Randomized trial of parathyroidectomy in mild asymptomatic primary hyperparathyroidism: patient description and effects on the SF-36 health survey

The effects of serum calcium and parathyroid hormone changes on psychological and cognitive function in patients undergoing parathyroidectomy for primary hyperparathyroidism

OBJECTIVE

This study had 2 aims: (1) to assess the timing and magnitude of psychological and neurocognitive changes before and after parathyroidectomy and (2) to examine correlations between changes in serum biomarkers and psychological symptoms and neurocognitive performance.

BACKGROUND

Psychological and neurocognitive changes are common in patients with primary hyperparathyroidism (pHPT), but the associations of serum biomarkers and these changes have not been established.

METHODS

This prospective cohort study carried out at a large tertiary care referral center from 2004 to 2008 screened all adult patients with the biochemical diagnosis of pHPT who underwent first-time parathyroidectomy. Laboratory results, psychological symptom reports, and results of neurocognitive testing using validated instruments were obtained preoperatively and at 1, 3, and 6 months postoperatively. Outcomes measures included serum calcium, intact parathyroid hormone (iPTH), and thyroid stimulating hormone; psychological symptom inventories (Beck Depression Inventory-II, Brief Symptom Inventory-18, and Spielberger State-Trait Anxiety Inventory); and neurocognitive test scores (Rey Auditory Verbal Learning Test and Groton Maze Learning Test).

RESULTS

Two hundred twelve patients were enrolled; mean age was 60 years; 78% were female and had low comorbidity; 78% had parathyroidectomy under ambulatory, minimally invasive techniques; cure rate was 99%. Improvements in psychological and neurocognitive measures were observed at all postoperative follow-up visits. The most pronounced improvements were noted in depressive and anxiety symptoms, and visuospatial and verbal memory. Examination of change scores revealed that postoperative reduction in iPTH was associated with a decrease in state anxiety, which was also associated with improvement in visuospatial working memory.

CONCLUSIONS

Reduction in mood and anxiety symptoms is associated with reductions in both iPTH and spatial working memory in patients with pHPT who undergo successful parathyroidectomy.

Parathyroid surgery in the elderly

The prevalence of primary hyperparathyroidism (PHPT) will increase with the growth of the elderly population. Elderly patients primarily present with nonclassic symptoms of PHPT that can sometimes be missed in favor of other diagnoses. Several recent studies demonstrate the safety and efficacy of outpatient, minimally invasive parathyroidectomy in elderly patients with PHPT, the majority of them reporting increased fracture-free survival and symptomatic relief postoperatively and thus experiencing improved quality of life.

Introduction.

The prevalence of primary hyperparathyroidism (PHPT) is expected to increase in developed nations as the aged population grows. This review discusses issues related to PHPT in the elderly population with a focus on differences in disease presentation, medical and surgical management, and outcomes.

Methods.

Literature review of English-language studies of PHPT or parathyroidectomy (PTx) in the elderly was performed. Surgical literature reviewed included original clinical studies published after 1990. Priority was given to studies with >30 patients where institutional practice and outcomes have not changed significantly over time.

Results.

Elderly patients primarily present with nonclassic symptoms of PHPT that can sometimes be missed in favor of other diagnoses. They have equivalent surgical outcomes, including morbidity, mortality, and cure rates, compared with younger patients, although their length of hospital stay is significantly longer. Several recent studies demonstrate the safety and efficacy of outpatient, minimally invasive parathyroidectomy in an elderly population. Patients are referred for PTx less frequently with each advancing decade, although surgical referral patterns have increased over time in centers that offer minimally invasive parathyroidectomy. Elderly patients experience increased fracture-free survival after PTx. The majority of elderly patients report symptomatic relief postoperatively.

Conclusion.

PTx can offer elderly patients with PHPT improved quality of life. PTx is safe and effective in elderly patients, and advanced age alone should not deter surgical referral.

What symptom improvement can be expected after operation for primary hyperparathyroidism?

BACKGROUND

The only cure for primary hyperparathyroidism (pHPT) is operative resection of the parathyroid gland(s) responsible for the disease. The 1990 National Institute of Health's (NIH) consensus development conference on asymptomatic pHPT and its subsequent workshop in 2001 established which clinical criteria warranted parathyroidectomy (PTx) versus observation. While there is no debate that these NIH criteria capture a group of patients likely to benefit from PTx, there is concern that these guidelines miss a significant percentage of pHPT patients who actually are symptomatic. Unfortunately, these additional symptoms are often subtle, nonspecific, not traditionally measured, frequently not assessed or considered in this patient population, and are usually attributed to other diagnoses or simply advanced age.

METHODS

An evidence-based literature review was performed assessing symptoms and clinical conditions associated with bone, neuropsychiatry, cognition, quality of life, and the neuromuscular system. The level of evidence and grade of recommendations were assigned to key studies to help determine recommendations regarding indications and potential benefits of parathyroidectomy (PTx).

RESULTS

Symptoms ranging from decreased bone mineral density, increased fracture risk, neuropsychiatric symptoms and cognitive changes, lower quality of life, and neuromuscular symptoms were found to be associated with pHPT. The effects of PTx on these symptoms was addressed in a variety of studies that varied in quality.

CONCLUSION

Although there are few Level I randomized clinical trials addressing the benefit of PTx in patients with pHPT, there are supportive data to suggest that most patients with pHPT would benefit from operative cure.

Persistent symptomatic improvement in the majority of patients undergoing parathyroidectomy for primary hyperparathyroidism

BACKGROUND

Parathyroidectomy for primary hyperparathyroidism (PHPT) is followed by a decrease in the severity of symptoms reported on the Pasieka's parathyroid symptoms score (PPSS) and SF-36 questionnaires. Some argue that such benefits are short-lived. This study investigates the severity of symptoms at more than 12 months after parathyroidectomy.

METHODS

A prospective database collected clinical/operative data on consecutive patients with PHPT. PPSS was calculated as the sum of the 13 parameters self-assessed using a visual analog scale. SF-36(v2) was analyzed using commercially available software (QualityMetric Inc., Lincoln, USA).

RESULTS

Over 3-year interval, 166 patients (119 F/47 M, age 15-89 years) were operated for with PHPT (Ca 2.90 ± 0.25 mmol/L, PTH 21.64 ± 23.05 pmol/L). Their preoperative PPSS ranged 0-1,260 (median 413) and did not correlate with the severity of hypercalcemia. One hundred and seven patients responded when contacted by post at 18 ± 6 months postoperatively. Their postoperative PPSS was significantly lower (398 ± 226 to 231 ± 203, p < 0.001) and in 55 of 107 patients the severity of symptoms reduced by at least 50%. Most significant improvements were for mood (36 ± 33 vs. 16 ± 23), weakness/tiredness (37 ± 32 vs. 17 ± 23), irritability (35 ± 31 vs. 17 ± 21), and thirst (37 ± 32 vs. 18 ± 25; p < 0.0001). Physical and mental component scores of SF-36 questionnaire improved in patients whose PPSS decreased postoperatively.

CONCLUSION

Symptomatic benefits persist for at least 1 year after parathyroidectomy in the majority of patients with PHPT.

