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Lunardi N, Meier J, Stevens A, Milburn J, Oo Y, Hathiramani S, Soe K, Balentine C. Results of a novel intervention to increase rates of diagnosis and treatment of primary hyperparathyroidism. Am J Surg 2024:S0002-9610(24)00266-6. [PMID: 38755025 DOI: 10.1016/j.amjsurg.2024.04.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 03/31/2024] [Accepted: 04/26/2024] [Indexed: 05/18/2024]
Abstract
BACKGROUND Veterans with primary hyperparathyroidism are under diagnosed and undertreated. We report the results of a pilot study to address this problem. METHODS We implemented a stakeholder-driven, multi-component intervention to increase rates of diagnosis and treatment for primary hyperparathyroidism at a single VA hospital. Intervention effects were evaluated using an interrupted time series analysis. RESULTS The mean age of Veterans affected by the intervention was 67 years (SD 12.1) and 84 % were men. Compared to the pre-intervention period, the intervention doubled the proportion of Veterans who were appropriately evaluated for hyperparathyroidism (absolute difference 25 %, 95 % CI 11 %-38 %, p < 0.001) and increased referrals for treatment by 27 % (95 % CI 7 %-47 %, p < 0.012). CONCLUSION Our pilot study suggests it is feasible to address the underdiagnosis and undertreatment of primary hyperparathyroidism among Veterans.
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Affiliation(s)
- Nicole Lunardi
- Department of Surgery, University of Texas Southwestern, Dallas, TX, USA; Department of Surgery, North Texas VA Health Care System, Dallas, TX, USA
| | - Jennie Meier
- Department of Surgery, University of Texas Southwestern, Dallas, TX, USA; Department of Surgery, North Texas VA Health Care System, Dallas, TX, USA
| | - Audrey Stevens
- Department of Surgery, University of Texas Southwestern, Dallas, TX, USA; Department of Surgery, North Texas VA Health Care System, Dallas, TX, USA
| | - Joseph Milburn
- Department of Internal Medicine, University of Texas Southwestern, Dallas, TX, USA; Department of Internal Medicine, North Texas VA Health Care System, Dallas, TX, USA
| | - Yin Oo
- Department of Internal Medicine, University of Texas Southwestern, Dallas, TX, USA; Department of Internal Medicine, North Texas VA Health Care System, Dallas, TX, USA
| | - Sumitha Hathiramani
- Department of Internal Medicine, University of Texas Southwestern, Dallas, TX, USA; Department of Internal Medicine, North Texas VA Health Care System, Dallas, TX, USA
| | - Kyaw Soe
- Department of Internal Medicine, University of Texas Southwestern, Dallas, TX, USA; Department of Internal Medicine, North Texas VA Health Care System, Dallas, TX, USA
| | - Courtney Balentine
- University of Wisconsin-Madison, Department of Surgery, USA; Wisconsin Surgical Outcomes Research Program, Madison, WI, USA; William S. Middleton VA, Madison, WI, USA.
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Liang G, Kaur MN, Wade CG, Edelen MO, Bates DW, Pusic AL, Liu JB. Patient-reported outcome measures for primary hyperparathyroidism: a systematic review of measurement properties. Health Qual Life Outcomes 2024; 22:31. [PMID: 38566079 PMCID: PMC10988805 DOI: 10.1186/s12955-024-02248-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 03/25/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND The quality of patient-reported outcome measures (PROMs) used to assess the outcomes of primary hyperparathyroidism (PHPT), a common endocrine disorder that can negatively affect patients' health-related quality of life due to chronic symptoms, has not been rigorously examined. This systematic review aimed to summarize and evaluate evidence on the measurement properties of PROMs used in adult patients with PHPT, and to provide recommendations for appropriate measure selection. METHODS After PROSPERO registration (CRD42023438287), Medline, EMBASE, CINAHL Complete, Web of Science, PsycINFO, and Cochrane Trials were searched for full-text articles in English investigating PROM development, pilot studies, or evaluation of at least one PROM measurement property in adult patients with any clinical form of PHPT. Two reviewers independently identified studies for inclusion and conducted the review following the Consensus-Based Standards for the Selection of Health Measurement Instruments (COSMIN) Methodology to assess risk of bias, evaluate the quality of measurement properties, and grade the certainty of evidence. RESULTS From 4989 records, nine PROM development or validation studies were identified for three PROMs: the SF-36, PAS, and PHPQoL. Though the PAS demonstrated sufficient test-retest reliability and convergent validity, and the PHPQoL sufficient test-retest reliability, convergent validity, and responsiveness, the certainty of evidence was low-to-very low due to risk of bias. All three PROMs lacked sufficient evidence for content validity in patients with PHPT. CONCLUSIONS Based upon the available evidence, the SF-36, PAS, and PHPQoL cannot currently be recommended for use in research or clinical care, raising important questions about the conclusions of studies using these PROMs. Further validation studies or the development of more relevant PROMs with strong measurement properties for this patient population are needed.
