Clin Med
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Secondary hyperparathyroidism in patients with chronic kidney disease (CKD) is common and usually caused by associated metabolic abnormalities, in particular, hypocalcaemia and hyperphosphataemia. Nevertheless, other causes of hyperparathyroidism can exist concurrently with CKD, challenging diagnostic interpretation and therapeutic intervention. We present four cases of hyperparathyroidism in patients with CKD that highlight some of these dilemmas.
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Athletes have always sought to outperform their competitors and regrettably some have resorted to misuse of drugs or doping to achieve this. Stimulants were taken by the first Olympic athletes to be disqualified in 1972. Although undetectable until 1975, from the 1950s androgenic anabolic steroids were administered for increased strength and power followed in the 1990s by erythropoietin for enhanced endurance. ⋯ When the International Olympic Committee (IOC) prohibited beta blockers (beneficial in shooting), diuretics (assist weight classified athletes) and glucocorticosteroids, some athletes with genuine medical conditions were denied legitimate medical therapy. To overcome this, in 1992 the IOC introduced a system known now as Therapeutic Use Exemption (TUE). This paper discusses Olympic athletes who have been known to dope at past Games and some medical indications and pitfalls in the TUE process.
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Infliximab is a biological agent that is licensed for the treatment of severe Crohn's disease. The annual cost of infliximab treatment is approximately pound 16,456 (excl VAT). In May 2010, the National Institute for Health and Clinical Excellence (NICE) recommended that patients should receive biological agents as a planned course of treatment only until treatment failure or until 12 months after the start of treatment, whichever is shorter. ⋯ Four patients were in deep clinical remission and discontinued infliximab. Implementation of the NICE recommendations on the use of infliximab in Crohn's disease is likely to be challenging in the face of significant resistance from patients who have an understandable fear of relapse. It might be more appropriate to discuss treatment withdrawal when high-quality evidence is available to support this management option.