Health-related quality of life improvement following surgical treatment of primary hyperparathyroidism in a United Kingdom population

OBJECTIVE

The aim of this study was to determine if parathyroidectomy for primary hyperparathyroidism produces improvement in health-related quality of life in a United Kingdom population.

METHODS

Since October 2002, patients undergoing parathyroidectomy for primary hyperparathyroidism were asked to complete the SF-36 questionnaire, a validated self assessment tool prior to surgery and at six months post surgery. The questionnaires were either mailed to the patients or given at the time of outpatient follow up.

RESULTS

24 out of 29 patients completed the questionnaire pre- and postoperatively. Compared to the national average, the median pre-operative scores were worse in all 8 domains. At 6 months post surgery, there were significant improvements in six out of eight domains (p<0.05); physical and social functioning, physical and emotional role limitations, energy and mental health. The median physical component summary score (PCS) and the mental component summary score (MCS) were also significantly improved postoperatively [Preop vs. Postop (PCS)=28.16 vs. 35.40 (P=0.03)] and Preop vs. Postop (MCS)=41.50 vs. 56.23 (P=0.005)]. The post-operative MCS was comparable with the national average.

CONCLUSION

This study shows that parathyroidectomy for primary hyperparathyroidism improves health-related quality of life in a United Kingdom population.

Prospective, randomized, controlled trial of parathyroidectomy versus observation in patients with "asymptomatic" primary hyperparathyroidism

BACKGROUND

Disruptions in cognitive function have been described in the constellation of symptoms associated with "asymptomatic" primary hyperparathyroidism (PHPT). The aim of this study was to determine the impact of parathyroidectomy (PTX) on brain function and sleep in "asymptomatic" PHPT patients.

METHODS

We conducted a prospective, randomized trial comparing immediate PTX with observation in patients with asymptomatic PHPT. We performed functional magnetic resonance imaging (fMRI) of the brain, sleep assessment, and validated neuropsychological battery at baseline, 6 weeks, and 6 months. Wilcoxon rank-sum and Pearson and Spearman correlations were used.

RESULTS

A total of 18 patients were randomized. Subjective sleepiness correlated with worse performance on executive function tests during fMRI at 6 weeks (Pearson, -0.473; P = .047) and 6 months (Pearson, -0.673; P = .002). Total sleep time correlated with PTH levels at both 6 weeks (Pearson, 0.518; P = .048) and 6 months (Pearson, 0.567; P = .018). At 6 weeks, hypersomnolence as measured subjectively was decreased in the PTX group, but increased in those observed (-2.56 vs 2.22; P = .03)

CONCLUSION

This prospective, randomized trial for asymptomatic PHPT patients demonstrated an association of sleep with brain function. Sleep seemed to be an indicator of brain activation in the anterior cingulate gyrus and precentral cortex. Subjective sleepiness was associated with executive function. The results of this pilot study suggest that decreased serum PTH levels correlate with improved sleep and that PTX decreases sleepiness in patients with asymptomatic PHPT.

Nonoperative management of primary hyperparathyroidism: the exception rather than the rule

The spectrum of classical primary hyperparathyroidism (pHPT) has expanded from a disabling disease to a largely asymptomatic one, leading to considerable uncertainty regarding which patients with pHPT will truly benefit from operative therapy. In the hands of an experienced endocrine surgeon, parathyroidectomy (PTx) is associated with a greater than 95% cure rate and long-term complication rates of less than 5%. We believe that all patients with pHPT should be referred to an experienced endocrine surgeon for consideration of PTx. Furthermore, our preference is to offer surgical intervention to all patients with pHPT who do not have prohibitive medical comorbidities. The purpose of this article is to outline the anticipated benefits of PTx in patients with nonclassical symptoms of pHPT with regard to improvement of the present condition, prevention of future complications or both.

Cinacalcet reduces serum calcium concentrations in patients with intractable primary hyperparathyroidism

CONTEXT

Patients with persistent primary hyperparathyroidism (PHPT) after parathyroidectomy or with contraindications to parathyroidectomy often require chronic treatment for hypercalcemia.

OBJECTIVE

The objective of the study was to assess the ability of the calcimimetic, cinacalcet, to reduce serum calcium in patients with intractable PHPT.

DESIGN

This was an open-label, single-arm study comprising a titration phase of variable duration (2-16 wk) and a maintenance phase of up to 136 wk.

SETTING

The study was conducted at 23 centers in Europe, the United States, and Canada.

PATIENTS

The study included 17 patients with intractable PHPT and serum calcium greater than 12.5 mg/dl (3.1 mmol/liter).

INTERVENTION

During the titration phase, cinacalcet dosages were titrated every 2 wk (30 mg twice daily to 90 mg four times daily) for 16 wk until serum calcium was 10 mg/dl or less (2.5 mmol/liter). If serum calcium increased during the maintenance phase, additional increases in the cinacalcet dose were permitted.

MAIN OUTCOME MEASURE

The primary end point was the proportion of patients experiencing a reduction in serum calcium of 1 mg/dl or greater (0.25 mmol/liter) at the end of the titration phase.

RESULTS

Mean +/- sd baseline serum calcium was 12.7 +/- 0.8 mg/dl (3.2 +/- 0.2 mmol/liter). At the end of titration, a 1 mg/dl or greater reduction in serum calcium was achieved in 15 patients (88%). Fifteen patients (88%) experienced treatment-related adverse events, none of which were serious. The most common adverse events were nausea, vomiting, and paresthesias.

CONCLUSIONS

In patients with intractable PHPT, cinacalcet reduces serum calcium, is generally well tolerated, and has the potential to fulfill an unmet medical need.

[Diagnostic evaluation and differential diagnosis of primary hyperparathyroidism]

Primary hyperparathyroidism (PHPT) is characterized by the autonomous production of parathyroid hormone (PTH), in which there is hypercalcemia or normal-high serum calcium levels, in the presence of elevated or inappropriately normal serum PTH concentrations. Exceptionally, in symptomatic patients, a diagnosis can be established on the basis of clinical data. PHPT must always be evaluated in patients with clinical histories of nephrolithiasis, nephrocalcinosis, osseous pain, subperiosteal resorption, and pathologic fractures, as well as in those with osteoporosis-osteopenia on dual-energy X-ray absorptiometry (DEXA), a personal history of neck irradiation, or a family history of multiple endocrine neoplasia syndrome (types 1 or 2). Diagnosis of PHPT is biochemical. Asymptomatic hypercalcemia (total serum calcium corrected by albumin), without guiding signs or symptoms, is the most frequent manifestation of the disease. For the differential diagnosis, PTH(1-84) must be measured, as well as phosphate, chloride, 25-hydroxyvitamin D, 1,25-dihydroxyvitamin D and calcium-to-creatinine clearance. Suppressed or inappropriately low PTH1-84 guides the diagnose toward tumoral hypercalcemia and less frequently to granulomatous disease (sarcoidosis, tuberculosis, etc.), inadequate intake of 1alpha-hydroxyvitamin D or calcitriol, vitamin D or A intoxication, lithium intake, endocrinopathies (hyperthyroidism, Addison's disease, etc.) or treatment with thiazides, among other possibilities. Diagnosis of PHPT is confirmed by demonstrating persistent hypercalcemia (or normal-high serum calcium levels) in the presence of inappropriately normal or elevated serum PTH(1-84) concentrations, unless the urinary calcium-to-creatinine clearance ratio is lower than 0.01. In these cases, in the absence of thiazide intake or severe vitamin D deficiency, diagnosis should focus on benign familial hypercalcemic hypocalciuria. Parathyroid gland imaging is useful for localization of PHPT, but not for diagnosis of this entity.