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Affiliation(s)
- George Liang
- Patient-Reported Outcomes, Value, and Experience (PROVE) Center, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Manraj N Kaur
- Patient-Reported Outcomes, Value, and Experience (PROVE) Center, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | | | - Maria O Edelen
- Patient-Reported Outcomes, Value, and Experience (PROVE) Center, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - David W Bates
- Harvard Medical School, Boston, MA, USA
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
- Clinical and Quality Analysis, Information Systems, Mass General Brigham, Boston, MA, USA
| | - Andrea L Pusic
- Patient-Reported Outcomes, Value, and Experience (PROVE) Center, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Division of Plastic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Jason B Liu
- Patient-Reported Outcomes, Value, and Experience (PROVE) Center, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
- Division of Surgical Oncology, Brigham and Women's Hospital, Boston, MA, USA.
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Patel AM, Shaari AL, Aftab OM, Lemdani MS, Choudhry HS, Filimonov A. Sex-Stratified Predictors of Prolonged Operative Time and Hospital Admission in Outpatient Parathyroidectomy. Indian J Otolaryngol Head Neck Surg 2024; 76:1910-1920. [PMID: 38566654 PMCID: PMC10982178 DOI: 10.1007/s12070-023-04444-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 12/13/2023] [Indexed: 04/04/2024] Open
Abstract
Our retrospective database study investigates sex-stratified predictors of prolonged operative time (POT) and hospital admission following parathyroidectomy for primary hyperparathyroidism (PHPT). The 2016 to 2018 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) was queried for patients with PHPT undergoing parathyroidectomy. Cases analyzed were all outpatient status, arrived from home, coded as non-emergent, and elective. POT was defined by the 75th percentile. Hospital admission was defined as LOS ≥ 1 day. Univariate and multivariable binary logistic regressions were utilized. Of 7442 cases satisfying inclusion criteria, the majority were female (78.0%) and White (78.5%). Median OT (IQR) for females and males was 77 (58-108) and 81 (61-109) minutes, respectively (P = 0.003). 1965 (33.9%) females and 529 (32.3%) males required hospital admission. Independent predictors of POT included ASA class III/IV (aOR 1.342, 95% CI 1.007-1.788) and obesity (aOR 1.427, 95% CI 1.095-1.860) for males (P < 0.05). Independent predictors of hospital admission included age (aOR 1.008, 95% CI 1.002-1.014), ASA class III/IV (aOR 1.490, 95% CI 1.301-1.706), obesity (aOR 1.309, 95% CI 1.151-1.489), dyspnea (aOR 1.394, 95% CI 1.041-1.865), chronic steroid use (aOR 1.674, 95% CI 1.193-2.351), and COPD (aOR 1.534, 95% CI 1.048-2.245) for females (P < 0.05); and ASA class III/IV (aOR 1.931, 95% CI 1.483-2.516) and bleeding disorder (aOR 2.752, 95% CI 1.443-5.247) for males (P < 0.005). In conclusion, predictors of POT and hospital admission following parathyroidectomy for PHPT differed by patient sex. Identifying patients at risk for POT and hospital admission may optimize healthcare resource utilization. Level of Evidence: IV. Supplementary Information The online version contains supplementary material available at 10.1007/s12070-023-04444-3.
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Affiliation(s)
- Aman M. Patel
- Department of Otolaryngology – Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NJ USA
| | - Ariana L. Shaari
- Department of Otolaryngology – Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NJ USA
| | - Owais M. Aftab
- Department of Otolaryngology – Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NJ USA
| | - Mehdi S. Lemdani
- Department of Otolaryngology – Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NJ USA
| | - Hassaam S. Choudhry
- Department of Otolaryngology – Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NJ USA
| | - Andrey Filimonov
- Department of Otolaryngology – Head and Neck Surgery, Rutgers New Jersey Medical School, Newark, NJ USA
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Bunch PM, Rigdon J, Lenchik L, Gorris MA, Randle RW. Testing for Primary Hyperparathyroidism in 17,491 Patients With Hypercalcemia. J Surg Res 2024; 296:456-464. [PMID: 38320365 DOI: 10.1016/j.jss.2024.01.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 11/08/2023] [Accepted: 01/07/2024] [Indexed: 02/08/2024]
Abstract
BACKGROUND Primary hyperparathyroidism (PHPT) is underdiagnosed and associated with many adverse health effects. Historically, many hypercalcemic patients have not received parathyroid hormone (PTH) testing; however, underlying reasons are uncertain. Our goals are to determine the PTH testing rate among hypercalcemic individuals at a large academic health system and to assess for characteristics associated with testing versus not testing for PHPT to inform future strategies for closing testing gaps. METHODS This retrospective study included adult patients with ≥1 elevated serum calcium result between 2018 and 2022. Based on the presence or absence of a serum PTH result, individuals were classified as "screened" versus "unscreened" for PHPT. Demographic and clinical characteristics of these groups were compared. RESULTS The sample comprised 17,491 patients: 6567 male (37.5%), 10,924 female (62.5%), mean age 59 y. PTH testing was performed in 6096 (34.9%). Characteristics independently associated with the greatest odds of screening were 5+ elevated calcium results (odds ratio [OR] 5.02, P < 0.0001), chronic kidney disease (OR 3.63, P < 0.0001), maximum calcium >12.0 mg/dL (OR 2.48, P < 0.0001), and osteoporosis (OR 2.42, P < 0.0001). Characteristics associated with lowest odds of screening were age <35 y (OR 0.60, P < 0.0001), death during the study period (OR 0.68, P < 0.0001), age ≥85 y (OR 0.70, P = 0.0007), and depression (OR 0.84; P = 0.0081). CONCLUSIONS Only 35% of hypercalcemic patients received PTH testing. Although the presence of PHPT-associated morbidity was generally associated with increased rates of screening, hypercalcemic patients with depression were 16% less likely to be tested.
