will doctors have an incentive to do less. Unlike the present perverted fee-for-service system, there would be no incentive to administer profitable but superficially attractive and potentially lethal procedures or drugs for non-life threatening disease. Also, unlike the present system, there would be a primordial incentive, less work for the same money, to prevent the diseases of lifestyle that account for most of the cost of the disease care system and most of the premature deaths in our society.

Getting more for less in health care
National Post
06 Oct 2009

Thanks to poor fiscal management, the government of Ontario finds itself in a difficult fiscal situation. It must find a way to eliminate the significant deficits that are expected until at least 2015/16. Given that tax increases are certain to damage…read more…

Posted in ethics, lifestyle, professionalism | Tagged: , | Leave a Comment »


Posted by Colin Rose on September 13, 2009

Great article, Joe. We appreciate there are those that are confused. But there are also large numbers who know what is healthy to eat, but easily blind themselves to reality; they are junk food addicts. That “food”  that the cruise passengers are piling on their plates is specifically formulated to appeal to addictions to sugar, salt and the mouth feel of fat. Unfortunately, treating junk food addiction is just as hard as treating addictions to tobacco, cocaine or heroin. Doctors are not trained to and not paid to treat addictions. They are paid to “treat” the symptoms of junk food addiction, like hypertension, Type 2 diabetes and “cholesterol” and do futile gastric bypasses. “Treatment” of these symptoms deceives the addict into believing that s/he can avoid the consequences of the addiction and makes the addiction worse. Americans are inundated with direct-to-consumer (DTC) drug advertising, claimed to be a First Amendment right by corporations with $billion ad budgets, promoting this deception and doctors are paid to prescribe those drugs.  Canada is catching up fast. Obesity rates are rising and there is pressure from the media to allow DTC in Canada, presumably guaranteed by the Bill of Rights.

The solution? Each individual has to balance the transient pleasure of addiction against the long term disastrous consequences of the addiction. In our society this is the hardest thing most people have to do 24/7/52 for a lifetime and doctors must avoid aggravating addictive behaviour.

The Gazette
13 Sep 2009

Occasionally, I like to spy on people. Only for the sake of science, of course. And what better opportunity to do that than on a cruise ship? I like cruising. Besides outstanding entertainment, impeccable service, interesting ports, activities galore…read more…


Posted in addiction, diet, drugs, ethics, food, junk food, lifestyle, moral hazard, obesity, professionalism, statins | Tagged: | 2 Comments »


Posted by Colin Rose on September 12, 2009

No professional should take any benefits from any industry for which s/he makes recommendations to clients. Medical licensing bodies should de-license any doctor who does so.

The Gazette
12 Sep 2009

Adam Hofmann is used to getting teased about his lunch. It’s not because his mom gave him something uncool to eat. It’s because he paid for it. Hofmann is a doctor and fifth-year medical resident at McGill University. Lunchtime is often when residents…read more…

Posted in drug marketing, drugs, ethics, professionalism | Leave a Comment »


Posted by Colin Rose on August 16, 2009

Those chiropractors certainly look like willfully ignorant charlatans but some medical doctors are also guilty of the same unwillingness to perform or abide by the results of randomized trials. For example angioplasty of coronary arteries for “treating” stable angina (chest pain caused by inadequate blood flow to the heart during exercise) has been shown in multiple randomized trials to cause more heart attacks than treating with drugs only. But these procedures are still done at great expense to our medical system. As an example of unwillingness to perform randomized trials, consider “bariatric” surgery. Even our Minister of Health and Social Services, Yves Bolduc, a neurosurgeon, believes various forms of gastric surgery is a cure for obesity but there has never been a single randomized, sham-operated controlled study showing surgery is any better than treatment for junk-food addiction alone without the operation. Bariatric surgeons refuse to do a randomized trial and are not compelled to. And yet $billions are being spent on these operations. Like the chiropractors, if you ask these doctors why they are ignoring or not doing randomized trials they will answer that they know what is right for the patient, no need to do trials.

The Gazette
16 Aug 2009

“Awhite crystalline substance is known to be either glucose or fructose. How would you identify it?” That’s been a standard question asked on organic chemistry exams for over a hundred years. Glucose and fructose are both simple sugars with exactly…read more…

Posted in bariatric surgery, coronary artery disease, ethics, obesity, professionalism, randomized trial, surgery | Tagged: , | Leave a Comment »