Hyperparathyroidism

Hyperparathyroidism is due to increased activity of the parathyroid glands, either from an intrinsic abnormal change altering excretion of parathyroid hormone (primary or tertiary hyperparathyroidism) or from an extrinsic abnormal change affecting calcium homoeostasis stimulating production of parathyroid hormone (secondary hyperparathyroidism). Primary hyperparathyroidism is the third most common endocrine disorder, with the highest incidence in postmenopausal women. Asymptomatic disease is common, and severe disease with renal stones and metabolic bone disease arises less frequently now than it did 20-30 years ago. Primary hyperparathyroidism can be cured by surgical removal of an adenoma, increasingly by minimally invasive parathyroidectomy. Medical management of mild disease is possible with bisphosphonates, hormone replacement therapy, and calcimimetics. Vitamin D deficiency is a common cause of secondary hyperparathyroidism, particularly in elderly people. However, the biochemical definition of vitamin D deficiency and its treatment are subject to much debate. Secondary hyperparathyroidism as the result of chronic kidney disease is important in the genesis of renal bone disease, and several new treatments could help achieve the guidelines set out by the kidney disease outcomes quality initiative.

Neuropsychological features in primary hyperparathyroidism: a prospective study

CONTEXT

Data regarding the presence, extent, and reversibility of psychological and cognitive features of primary hyperparathyroidism (PHPT) are conflicting.

OBJECTIVE

This study evaluated psychological symptoms and cognitive function in PHPT.

DESIGN

This is a case-control study in which symptoms and their improvement 6 months after surgical cure of PHPT were assessed.

SETTINGS

The study was conducted in a university hospital metabolic bone disease unit and endocrine surgery practice.

PARTICIPANTS

Thirty-nine postmenopausal women with PHPT and 89 postmenopausal controls without PHPT participated in the study.

INTERVENTION

Participants with PHPT underwent parathyroidectomy.

OUTCOME MEASURES

Measurements used in the study were: Beck Depression Inventory (BDI); State-Trait Anxiety Inventory, Form Y (STAI-Y); North American Adult Reading Test (NAART); Wechsler Memory Scale Logical Memory Test, Russell revision (LM); Buschke Selective Reminding Test (SRT); Rey Visual Design Learning Test (RVDLT); Booklet Category Test, Victoria revision (BCT); Rosen Target Detection Test (RTD); Wechsler Adult Intelligence Scale-Revised Digit Symbol Subtest (DSy); Wechsler Adult Intelligence Scale Digit Span Subtest (DSpan).

RESULTS

At baseline, women with PHPT had significantly higher symptom scores for depression and anxiety than controls and worse performance on tests of verbal memory (LM and SRT) and nonverbal abstraction (BCT). Depressive symptoms, nonverbal abstraction, and some aspects of verbal memory (LM) improved after parathyroidectomy to the extent that scores in these domains were no longer different from controls. Baseline differences and postoperative improvement in cognitive measures were independent of anxiety and depressive symptoms and were not linearly associated with serum levels of calcium or PTH.

CONCLUSIONS

Mild PHPT is associated with cognitive features affecting verbal memory and nonverbal abstraction that improve after parathyroidectomy.

Preserving function and quality of life after thyroid and parathyroid surgery

Endocrine disease has been recognised for thousands of years, but surgical treatment of endocrine disorders has only been widely used in the past century. Surgery is an effective treatment for hyperfunctioning glands and benign and malignant tumours. Advances in surgical technique have led to the development of short and safe operations with a high cure rate, and recent studies have not only assessed the success of the operations but also have focused on how these diseases affect patient-reported quality of life before and after surgery. In this Review, we summarise current approaches to surgical treatment of thyroid and parathyroid disease, focusing on how these approaches both preserve function and improve quality of life after surgery.

Pasieka's parathyroid symptoms scores correlate with SF-36 scores in patients undergoing surgery for primary hyperparathyroidism

BACKGROUND

Parathyroidectomy for primary hyperparathyroidism (PHPT) is expected to trigger an improvement in the quality of life. This has been demonstrated previously by using the SF-36 questionnaire, whose interpretation is difficult in routine clinical practice. As an alternative, the 13-item questionnaire developed by Pasieka et al. can be used to assess the severity of symptoms on a visual analogue from which a parathyroid assessment of symptoms score (PAS) can be calculated. The purpose of this study was to correlate results of these two assessment tools.

METHODS

Prospective case-series study recruiting consecutive unselected patients who underwent successful parathyroidectomy for PHPT. SF-36(v2) and Pasieka's questionnaires were collected before parathyroidectomy and at 3, 6, and 12 months postoperatively.

RESULTS

Between November 2005 and December 2006, 101 patients were diagnosed with PHPT (30 men; aged 18-89 years). Preoperative PAS ranged 0-1040 and did not correlate with the severity of hypercalcemia (2.91+/-0.25; range, 2.56-3.4 mmol/l). Scores from the SF-36 questionnaire were under the 50th percentile for the normal population in three domains (vitality, emotional role, and physical role). Minimally invasive parathyroidectomy was performed in 69 patients and bilateral cervical exploration in 32 patients. All were found to have a single parathyroid adenoma and were normocalcemic at 3-12 months after parathyroidectomy. At follow-up, there was a significant reduction of PAS from 460+/-257 preoperatively to 254+/-234 at 3 months postoperatively (n=72), to 245+/-215 at 6 months (n=50), and 249+/-212 at 12 months (n=63) (p<0.05, Student's t-test). There was a significant and persistent improvement in five domains of SF-36 questionnaire: bodily pain, general health, vitality, social functioning and mental health. Overall analysis of 244 assessments using both questionnaires demonstrated a negative correlation between increasing PAS and decreasing mental component scores and physical component scores of the SF-36 assessment (r2=0.372 and 0.301, respectively).

CONCLUSIONS

Pasieka's parathyroid assessment of symptom scores (PAS) correlate with SF-36 questionnaire scores. Because PAS allows easier and faster analysis, we advocate that Pasieka's questionnaire should be integrated into the assessment of patients with PHPT as a reliable tool to identify symptomatic changes that correlate with improved quality of life.

Very low or undetectable intact parathyroid hormone levels in patients with surgically verified parathyroid adenomas

OBJECTIVES

To report and explore potential reasons for undetectable or low-normal serum intact PTH levels in patients with surgically verified primary hyperparathyroidism with parathyroid adenomas, review the relevant literature, and offer suggestions for management of such patients occasionally encountered in clinical practice. For future research, to help understand mechanisms underlying 'undetectable' or inappropriately low serum intact PTH levels.