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Affiliation(s)
- Paul M Bunch
- Department of Radiology, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina.
| | - Joseph Rigdon
- Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina
| | - Leon Lenchik
- Department of Radiology, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina
| | - Matthew A Gorris
- Department of Endocrinology, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina
| | - Reese W Randle
- Department of Surgery, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, North Carolina
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Moore CD, Azam B, Do H, Williamson K, Chambers AH, Ghani MOAA. Underdiagnosis of Hyperparathyroidism in Patients With Nephrolithiasis in a Community Setting. Cureus 2023; 15:e49290. [PMID: 38143641 PMCID: PMC10748449 DOI: 10.7759/cureus.49290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2023] [Indexed: 12/26/2023] Open
Abstract
Objective Untreated primary hyperparathyroidism (PHPT) has wide-ranging multisystemic effects. Recent studies based in the US have shown a less than 25% screening rate for PHPT. Our study aims to detect whether similar deficiencies exist in our community healthcare system while quantifying the prevalence of PHPT underdiagnosis and inadequate surgical referrals. Study design This retrospective quantitative study enrolled patients aged ≥18 years with imaged-confirmed nephrolithiasis at our healthcare facilities from 2017 to the present (n=2021). Patients with documented calcium levels and kidney/ureter stones were included. Descriptive and univariate analyses were performed. Results A total of 2021 subjects met the criteria to be enrolled in the study. 26.6% (n=537) of patients with nephrolithiasis had elevated calcium levels on record. 13.6% (n=73) of hypercalcemic patients were screened for PHPT with an intact parathyroid hormone (PTH). A majority (63%, n=46) of patients with intact PTH had PHPT defined as PTH levels >55 pg/mL. Ultimately, only 19.6% (n=9) of patients with PHPT were referred for surgical intervention, and there was no significant difference in referral rate between patients with PHPT and those without (p=0.913). Conclusions PHPT is underdiagnosed in our community, leading to a significantly low rate of surgical referral and delay in management. Implementation of hospital protocols to aid in improving diagnosis and interventions could improve outcomes for PHPT patients.
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Affiliation(s)
- Cameron D Moore
- General Surgery, University of Kentucky Bowling Green Campus, The Medical Center, Bowling Green, USA
| | - Bassil Azam
- Trauma and Orthopaedics, Maidstone and Tunbridge Wells NHS Trust, Kent, GBR
| | - Helena Do
- General Surgery, University of Kentucky Bowling Green Campus, The Medical Center, Bowling Green, USA
| | - Kayla Williamson
- Surgery, University of Kentucky Bowling Green Campus, The Medical Center, Bowling Green, USA
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Sada A, Hanson KT, Habermann EB, McKenzie TJ, Lyden ML, Foster TR, Clarke BL, Dy BM. Disparities in Parathyroidectomy: Who Receives Appropriate Treatment for Primary Hyperparathyroidism? J Surg Res 2023; 291:151-157. [PMID: 37399633 DOI: 10.1016/j.jss.2023.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 05/05/2023] [Accepted: 05/15/2023] [Indexed: 07/05/2023]
Abstract
INTRODUCTION Parathyroidectomy is underperformed despite clear benefits in primary hyperparathyroidism (PHPT). We evaluated disparities in receipt of parathyroidectomy following PHPT diagnosis to explore barriers to care. METHODS Adults diagnosed with PHPT 2013-2018 at a health system were identified. Recommended indications for parathyroidectomy include age ≤50 y, calcium >11 mg/dL, or the presence of nephrolithiasis, hypercalciuria, nephrocalcinosis, decreased glomerular filtration rate, osteopenia, osteoporosis, or pathological fracture 1 y prior to diagnosis. Kaplan-Meier analysis assessed rates of parathyroidectomy within 12 mo following diagnosis as well as median time to parathyroidectomy, and multivariable Cox proportional hazards analyses assessed factors associated with undergoing parathyroidectomy. RESULTS Of 2409 patients, 75% were females, 12% aged ≤50 y, and 92% non-Hispanic White, while 52% had Medicaid/Medicare, 36% were commercial/self-pay or uninsured, and 12% unknown. Parathyroidectomy was performed within 1 y in 50% of patients. Within the 68% that met recommendations, parathyroidectomy was performed within 1 y in 54%; median time from diagnosis to surgery was shorter for males, patients aged ≤50 y, commercial/self-pay/no insurance patients (versus Medicaid/Medicare), and those with fewer comorbidities, P < 0.05. Multivariable analysis demonstrated non-Hispanic White patients and those with commercial/self-pay/uninsured were more likely to undergo parathyroidectomy after adjusting for comorbidity, age, and facility site. Among those strongly indicated, patients not on Medicare/Medicaid and aged ≤50 y were more likely to undergo parathyroidectomy after adjusting for race, comorbidity, and facility site. CONCLUSIONS Disparities in parathyroidectomy for PHPT were observed. Insurance type was associated with undergoing parathyroidectomy; patients on governmental insurance were less likely to undergo surgery and waited longer for surgery despite strong indications. Barriers to referral and access to surgery should be investigated and addressed to optimize all patients' access to care.
