After 18 months the APPROVe study of rofecoxib 25 mg daily to prevent colon polyps, shows a four times increase risk of thrombotic cardiovascular events [1].
Putting this risk into perspective: When I discuss smoking & heart risks with patients, I usually say there is a "a four hundred percent increase risk of heart attack for one pack per day." The APPROVe study puts rofecoxib use at the same risk level. (I will check my smoking risk estimate.)
APPROVe investigators suggest that heart risks are not just thrombotic. After five months COX-2 inhibition was associated with increased hypertension-associated or edema-associated events (CHF, pulmonary embolism). I have not deciphered the risk of CHF alone. Looking at plain NSAIDs other studies have shown an increase in CHF risk [2].
The New England Journal of Medicine has pre-released several papers about COX-2 inhibitors. CSPAN covered the FDA Panel's deliberations on COX-2 inhibitors. I have not yet found links to their coverage [3].
Lifting a weight in the hand, flexing the elbow, contracts the bicep. That is "concentric contraction" of the bicep. When the person lowers the weight slowly, there is still tension in the bicep as it lengthens, that is called "eccentric" contraction [1].
Intentional eccentric muscle contraction can help muscle strengthening. In addition to physical therapists, weight lifters and trainors are familiar with these concepts [2]. ....Will search for published papers on eccentric role in muscle strengthening versus injury [3].
"The people who come to see us bring us their stories. They hope they tell them well enough so that we understand the truth of their lives. They hope we know how to interpret their stories correctly. We have to remember that what we hear is their story."
This advice from a mentor was given to Dr. Robert Coles [1].
Here is Ohio Revised Code defining a coroner's case [1].
Coroner's Findings
About a third of deaths referred to the coroner's office are accepted for autopsy. Of those autopsied about 40% end up being natural causes, about 40% accidental. The final 20% are suicides, homicides, and undetermined.
Referred to Coroner in Year 2003 = 3719
Autopsied = 1027
Natural Causes = 450
Accidental = 365
Suicides = 84
Homicides = 99
Undetermined = 21
Of the natural causes of these coroner-referred cases, about 3% have ended up being deaths due to infectious diseases.
Two years ago a woman in her 30's had arthralgias at the time of confirmed acute parvovirus infection. Now she has serositis, arthralgias, Raynaud's phenomenon and some fever. ANA is positive 1:640 speckled. Her mother had rheumatoid arthritis and psoriasis. Is her past parvovirus associated with her current rheumatologic condition?
Parvovirus B19 can provoke rheumatologic symptoms acutely. A literature review was recently published. [1]. They conclude: "Although B19 may modulate the clinical and biological features of rheumatic disease, studies in large series do not support a causative role for B19 in the pathogenesis of SLE."
I am looking for large prospective natural history trials measuring the subsequent prevalence of lupus and other diseases years after parvovirus infection. Others are looking as well. [2, 3, 4, 5, 6].
Our patient's history is striking: a lupus-like illness two years after parvovirus-associated arthralgias.
This is simply a link to the 1996 NEJM review article on metformin [1]. Inhibition of gluconeogenesis, emphasized by Dr. Coles, as well as increased peripheral utilization of glucose are summarized as the mechanisms of action.
A more recent review covers thiazolidinediones, TZD's [2].
I could not find references on optimal therapy of corticosteroid induced hyperglycemia.