METHODS

Serum intact PTH levels were measured pre- and postoperatively by immunochemiluminescent assay (ICMA) and the results were confirmed by at least two repeated measurements on different occasions in each patient.

PATIENTS

We encountered two unusual patients with primary hyperparathyroidism who had suggestive biochemical and/or clinical features of primary hyperparathyroidism. However, serum intact PTH levels were either very low or undetectable in the context of hypercalcaemia, with no other obvious cause. A (99m)Tc sestamibi scan showed increased uptake in one of the parathyroid glands, suggesting a single adenoma in each case that was confirmed at surgery.

RESULTS

In the first patient, from India, mean +/- SD serum calcium was 2.6 +/- 0.32 mmol/l (reference range 2.12-2.74 mmol/l) with intact PTH of 0.11 pmol/l (reference range 1.1-7.59 pmol/l). In the second patient, from the USA, mean +/- SD serum calcium and intact PTH were 2.9 +/- 0.07 mmol/l (reference range 2.17-2.51 mmol/l) and 1.35 pmol/l (reference range 1.1-7.59 pmol/l), respectively. Following curative parathyroidectomy, serum calcium levels normalized in both patients. By contrast, serum intact PTH levels, which were either suppressed or very low before surgery, rose into the low-normal reference range in all patients.

CONCLUSIONS

When the clinical suspicion is high, the diagnosis of primary hyperparathyroidism should be pursued despite suppressed or low-normal serum intact PTH levels after carefully excluding other causes of hypercalcaemia. Further research on various intact PTH molecular species secreted by parathyroid adenomas or post-translational changes in the intact PTH molecule that might interfere with in vitro measurements should be undertaken to understand the precise reason(s) for such anomalous findings.

Asymptomatic hyperparathyroidism--need for multicentre studies

Long-term follow-up is initially considered appropriate for the majority of patients with primary hyperparathyroidism (PHPT) having small increases in calcium levels (< 2.8 mmol/l) and lacking the 'classical' symptoms of PHPT. The supportive reasoning is that many such patients never progress to more severe biochemical or clinical disease. There are, however, arguments in favour of early surgical treatment of such patients but adequately powered studies have not been carried out in this subgroup of patients to asses the impact of PHPT on their quality of life, cardiovascular risk and bone density. Progressive loss in bone mineral density and an increased risk of bone fracture become increasingly significant in an ageing population. Left ventricular hypertrophy, an increased risk of arrhythmia and/or myocardial infarction in addition to changes in atherogenic lipid profile and impaired glucose tolerance may translate into an increased risk of premature death in this group of patients. Changes in the quality of life identified using standardized questionnaires are sometimes recognized by patients only in retrospect (i.e. after resolution of symptoms following successful parathyroidectomy). In addition, many series fail to assess and record accurately such symptoms. Multicentre cohort studies of patients with asymptomatic PHPT randomized to immediate or delayed surgical treatment could address some of the debated issues highlighted in this review. Until such studies are set up, most surgeons would consider that parathyroid surgery should represent the first choice of treatment for all patients, but many physicians would favour a long-term follow-up. Nevertheless, the threshold for referral for surgical treatment has been lowered since the introduction of scan-directed minimally invasive parathyroidectomy, which enables the experienced parathyroid surgeon to successfully treat patients with PHPT with a minimum of complications as a day-case operation. In the context of improved surgical treatment, we need more data on the benefits or otherwise in so-called asymptomatic patients with a thorough assessment of their bone quality, cardiovascular risk and quality of life.

Surgery did not improve the subjective neuropsychological symptoms of patients with incidentally detected mild primary hyperparathyroidism

Primary hyperparathyroidism (PHPT) is known to cause diverse subjective symptoms, in addition to those related to osteitis fibrosa cystica and kidney stones. The treatment of the disease ameliorates the subjective symptoms and improves the patients' quality of life. In this prospective study, patients undergoing surgery for incidentally detected, mild, asymptomatic PHPT were assessed to determine whether subjective neuropsychological symptoms are improved even in patients with "asymptomatic" PHPT. From October 1995 to March 2004, 25 patients who had one or more neuropsychological symptoms preoperatively and were followed up 1 year after parathyroidectomy were enrolled. The subjective symptoms were identified using questionnaires distributed to patients; eight questions were used to determine the presence or absence of psychoneurological symptoms. Compared to their preoperative status, patients responded that their general health perceptions 1 year after surgery were improved (13 cases, 52%), unchanged (11 cases, 44%), or aggravated (1 case, 4%). There were no statistically significant differences in the patients' responses before and after surgery with respect to individual neuropsychological symptoms, such as "tiring easily, "forgetfulness," "decreased concentration," "depression," "irritability," "uneasiness," and "sleeplessness." Therefore, subjective neuropsychological symptoms did not improve in otherwise asymptomatic PHPT patients following parathyroidectomy. However, patients' questionnaire responses may not reflect their actual status as accurately as laboratory examination results. Overall, 52% of patients were subjectively satisfied with surgery; this may result from patients' expectations of treatment.

Effect of parathyroidectomy on quality of life and neuropsychological symptoms in primary hyperparathyroidism

Neuropsychological symptoms are found in a certain number of patients with primary hyperparathyroidism (PHPT). Preoperative and postoperative quality of life, anxiety, and depression are measured to analyze the impact of parathyroidectomy on these symptoms. In this prospective study, 66 patients underwent parathyroidectomy for PHPT and were evaluated pre- and postoperatively with two validated psychometric instruments (HADS, PHQ-9). Health-related quality of life was measured with a 12-item short-form health survey (SF-12). Preoperatively, the median physical component score (SF-12) of 43.0 and mental component score of 43.5 were lower than those of the general population (52.8 and 54.2 points, respectively). One year postoperatively the mental component score increased to 48.6 (p = 0.011), whereas the physical functioning scale scored 45.3 and therefore did not change significantly (p = 0.585). Preoperatively, symptoms of depression were found in 23.4% of the patients, and 15.6% of the patients displayed symptoms of anxiety (HADS). The prevalence of depression was significantly higher in patients with preoperative serum calcium levels > 11.2 mg/dl (2.8 mmol/L) (p = 0.015). Twelve months postoperatively, the overall proportion of patients with anxiety and depression decreased to 7.8% and 15.7%, respectively (p = NS). The severity of depression as measured with the PHQ-9 declined postoperatively as well. In this study, preoperative neuropsychological symptoms were related to the serum calcium levels. Postoperative health-related quality of life improved significantly. Among patients with preoperative symptoms of depression and anxiety, both symptoms were alleviated significantly at the 12-month follow-up. Therefore, surgery for PHPT seems to be effective in reducing neuropsychological morbidity associated with PHPT.

Asymptomatic primary hyperparathyroidism

Primary hyperparathyroidism is a common disorder of mineral metabolism characterized by incompletely regulated, excessive secretion of parathyroid hormone from one or more of the parathyroid glands. In adults with the disease, a single, benign adenoma is seen approximately 80 percent of the time, with multiple gland involvement comprising most of the remaining patients. Very rarely, a parathyroid cancer is responsible but it is seen in less than 0.5 percent of patients with primary hyperparathyroidism. In this article, we will review important clinical and diagnostic features of asymptomatic primary hyperparathyroidism as well as considerations for surgical or medical management of the disease.