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Affiliation(s)
- Alaa Sada
- Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Kristine T Hanson
- Division of Health Care Delivery Research, Mayo Clinic, Rochester, Minnesota
| | | | | | | | | | - Bart L Clarke
- Division of Endocrinology, Mayo Clinic, Rochester, Minnesota
| | - Benzon M Dy
- Department of Surgery, Mayo Clinic, Rochester, Minnesota.
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Bartz-Kurycki MA, Dream S, Yen TW, Doffek K, Shaker J, Evans DB, Wang TS. Older Patients With Asymptomatic Primary Hyperparathyroidism: Should Criteria for Surgery Be Expanded? J Endocr Soc 2023; 7:bvad098. [PMID: 37873505 PMCID: PMC10590644 DOI: 10.1210/jendso/bvad098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Indexed: 10/25/2023] Open
Abstract
Context Patients with primary hyperparathyroidism (PHPT) can present with variable signs, symptoms, and end-organ effects. Clinical practice guidelines influence referral for consideration of parathyroidectomy. Objective This study compared the demographic, biochemical, and symptom profile and examine indications for surgery in patients older than 50 years who underwent parathyroidectomy to determine how changes to current guidelines may affect recommendations for parathyroidectomy. Methods A retrospective review was conducted of patients age 50 years or older who underwent initial parathyroidectomy for sporadic PHPT from 2012 to 2020. Patients were classified by indications for surgery per guideline criteria (classic, asymptomatic, and no criteria met) and age group (AG): 50 to 59 years; 60 to 69 years; 70 years or older. Patients were treated at a high-volume tertiary medical center by endocrine surgeons. Results Of 1182 patients, 367 (31%) classic and 660 (56%) asymptomatic patients met the criteria for surgery. The most common indications for surgery were extent of hypercalcemia (51%), osteoporosis (28%), and nephrolithiasis (27%). Of the 155 (13%) patients who did not meet the criteria, neurocognitive symptoms (AG1: 88% vs AG2: 81% vs AG3: 70%; P = .14) and osteopenia (AG1: 53% vs AG2: 68% vs AG3: 68%; P = .43) were frequently observed regardless of patient age. If the age threshold of younger than 50 years was expanded to 60, 65, or 70 years, an additional 61 (5%), 99 (8%), and 124 (10%) patients in the entire cohort would have met the guideline criteria for surgery, respectively. Conclusion Expanding current guidelines for PHPT to include a broader age range, osteopenia, and neurocognitive symptoms may allow for earlier surgical referral and evaluation for definitive treatment.
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Affiliation(s)
| | - Sophie Dream
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Tina W Yen
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Kara Doffek
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Joseph Shaker
- Division of Endocrinology, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Douglas B Evans
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Tracy S Wang
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA
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Bunch PM, Aribindi S, Gorris MA, Randle RW. Opportunistic CT Assessment of Parathyroid Glands: Utility of Radiologist-Recommended Biochemical Evaluation for Diagnosing Primary Hyperparathyroidism. AJR Am J Roentgenol 2023; 221:218-227. [PMID: 36946894 DOI: 10.2214/ajr.23.29049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
BACKGROUND. Existing gaps in primary hyperparathyroidism (PHPT) diagnosis and treatment have prompted calls for systemic change in the approach to this disease. One proposed change is opportunistic assessment for enlarged parathyroid glands on routine CT examinations, to target biochemical testing to individuals most likely to have un-diagnosed PHPT. OBJECTIVE. The purpose of our study was to assess the utility of a radiologist recommendation for biochemical testing in patients with a suspected enlarged parathyroid gland on routine CT for identifying previously undiagnosed PHPT. METHODS. This retrospective study included patients without known or suspected PHPT who underwent routine CT (i.e., performed for reasons other than known or suspected parathyroid disease) between August 2019 and September 2021 in which the clinical CT report included a radiologist recommendation for biochemical testing to evaluate for possible PHPT because of a suspected enlarged parathyroid gland. Neuroradiologists at the study institution included this recommendation on the basis of individual judgment without formal criteria. The EHR was reviewed to identify patients who underwent subsequent laboratory evaluation for PHPT. An endocrine surgeon used available laboratory results and clinical data to classify patients as having PHPT, secondary hyper-parathyroidism, or no parathyroid disorder independent of the CT findings. RESULTS. The sample comprised 39 patients (median age, 68 years; 20 women, 19 men) who received the radiologist recommendation for biochemical evaluation. Of these patients, 13 (33.3%) received the recommended biochemical evaluation. Of the 13 tested patients, three (23.1%) were classified as having PHPT, four (30.8%) as having secondary hyperparathyroidism, and six (46.2%) as having no parathyroid disorder. Thus, the number of patients needing to receive a radiologist recommendation for biochemical testing per correct PHPT diagnosis was 13.0, and the number of patients needing to undergo laboratory testing per correct PHPT diagnosis was 4.3. One of the three patients classified as having PHPT underwent surgical resection of the lesion identified by CT, which was shown on histopathologic evaluation to represent hypercellular parathyroid tissue. CONCLUSION. Radiologist recommendations for biochemical testing in patients with suspected enlarged parathyroid glands on routine CT helped to identify individuals with undiagnosed PHPT. CLINICAL IMPACT. Opportunistic assessment for enlarged parathyroid glands on routine CT may facilitate PHPT diagnosis.