Surgery or surveillance for mild asymptomatic primary hyperparathyroidism: a prospective, randomized clinical trial

CONTEXT

It is unclear whether patients with asymptomatic primary hyperparathyroidism (PHPT) do better with parathyroidectomy (PTx) as compared with conservative medical management.

OBJECTIVE

The aim of the study was to evaluate the beneficial effect of PTx vs. conservative management in patients with mild asymptomatic PHPT.

DESIGN

We conducted a prospective, randomized study.

SETTING

The study took place at a referral center.

PATIENTS

We studied 50 patients who did not meet any guidelines for parathyroid surgery as recommended by the National Institutes of Health Consensus Development Conference on Asymptomatic PHPT.

INTERVENTION

Patients were randomly assigned to PTx or no PTx and were evaluated at 6 months and at 1 yr.

MAIN OUTCOME MEASURES

We compared changes (percentage of basal) of lumbar spine bone mineral density (BMD) between the two groups at 1 yr.

RESULTS

The change in BMD at lumbar spine was greater after PTx (+4.16 +/- 1.13 for PTx vs. -1.12 +/- 0.71 for no PTx; P = 0.0002). The change in BMD at the total hip was also significantly greater in the PTx group (+2.61 +/- 0.71 for PTx vs. -1.88 +/- 0.60 for no PTx; P = 0.0001). There was no difference in BMD after 1 yr between both groups at the one-third radius site. In comparison with those who did not undergo surgery, the PTx subjects, after 1 yr, showed significant differences in four quality of life measures as determined by the 36-item short form health survey scale: bodily pain (P = 0.001), general health (P = 0.008), vitality (P = 0.003), and mental health (P = 0.017).

CONCLUSIONS

In patients with mild asymptomatic PHPT, successful PTx is followed by an improvement in BMD and quality of life. Most patients followed without surgery did not show evidence of progression.

Improvement of Sleep Disturbance and Neurocognitive Function after Parathyroidectomy in Patients with Primary Hyperparathyroidism

OBJECTIVE

To investigate the frequency of the nontraditional symptoms of sleep disturbance and impaired cognitive functioning in patients with primary hyper-parathyroidism (PHPT) and to assess changes in such patients after parathyroidectomy.

METHODS

In this study, we used formal neurocognitive assessment of patients undergoing parathyroidectomy for PHPT. The Brief Sleep Disturbance Inventory assessed sleep disturbance, and Stroop tests evaluated for cognitive impairment. Study patients underwent preoperative and postoperative neurocognitive testing.

RESULTS

Fifty-five patients underwent neurocognitive evaluation; the 43 women and 12 men had a mean age of 63 years. Sleep disturbance was assessed in all 55 patients, whereas evaluation for cognitive impairment was performed in 47. Sleep disturbance was identified preoperatively in 24 (44%) of the 55 patients. This disorder affected 17 (31%) of 55 patients postoperatively (P<0.01). Impaired executive functioning was found at baseline in 6 (13%) of 47 patients and decreased to 1 (2%) of 47 post-operatively (P<0.01), whereas impaired cognitive processing speed was detected in 12 (26%) of 47 patients at baseline and decreased to 3 (6%) of 47 after parathyroidectomy (P<0.01). Eight patients did not meet the National Institutes of Health consensus statement criteria for parathyroidectomy; 4 of these patients had preoperative impairment of sleep or cognitive functioning, 3 of whom showed improvement postoperatively.

CONCLUSION

Sleep disturbance and neurocognitive impairment occur in patients with PHPT, and these disorders improve after parathyroidectomy. Further objective evaluation of nontraditional symptoms in patients diagnosed as having PHPT is warranted.

A patient with persistent primary hyperparathyroidism due to a second ectopic adenoma

BACKGROUND

A 33-year-old woman presented with recurrent renal stones and malaise to her primary-care physician. Laboratory investigations revealed the patient had hypercalcemia and an elevated serum parathyroid hormone concentration. A diagnosis of primary hyperparathyroidism was established and the patient was referred for parathyroidectomy. At neck exploration, three parathyroid glands were visualized, one of which was enlarged and subsequently removed. The patient's serum calcium and parathyroid hormone levels decreased postoperatively but did not normalize, and her symptoms persisted. Planar (99m)Tc-sestamibi and ultrasound scans failed to provide conclusive localization for another enlarged parathyroid gland. The patient was referred to our Endocrinology Unit for further investigations and management.

INVESTIGATIONS

Laboratory investigations, ultrasound of the kidneys, BMD measurements, selective venous sampling for parathyroid hormone, and (99m)Tc-sestamibi single photon emission CT imaging.

DIAGNOSIS

Persistent hyperparathyroidism due to an ectopically located parathyroid adenoma.

MANAGEMENT

At further neck exploration, a 1.5 cm by 0.7 cm by 0.5 cm ectopic parathyroid adenoma was excised from the site indicated by the localization studies. No further exploration was attempted after intraoperative parathyroid hormone levels fell by 70%. Serum calcium levels and 24 h urine excretion of calcium rapidly normalized and all of the patient's symptoms completely disappeared within a few weeks of surgery.

Prospective evaluation of quality of life (SF-36v2) and nonspecific symptoms before and after cure of primary hyperparathyroidism (1-year follow-up)

BACKGROUND

Only a minority of patients with primary hyperparathyroidism (pHPT) present with the "classic" symptoms. Most patients have numerous nonspecific symptoms. The aim of this study was to evaluate patients' quality of life and nonspecific symptoms before and after cure for pHPT.

METHODS

This prospective, multicentric study, which took place from May 2003 to September 2004, included 100 patients. Six academic departments of Endocrine Surgery in France participated in the study: the University of Angers, Limoges, Nancy, Nantes, Marseille, and Poitiers. Only cured patients were included. All patients were given preoperative and postoperative questionnaires (the SF-36v2 Health Survey) at 3, 6, and 12 months to evaluate quality of life and nonspecific symptoms.

RESULTS

Preoperatively, the main nonspecific symptoms included the following: anxiety (89%); muscular, bone, or join pain (87%); abdominal distention (82%); forgetfulness (81%); headaches (81%); and mood swings (79%). Quality of life was significantly improved at 3 and 6 months (P < .05). At 1 year postoperatively, statistically significant improvement (P < .05) persisted in all 8 domains of the SF-36v2. At 1 year after parathyroidectomy, 5 symptoms remained significantly improved: appetite loss, weight loss, thirst, headache, and nausea.

CONCLUSIONS

Operative cure of primary hyperparathyroidism significantly improves quality of life and nonspecific symptoms for at least 1 year.

Psychiatric and cognitive aspects of primary hyperparathyroidism

PURPOSE OF REVIEW

Clinical guidelines for the treatment of primary hyperparathyroidism have been established by the 2002 NIH workshop on asymptomatic primary hyperparathyroidism. The panel called for further study of the ill-defined psychiatric and cognitive changes often seen in patients with primary hyperparathyroidism. The present paper provides a rigorous, updated review of the most recent advances and studies that have measured health-related quality of life, neurocognitive and psychiatric changes, as well as neurophysiologic imaging in patients with primary hyperparathyroidism undergoing parathyroidectomy.