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Affiliation(s)
- Paul M Bunch
- Department of Radiology, Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157
| | - Swetha Aribindi
- Department of Radiology, Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157
| | - Matthew A Gorris
- Department of Endocrinology, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Reese W Randle
- Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, NC
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Zhu CY, Zhou HX, Tseng CH, Fackelmayer OJ, Haigh PI, Adams AL, Yeh MW. Long-term effects of primary hyperparathyroidism and parathyroidectomy on kidney function. Eur J Endocrinol 2023; 189:115-122. [PMID: 37449311 DOI: 10.1093/ejendo/lvad081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 04/10/2023] [Accepted: 06/23/2023] [Indexed: 07/18/2023]
Abstract
IMPORTANCE Limited evidence supports kidney dysfunction as an indication for parathyroidectomy in asymptomatic primary hyperparathyroidism (PHPT). OBJECTIVE To investigate the natural history of kidney function in PHPT and whether parathyroidectomy alters renal outcomes. DESIGN Matched control study. SETTING A vertically integrated health care system serving 4.6 million patients in Southern California. PARTICIPANTS 6058 subjects with PHPT and 16 388 matched controls, studied from 2000 to 2016. EXPOSURES Biochemically confirmed PHPT with varying serum calcium levels. MAIN OUTCOMES Estimated glomerular filtration rate (eGFR) trajectories were compared over 10 years, with cases subdivided by severity of hypercalcemia: serum calcium 2.62-2.74 mmol/L (10.5-11 mg/dL), 2.75-2.87 (11.1-11.5), 2.88-2.99 (11.6-12), and >2.99 (>12). Interrupted time series analysis was conducted among propensity-score-matched PHPT patients with and without parathyroidectomy to compare eGFR trajectories postoperatively. RESULTS Modest rates of eGFR decline were observed in PHPT patients with serum calcium 2.62-2.74 mmol/L (−1.0 mL/min/1.73 m2/year) and 2.75-2.87 mmol/L (−1.1 mL/min/1.73 m2/year), comprising 56% and 28% of cases, respectively. Compared with the control rate of −1.0 mL/min/1.73 m2/year, accelerated rates of eGFR decline were observed in patients with serum calcium 2.88-2.99 mmol/L (−1.5 mL/min/1.73 m2/year, P < .001) and >2.99 mmol/L (−2.1 mL/min/1.73 m2/year, P < .001), comprising 9% and 7% of cases, respectively. In the propensity score–matched population, patients with serum calcium >2.87 mmol/L exhibited mitigation of eGFR decline after parathyroidectomy (−2.0 [95% CI: −2.6 to −1.5] to −0.9 [95% CI: −1.5 to 0.4] mL/min/1.73 m2/year). CONCLUSIONS AND RELEVANCE Compared with matched controls, accelerated eGFR decline was observed in the minority of PHPT patients with serum calcium >2.87 mmol/L (11.5 mg/dL). Parathyroidectomy was associated with mitigation of eGFR decline in patients with serum calcium >2.87 mmol/L.