RECENT FINDINGS

In studies conducted pre and postparathyroidectomy, six recent articles have described improvements in health-related quality of life. Five studies included evaluations with validated psychiatric and cognitive tests in prospective case-control trials, and showed varied improvements in depression, memory and concentration after parathyroidectomy. Two studies evaluated in a preliminary fashion the brains of patients with primary hyperparathyroidism with functional imaging studies, showing regional cerebral blood flow changes and prefrontal cortical activation with sleep improvement in postsurgical patients.

SUMMARY

The studies described in this paper underline the benefits of surgical treatment on nontraditional symptoms in patients with primary hyperparathyroidism, and open the door to the continued study of the endocrine effects of primary hyperparathyroidism on brain function.

The diagnosis and management of asymptomatic primary hyperparathyroidism

Classical primary hyperparathyroidism--a disease of 'bones, stones, and psychic groans'--is a rarity in the US, although it is still seen in some parts of the world. Today, most patients with primary hyperparathyroidism are asymptomatic. This change in clinical profile is not merely because of improved detection techniques, and patients with primary hyperparathyroidism who lack symptoms, if left untreated, rarely develop the 'classical' features that were common previously. Indeed, currently available data suggest that there is, today, a disorder with different, yet characteristic, effects on the end-organs of the hyperparathyroid process. In this review, the features of the skeletal, renal, neuropsychologic, cardiovascular, and gastrointestinal manifestations of 'asymptomatic' primary hyperparathyroidism will be discussed. The considerable body of data that has emerged since the recognition of the new clinical profile of primary hyperparathyroidism has allowed a reconsideration of standards of care for this disease. These data were reviewed and incorporated into new clinical guidelines at the 2002 NIH workshop on asymptomatic primary hyperparathyroidism. These recommendations highlight both what is known about the disease, and important areas that need investigation. Continued interest in the skeletal, cardiovascular, and neuropsychiatric manifestations of the disease, and therapeutic trials of medical approaches for its management, will further refine our current understanding, and could lead to additional modifications in the approach to patients with this common endocrine disorder.

Improvement in the health-related quality-of-life symptoms of hyperparathyroidism is durable on long-term follow-up

BACKGROUND

Subjective symptoms such as decreased energy, chronic fatigue, and depression are associated with hyperparathyroidism. Studies have shown that these symptoms are improved during short-term follow-up after parathyroidectomy. This study evaluates the durability of this subjective improvement in quality-of-life symptoms in a large population of patients with follow-up greater than 1 year after operation.

METHODS

Between 2002 and 2005, 258 patients underwent parathyroidectomy, 100 (81 females and 19 males) of whom were available for this study. The patients were evaluated with a survey based on the Health Outcomes Institute Health Status Questionnaire. Some answers were quantified on a 1 to 6 scale, while others consisted of "yes" or "no" responses. Patients completed a questionnaire prior to parathyroidectomy and postoperatively at 1 month, 3 to 6 months, and 1 to 2 years or greater intervals. Statistical analysis was used to detect changes attributable to parathyroidectomy. A P value <.05 was considered statistically significant.

RESULTS

At 1-month follow-up, patients' perceptions of their overall health, energy level, and mood significantly improved. At 6-month follow-up, significant improvements in muscle strength, health, endurance, and relief of anxiety were documented. At the interval of 1 to 2 years, overall health, energy level, endurance, and relief of anxiety were improved. There was no significant decrement in the quality of life in these patients after parathyroidectomy.

CONCLUSIONS

Parathyroidectomy for hyperparathyroidism is associated with significant lasting improvement in subjective symptoms. The potential durable improvement in these quality-of-life symptoms is a valid indication for parathyroidectomy.

Primary hyperparathyroidism, cognition, and health-related quality of life

OBJECTIVE

To provide a rigorous and critical review of studies in which formal neuropsychological (NP) testing and measurement of health-related quality of life (HRQL) were conducted pre- and post-parathyroidectomy for primary hyperparathyroidism (PHPT). These data contribute to the discussion on the utility of surgical intervention for nonclassic PHPT.

SUMMARY BACKGROUND DATA

PHPT is a complex endocrinopathy involving calcium metabolism and a potent hormone made by the parathyroid glands. Approximately 1.5% of Americans age 65 years and older, representing more than 3.9 million people, have PHPT, and the prevalence in postmenopausal women is estimated at 3.4%. Current National Institutes of Health guidelines for curative, surgical intervention of PHPT exclude 80% of patients with hyperparathyroid disease who have subjective neurobehavioral and physical symptoms that affect the quality of their lives.

METHODS

An electronic search was conducted of prospective studies in which cognitive functioning was measured with formal NP tests and HRQL was measured with valid and reliable instruments before and following parathyroidectomy for PHPT.

RESULTS

: In studies conducted pre- and post-parathyroidectomy for PHPT, 6 small studies of cognitive functioning report inconsistent findings; however, 7 well-designed studies of HRQL report improvement across multiple domains following surgery.

CONCLUSIONS

Surgical treatment of PHPT is a viable option for patients with laboratory diagnosed, "nonclassic" PHPT. Formal NP testing and evaluation of HRQL are useful tools that may assist physicians in choosing whom to refer for parathyroidectomy. Further longitudinal study of NP functioning and HRQL in patients with laboratory diagnosed PHPT is warranted.

Primary hyperparathyroidism. Update on pathophysiology, clinical presentation and surgical treatment

The most important step in calcium homeostasis is the regulation of parathyroid hormone (PTH) secretion. The discovery and characterization of the calcium sensing receptor (CaR) of the parathyroid cell has led to a better understanding not only of the physiology of the parathyroid glands, but also of the development of hyperparathyroidism. Drugs acting on CaR can now be designed to treat hyperparathyroidism and osteoporosis. The workshop on primary hyperparathyroidism held at the National Institutes of Health in 2002 has recommended new guidelines for the treatment of asymptomatic hyperparathyroidism. Controversy still exists regarding the treatment of patients with non-classical symptoms, such as weakness, fatigue and depression. Primary hyperparathyroidism as a risk factor for cardiovascular disease and mortality is also debated. Improved techniques for the preoperative localization of pathological parathyroid glands have led to a shift in surgical strategy: surgeons abandon the traditional bilateral neck exploration in favor of a more limited approach. This change of strategy has not been based on the results of prospective randomized studies and the long term results are not known.

Early parathyroidectomy increases bone mineral density in patients with mild primary hyperparathyroidism: a prospective and randomized study

BACKGROUND

There is an ongoing controversy regarding how to take care of patients with mild primary hyperparathyroidism (PHPT) and how to grade their disease activity in terms of bone parameters. This prospective and randomized study was undertaken to evaluate skeletal effects of delayed surgical treatment in such patients.