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Affiliation(s)
- Catherine Y Zhu
- Section of Endocrine Surgery, Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA 90095, United States
| | - Hui X Zhou
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, United States
| | - Chi-Hong Tseng
- Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, CA, United States
| | - Oliver J Fackelmayer
- Section of Endocrine Surgery, Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA 90095, United States
| | - Philip I Haigh
- Department of Surgery, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, United States
| | - Annette L Adams
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
| | - Michael W Yeh
- Section of Endocrine Surgery, Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA 90095, United States
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Seib CD, Ganesan C, Furst A, Pao AC, Chertow GM, Leppert JT, Suh I, Montez-Rath ME, Harris AHS, Trickey AW, Kebebew E, Kurella Tamura M. Estimated Effect of Parathyroidectomy on Long-Term Kidney Function in Adults With Primary Hyperparathyroidism. Ann Intern Med 2023; 176:624-631. [PMID: 37037034 PMCID: PMC10866201 DOI: 10.7326/m22-2222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/12/2023] Open
Abstract
BACKGROUND Multidisciplinary guidelines recommend parathyroidectomy to slow the progression of chronic kidney disease in patients with primary hyperparathyroidism (PHPT) and an estimated glomerular filtration rate (eGFR) less than 60 mL/min/1.73 m2. Limited data address the effect of parathyroidectomy on long-term kidney function. OBJECTIVE To compare the incidence of a sustained decline in eGFR of at least 50% among patients with PHPT treated with parathyroidectomy versus nonoperative management. DESIGN Target trial emulation was done using observational data from adults with PHPT, using an extended Cox model with time-varying inverse probability weighting. SETTING Veterans Health Administration. PATIENTS Patients with a new biochemical diagnosis of PHPT in 2000 to 2019. MEASUREMENTS Sustained decline of at least 50% from pretreatment eGFR. RESULTS Among 43 697 patients with PHPT (mean age, 66.8 years), 2928 (6.7%) had a decline of at least 50% in eGFR over a median follow-up of 4.9 years. The weighted cumulative incidence of eGFR decline was 5.1% at 5 years and 10.8% at 10 years in patients managed with parathyroidectomy, compared with 5.1% and 12.0%, respectively, in those managed nonoperatively. The adjusted hazard of eGFR decline did not differ between parathyroidectomy and nonoperative management (hazard ratio [HR], 0.98 [95% CI, 0.82 to 1.16]). Subgroup analyses found no heterogeneity of treatment effect based on pretreatment kidney function. Parathyroidectomy was associated with a reduced hazard of the primary outcome among patients younger than 60 years (HR, 0.75 [CI, 0.59 to 0.93]) that was not evident among those aged 60 years or older (HR, 1.08 [CI, 0.87 to 1.34]). LIMITATION Analyses were done in a predominantly male cohort using observational data. CONCLUSION Parathyroidectomy had no effect on long-term kidney function in older adults with PHPT. Potential benefits related to kidney function should not be the primary consideration for PHPT treatment decisions. PRIMARY FUNDING SOURCE National Institute on Aging.
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Affiliation(s)
- Carolyn D Seib
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine; Division of General Surgery, Palo Alto Veterans Affairs Health Care System; and Geriatric Research, Education and Clinical Center, Veterans Affairs Palo Alto, Palo Alto, California (C.D.S.)
| | - Calyani Ganesan
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California (C.G., M.E.M.)
| | - Adam Furst
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine, Palo Alto, California (A.F., A.W.T.)
| | - Alan C Pao
- Division of Nephrology, Department of Medicine, and Department of Urology, Stanford University School of Medicine, Palo Alto, California (A.C.P., J.T.L.)
| | - Glenn M Chertow
- Division of Nephrology, Department of Medicine, and Department of Epidemiology and Population Health, Stanford University School of Medicine, Palo Alto, California (G.M.C.)
| | - John T Leppert
- Division of Nephrology, Department of Medicine, and Department of Urology, Stanford University School of Medicine, Palo Alto, California (A.C.P., J.T.L.)
| | - Insoo Suh
- Department of Surgery, New York University Grossman School of Medicine, New York, New York (I.S.)
| | - Maria E Montez-Rath
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California (C.G., M.E.M.)
| | - Alex H S Harris
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine, and Center for Innovation to Implementation, Veterans Affairs Palo Alto, Palo Alto, California (A.H.S.H.)
| | - Amber W Trickey
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine, Palo Alto, California (A.F., A.W.T.)
| | - Electron Kebebew
- Department of Surgery, Stanford University School of Medicine, Palo Alto, California (E.K.)
| | - Manjula Kurella Tamura
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, and Geriatric Research, Education and Clinical Center, Veterans Affairs Palo Alto, Palo Alto, California (M.K.T.)
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11
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Green RL, Karhadkar SS, Kuo LE. Missed Opportunities to Diagnose and Treat Tertiary Hyperparathyroidism After Transplant. J Surg Res 2023; 287:8-15. [PMID: 36857809 DOI: 10.1016/j.jss.2023.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 01/12/2023] [Accepted: 01/30/2023] [Indexed: 03/03/2023]
Abstract
INTRODUCTION Tertiary hyperparathyroidism (3HPT) is common after renal transplant. However, guidelines for diagnosis are not clear and few patients are treated surgically. This study aims to determine rates of diagnosis and treatment of 3HPT in renal transplant patients with hypercalcemia. MATERIALS AND METHODS This retrospective chart review identified all renal transplant recipients at a single tertiary care institution between 2011 and 2021. Patients with post-transplant hypercalcemia (> 10.2 mg/dL) were identified. The time in months of index hypercalcemia was noted. Measurement of parathyroid hormone (PTH) levels after index hypercalcemia was determined and noted as elevated if > 64 pg/mL at least 6 mo after transplant. Documentation of symptoms of hyperparathyroidism, a diagnosis of hyperparathyroidism in the electronic medical record, and medical or surgical management of patients with classic 3HPT (elevated calcium and PTH) were determined. RESULTS Of 383 renal transplant recipients, hypercalcemia was identified in 132 patients. The majority of hypercalcemic patients had PTH levels measured (127, 96.2%). PTH was elevated in 109 (82.6%). Among the 109 patients with classic 3HPT, 54 (49.5%) had a documented diagnosis of hyperparathyroidism in the electronic medical record (P = 0.01). Kidney stones or abnormal DEXA scan were present in 16 (14.7%) and 18 (16.5%), respectively. Most patients were managed non-surgically (101, 92.6%); calcimimetics were prescribed for 42 (38.5%, P = 0.01). Eight (7.3%) patients with classic 3HPT were referred to a surgeon (P = 0.35); all were initially prescribed calcimimetics (P = 0.001). CONCLUSIONS 3HPT is underdiagnosed in patients with elevated calcium and PTH levels post-transplant. A significant percentage of these patients go without surgical referral and curative treatment.
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Affiliation(s)
- Rebecca L Green
- Temple University Lewis Katz School of Medicine, Department of General Surgery, Philadelphia, Pennsylvania.
| | - Sunil S Karhadkar
- Temple University Lewis Katz School of Medicine, Department of General Surgery, Philadelphia, Pennsylvania
| | - Lindsay E Kuo
- Temple University Lewis Katz School of Medicine, Department of General Surgery, Philadelphia, Pennsylvania
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12
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Horowitz G, Leshno M, Izkhakov E, Halpern D, Muhanna N, Greenman Y, Ungar OJ, Carmel-Neidermann NN, Kampel L, Warshavsky A. Revisiting Age Criterion for Surgery in Asymptomatic Primary Hyperparathyroidism. Otolaryngol Head Neck Surg 2023. [PMID: 36808632 DOI: 10.1002/ohn.298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 01/21/2023] [Accepted: 01/27/2023] [Indexed: 02/19/2023]
Abstract
OBJECTIVE To revisit the current age criterion (50 years) for surgical candidacy in patients diagnosed with asymptomatic primary hyperparathyroidism (PHPT). STUDY DESIGN A predictive model relying on past publications using the electronic databases "PubMed," "Embase," "Medline," and "Google Scholar." SETTING Hypothetical large cohort. METHODS A Markov model was constructed, based on relevant literature, to compare 2 potential treatment algorithms for asymptomatic PHPT patients, parathyroidectomy (PTX), and observation. The various potential health states were characterized for the 2 treatment options and included potential surgical complications, end-organ deterioration, and death. A 1-way sensitivity analysis was performed to calculate the quality-adjusted life year (QALY) gains of both strategies. A Monte-Carlo simulation for 30,000 subjects was performed and cycled per annum. RESULTS On the basis of the model's assumptions, the QALY value for the PTX strategy was 19.17 versus 17.82 for the observation strategy. The incremental QALY gains for various ages according to the sensitivity analyses for PTX in comparison to observation were: 2.84 QALY for 40-year-old patients, 2.2 QALY for 50-year-old patients, 1.81 QALY for 55-year-old patients, 1.35 QALY for 60-year-old patients, and 0.86 QALY for 65-year-old patients. The incremental QALY is below 0.5 after the age of 75 years. CONCLUSION This study found PTX to be advantageous for asymptomatic PHPT patients older than the current age criterion of 50 years. The calculated QALY gains support a surgical approach for medically fit patients in their 50s. The current guidelines for the surgical treatment of young asymptomatic PHPT patients should be revisited by the next steering committee.