METHODS

Fifty patients with mild PHPT (serum calcium, 2.55 to 2.95 mmol/L; 10.2 to 11.8 mg/dL) were randomized to parathyroidectomy either at diagnosis or 1 year later. Hip and spine bone mineral density (BMD, determined by dual energy x-ray absorptiometry), bone alkaline phosphatase in serum, osteocalcin and beta-CrossLaps in plasma, and calcium in urine were measured in all patients at inclusion in the study and 1 and 2 years later.

RESULTS

The skeletal effects of mild PHPT varied with anatomy and time of exposure. Parathyroidectomy decreased all biochemical bone markers ( P < .0001) and increased lumbar spine BMD ( P < .05) equally in both groups, even in patients without overt osteoporosis, whereas hip BMD was increased ( P < .05) in the early intervention group only.

CONCLUSION

Prolonged exposure to mild and seemingly stable PHPT is a risk factor for hip fractures, which adds to other reasons for surgical treatment of this condition without delay regardless of serum calcium levels.

Primary hyperparathyroidism: new concepts in clinical, densitometric and biochemical features

Primary hyperparathyroidism (PHPT) is characterized most commonly now as an asymptomatic disorder with hypercalcaemia and elevated levels of parathyroid hormone (PTH). The elevation in PTH is detected by both the standard immunoradiometric assays (IRMA) and a more recent IRMA that detects only the 1-84 full-length PTH molecule. The serum calcium concentration is usually <1 mg dL(-1) above normal. Recently, another variant of PHPT (normocalcaemic PHPT) has been described in which the serum calcium is normal but the serum PTH is elevated, in the absence of any secondary cause for PTH elevation. Although usually sporadic, PHPT also occurs in inherited syndromes. Skeletal manifestations are appreciated by densitometry showing a typical pattern in which cancellous bone of the lumbar spine is reasonably well preserved whilst the cortical bone of the distal third of the radius is preferentially reduced. Although reduced in incidence, renal stones remain the most common overt complication of PHPT. Other organs are theoretical targets of PHPT such as the neurobehavioural axis and the cardiovascular system. Vitamin D looms as an important determinant of the activity of the PHPT state. The 2002 NIH Workshop on asymptomatic PHPT has led to revised guidelines to help doctors determine who is best advised to have parathyroid surgery and who can be safely followed without surgery. New information about the natural history of PHPT in those who did not undergo surgery has helped to define more precisely who is at-risk for complications. At the NIH workshop, a number of items were highlighted for further investigation such as pharmacological approaches to controlling hypercalcaemia, elevated PTH levels and maintaining bone density.

Symptoms In Patients With Primary Hyperparathyroidism: Muscle Weakness Or Sleepiness

OBJECTIVE

To evaluate the effects of parathyroidectomy on the nonspecific symptoms associated with primary hyperparathyroidism, with an emphasis on distinguishing sleepiness from muscle weakness.

METHODS

We conducted a prospective cohort study of consecutive patients presenting for parathyroidectomy for the treatment of primary hyperparathyroidism. Twenty-three patients underwent assessment preoperatively and postoperatively. The Functional Outcomes of Sleep Questionnaire (FOSQ), the Epworth Sleepiness Scale (ESS), and a questionnaire of disease-specific symptoms were administered preoperatively, 2 weeks postoperatively, and 4 to 6 months postoperatively. The FOSQ assesses how sleepiness alters daytime performance, and the ESS reflects the degree of daytime sleepiness.

RESULTS

All 23 patients achieved normocalcemia postoperatively. Although no significant changes were found in the overall scores for the FOSQ and ESS after parathyroidectomy, there was a significant decline in the overall mean incidence of disease-specific symptoms postoperatively (P <or=0.0001 after 2 weeks and P = 0.0020 after 4 to 6 months). The five disease-specific symptoms that significantly decreased in frequency postoperatively were (1) muscle weakness, (2) polydipsia, (3) dry skin and itching, (4) memory loss, and (5) anxiety.

CONCLUSION

In this study, patients with primary hyperparathyroidism did not demonstrate daytime sleepiness or difficulty performing everyday activities because of sleepiness at baseline or after successful parathyroidectomy. The overall mean percentage for incidence of disease-specific symptoms, however, significantly declined postoperatively, especially in reference to muscle weakness.

An update from the latest workshop on asymptomatic primary hyperparathyroidism

Considerable data have accumulated since 1990 concerning the natural history of asymptomatic primary hyperparathyroidism,the extent of target organ involvement, techniques for preoperative localization of parathyroid glands, and new surgical approaches for parathyroidectomy. Therefore a Workshop on Asymptomatic Primary Hyperparathyroidism: a Perspective for the Twenty-first Century was held in April 2002 with a goal of reevaluating the conclusions from the 1990 National Institutes of Health (NIH)Consensus Development Conference. This article presents the recommendations of the workshop panel and discusses the evidence leading to the changes in the recommendations of the 1990 NIH conference.

Asymptomatic primary hyperparathyroidism: a surgical perspective

Since the advent of multichannel autoanalyzers and routine screening of serum calcium levels, prevalence of primary hyperparathyroidism (pHPT) has increased to between 0.1% and 0.4%. As more patients present with "asymptomatic" pHPT, ideal treatment of "mild" disease becomes more controversial, with the possibility of safe, nonoperative management in a selected group of patients. Accumulated evidence confirms that the majority of these patients suffer from vague, nonspecific complaints that are very real and can improve following parathyroidectomy. Furthermore, parathyroidectomy in patients with pHPT has been demonstrated to improve bone mineral density, reduce fracture risk, and improve health-related quality of life and possibly overall survival. Therefore, all patients with primary hyperparathyroidism should be referred for surgical evaluation by an experienced endocrine surgeon.

The NIH criteria for parathyroidectomy in asymptomatic primary hyperparathyroidism: are they too limited?

OBJECTIVE

To determine whether preoperative and postoperative symptoms and outcome differ in patients who meet or fail to meet the NIH criteria for parathyroidectomy.

SUMMARY BACKGROUND DATA

The NIH Consensus Conference on primary hyperparathyroidism in 1990 defined criteria for surgical intervention suggesting that some patients can be safely managed without surgery.

METHODS

Over a 3-year period, 202 consecutive patients undergoing parathyroidectomy for primary hyperparathyroidism at a tertiary referral center were prospectively given a questionnaire regarding their symptoms and associated conditions during their initial and follow-up office visits as were 63 thyroid control patients. The 178 patients who completed the follow-up questionnaire were assigned to 2 groups according to the NIH criteria for parathyroidectomy. The frequency of preoperative symptoms and conditions associated with primary hyperparathyroidism as well as postoperative improvement in symptoms and surgical outcome were compared.

RESULTS

Of the 178 parathyroid patients, 103 met the NIH criteria for parathyroidectomy whereas 75 did not. Patient profiles were similar in each group except mean ages, 55 versus 65, and preoperative serum calcium levels, 11.5 mg/dL versus 11.0 mg/dL (NIH and non-NIH groups, respectively; P < 0.001). The incidence of preoperative nonspecific somatic and neuropsychiatric symptoms and associated conditions was equivalent in both groups and more common than in the 63 thyroid control patients. After parathyroidectomy, symptomatic improvement was dramatic and equal between the 2 parathyroid groups. Postoperative mean serum calcium levels were similar (8.78 mg/dL, NIH group, versus 8.75 mg/dL, non-NIH group).

CONCLUSION

Symptoms were more common in patients with primary hyperparathyroidism versus thyroid controls, but were not different between those patients who met the NIH criteria for parathyroidectomy and those who did not. Patients in both parathyroid groups benefited symptomatically after successful parathyroidectomy.

Pasieka Illness Questionnaire: its value in primary hyperparathyroidism

BACKGROUND

A prospective study was undertaken to assess the Pasieka Illness Questionnaire (PIQ) as a clinical evaluation and outcome tool in an Australian setting. The PIQ was specifically designed to assess the impact of surgery on the preoperative symptoms of patients with primary hyperparathyroidism (1 degrees HPT).

METHODS

Sixty of 71 consecutive patients referred with 1 degrees HPT completed the PIQ preoperatively and 3 months after parathyroid surgery. Fifty-four of the 60 patients filled in a 12-month follow-up questionnaire that included a quality of life (QOL) and a self-rated health uni-scale. Serum calcium, ionized calcium and parathyroid hormone levels were obtained on each occasion.

RESULTS

Eighty per cent of patients identified a significant decrease in symptoms following surgery. QOL and self-rated health improved after undergoing parathyroid surgery. Serum calcium levels returned to normal in 97% of patients 12 months after surgery.

CONCLUSIONS

The present study supports the use of the Pasieka Illness Questionnaire as a useful method to measure disease-specific symptoms in patients with 1 degrees HPT and is applicable to Australian patients. It also shows, once again, that parathyroid surgery produces a significant improvement in the preoperative symptoms of 1 degrees HPT.

Major Depression Due to Primary Hyperparathyroidism: A Frequent and Correctable Disorder

While primary hyperparathyroidism (1° HPT) is recognized as a correctable cause of nephrolithiasis and osteoporosis, its role as an organic cause of major depression is less clear. The rate of major depression in 1° HPT, response of symptoms to parathyroidectomy, and potential cost benefits were reviewed. From August 1994 to September 2002, 360 patients underwent parathyroidectomy for 1° HPT. Thirty-five patients met Diagnostic and Statistical Manual of Mental Disorders TV-Text Revision (DSM IV-TR) criteria for major depression. Postoperatively, a modified form of the Outcomes Institutes Health Status Questionnaire 2.0 was used to evaluate patient mood and continued need for antidepressant medication (ADM). Cost analysis of ADM use was performed. Thirty-five of 360 patients (10%) with 1° HPT met criteria for major depression. Thirteen of 35 (37%) required ADM preoperatively. Postoperatively, 29/35 (83%) patients responded to a phone survey: 90 per cent stated depression no longer impacted their ability to work or activities of daily living; 52 per cent reported an improved quality of life; 27 per cent discontinued preoperative ADM; and 27 per cent reduced their ADM dose. Reduction in ADM resulted in a savings of $700 to $3000 per patient per year. Major depression occurs in 10 per cent of patients undergoing parathyroidectomy for 1° HPT. Parathyroidectomy reduces symptoms of major depression, improves quality of life, and can eliminate or reduce the need for antidepressant medication in up to 54 per cent of patients.

Primary hyperparathyroidism: is there anything new?

Primary hyperparathyroidism remains the most common cause of hypercalcemia encountered in outpatient practice. Management of the asymptomatic patient with mild disease remains controversial. Surgery is the only curative therapy, and minimally invasive procedures are now possible.

Cohort study on effects of parathyroid surgery on multiple outcomes in primary hyperparathyroidism

OBJECTIVES

To assess the effects of surgery compared with conservative treatment (no surgery) for primary hyperparathyroidism.

DESIGN

Cohort study.

SETTING

Nationwide Danish cohort.

PARTICIPANTS

3213 patients, mean age 61 (SD 16) years, with a diagnosis of primary hyperparathyroidism between 1980 and 1999. 1934 (60%) underwent surgery and 1279 (40%) were treated conservatively.

MAIN OUTCOME MEASURES

Occurrence of fractures, osteoporosis, kidney or urinary tract stones, acute myocardial infarction, angina pectoris, cardiac arrhythmias, arterial hypertension, heart failure, stroke, acute pancreatitis, stomach or duodenal ulcers, muscle pain, malignant diseases, psychiatric disorders, and mortality.

RESULTS

At diagnosis of primary hyperparathyroidism, patients who subsequently underwent surgery had a lower prevalence of previous fracture (odds ratio 0.64, 95% confidence interval 0.51 to 0.80), acute myocardial infarction (0.59, 0.42 to 0.83), stroke (0.57, 0.37 to 0.88), psychiatric disorders (0.54, 0.31 to 0.94), and painful muscle disorders (0.44, 0.26 to 0.76), whereas kidney stones (2.49, 1.93 to 3.23) and acute pancreatitis (2.77, 1.33 to 5.76) were more prevalent. After diagnosis, the risks of fractures (hazards ratio 0.69, 0.56 to 0.84) and gastric ulcers (0.59, 0.41 to 0.84) were lower in patients treated surgically than those treated conservatively. Events involving kidney or urinary tact stones were more prevalent in patients treated surgically than patients treated conservatively (1.87, 1.30 to 2.68). Mortality was lower in patients treated surgically (0.65, 0.57 to 0.73).

CONCLUSIONS

Patients treated surgically for primary hyperparathyroidism have a lower prevalence of fractures and gastric ulcers than patients treated conservatively. The type of treatment had no effect on the occurrence of cardiovascular events.

Impact of Hypercalcemia and Parathyroid Hormone Level on the Sensitivity of Preoperative Sestamibi Scanning for Primary Hyperparathyroidism

Technetium 99m sestamibi scanning (MIBI) can direct unilateral parathyroidectomy. However, the clinical application remains variable with sensitivities ranging from 55 to 100 per cent. We examined whether patient factors including serum calcium (Ca) and parathyroid hormone (PTH) levels impact the sensitivity of MIBI. We completed a retrospective review of 102 patients with primary hyperparathyroidism and mild hypercalcemia who underwent preoperative MIBI. All patients underwent bilateral neck explorations with abnormalities confirmed by histopathology. MIBI sensitivity was correlated with preoperative Ca and PTH levels using univariate and logistic regression analysis. The mean preoperative Ca was 11.0 mg/dL and the mean PTH was 158 pg/mL. More than 95 per cent of patients with Ca greater than 11.3 mg/dL had a positive scan as compared with 60 per cent of those with lesser values ( P = 0.0024). Similarly a serum PTH level greater than 160 pg/mL correlated with positive scans in 93 per cent as opposed to 57 per cent in those with lower levels ( P = 0.006). Using a scan-directed approach 65 of 74 patients would have undergone unilateral exploration; this would yield a 7.7 per cent operative failure rate because of contralateral multigland disease. Lower Ca and PTH levels seem to correlate with reduced sensitivity of MIBI. Increasing acceptance of surgery for hyperparathyroidism with minimal hypercalcemia may make MIBI less attractive without ancillary diagnostic measures such as rapid parathormone assays.