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Affiliation(s)
- Gilad Horowitz
- Department of Otolaryngology-Head and Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center (Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University), Tel-Aviv, Israel
| | - Moshe Leshno
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Coller School of Management, Tel-Aviv University, Tel-Aviv, Israel
| | - Elena Izkhakov
- The Institute of Endocrinology, Metabolism and Hypertension, Tel-Aviv Sourasky Medical Center, (Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University), Tel-Aviv, Israel
| | - Daniel Halpern
- Department of Otolaryngology-Head and Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center (Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University), Tel-Aviv, Israel
| | - Nidal Muhanna
- Department of Otolaryngology-Head and Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center (Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University), Tel-Aviv, Israel
| | - Yona Greenman
- The Institute of Endocrinology, Metabolism and Hypertension, Tel-Aviv Sourasky Medical Center, (Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University), Tel-Aviv, Israel
| | - Omer J Ungar
- Department of Otolaryngology-Head and Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center (Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University), Tel-Aviv, Israel
| | - Narin N Carmel-Neidermann
- Department of Otolaryngology-Head and Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center (Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University), Tel-Aviv, Israel
| | - Liyona Kampel
- Department of Otolaryngology-Head and Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center (Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University), Tel-Aviv, Israel
| | - Anton Warshavsky
- Department of Otolaryngology-Head and Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center (Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University), Tel-Aviv, Israel
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13
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Parathyroidectomy for primary hyperparathyroidism: A retrospective analysis of localization, surgical characteristics, and treatment outcomes. Asian J Surg 2023; 46:788-793. [PMID: 35850895 DOI: 10.1016/j.asjsur.2022.07.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 06/11/2022] [Accepted: 07/07/2022] [Indexed: 02/08/2023] Open
Abstract
OBJECTIVE To evaluate parathyroidectomy for primary hyperparathyroidism (PHPT) regarding localization, surgical characteristics, and treatment outcomes. METHODS Seventy-eight patients who underwent parathyroidectomy for PHPT were retrospectively reviewed. The results were analyzed according to intraoperative localization technique (IOLT), intraoperative parathyroid hormone (IOPTH) monitoring, and intraoperative nerve monitoring (IONM). The localization accuracy of ultrasonography (US), computed tomography (CT), and single-photon emission computed tomography (SPECT)-CT with sestamibi Tc99m was evaluated. RESULTS Parathyroidectomy was successfully completed in all 78 patients, achieving 100% surgical cure. For 60 patients with IOPTH monitoring, 10-min IOPTH decreased >50% from baseline in 57 (95.0%), and they achieved surgical cure. In the remaining three (5.0%) patients with ≤50% decrease in 10-min IOPTH, 20-min IOPTH decreased >50% from baseline in two (3.3%) patients, achieving surgical cure without additional neck exploration. There were no differences in surgical cure and complications as a function of IOLT use or IOPTH monitoring. Operating time was significantly shorter with IOLT and IOPTH monitoring than without (IOLT: 70.9 min vs. 88.0 min, p = 0.013; IOPTH: 74.9 min vs. 91.9 min, p = 0.037). All 78 patients had adenoma including one patient with a double adenoma. Vocal cord paralysis was not observed in our series, regardless of IONM. US, CT, and SPECT-CT localized the pathological parathyroid gland accurately in 88.1%, 85.5%, and 86.8% of patients, respectively (p = 0.894). CONCLUSION The surgical outcomes of parathyroidectomy for PHPT were excellent regardless of IOLT and IOPTH monitoring. However, these techniques can maximize the performance of parathyroid surgery by reducing operating time and rescuing challenging cases.
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14
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Lorenz FJ, Beauchamp-Perez F, Manni A, Chung T, Goldenberg D, Goyal N. Analysis of Time to Diagnosis and Outcomes Among Adults With Primary Hyperparathyroidism. JAMA Netw Open 2022; 5:e2248332. [PMID: 36574247 PMCID: PMC9857508 DOI: 10.1001/jamanetworkopen.2022.48332] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
IMPORTANCE Despite access to routine laboratory evaluation, primary hyperparathyroidism (PHP) remains underdiagnosed and undertreated. OBJECTIVE To determine the consequences associated with missed diagnoses and prolonged time to diagnosis and treatment of PHP. DESIGN, SETTING, AND PARTICIPANTS This is a retrospective cohort study of patients older than 40 years with 2 instances of hypercalcemia during 2010 to 2020 and 3 years of follow-up. Patients were recruited from 63 health care organizations in the TriNetX Research Network. Data analysis was performed from January 2010 to September 2020. EXPOSURES Elevated serum calcium. MAIN OUTCOMES AND MEASURES Existing symptoms and diagnoses associated with PHP (osteoporosis, fractures, urolithiasis, major depressive disorder, anxiety, hypertension, gastroesophageal reflux disease, malaise or fatigue, joint pain or myalgias, constipation, insomnia, polyuria, weakness, abdominal pain, headache, nausea, amnesia, and gallstones) compared in patients deemed high-risk and without a diagnosis and matched controls, and those who experienced times from documented hypercalcemia to diagnosis and diagnosis to treatment within or beyond 1 year. RESULTS There were 135 034 patients analyzed (96 554 women [72%]; 28 892 Black patients [21%] and 88 010 White patients [65%]; 3608 Hispanic patients [3%] and 98 279 non-Hispanic patients [73%]; mean [SD] age, 63 [10] years). Two groups without a documented diagnosis of PHP were identified as high risk: 20 176 patients (14.9%) with parathyroid hormone greater than or equal to 50 pg/mL and 24 905 patients (18.4%) with no parathyroid hormone level obtained or recorded explanation for hypercalcemia. High-risk patients experienced significantly increased rates of all associated symptoms and diagnoses compared with matched controls. Just 9.7% of those with hypercalcemia (13 136 patients) had a diagnosis of PHP. Compared with individuals who received a diagnosis within 1 year of hypercalcemia, those whose workup exceeded 1 year had significantly increased rates of major depressive disorder, anxiety, hypertension, gastroesophageal reflux disease, malaise or fatigue, joint pain or myalgias, polyuria, weakness, abdominal pain, and headache at 3 years. The rate of osteoporosis increased from 17.1% (628 patients) to 25.4% (935 patients) over the study period in the group with delayed diagnosis. Among those with a diagnosis, 5280 patients (40.2%) underwent parathyroidectomy. Surgery beyond 1 year of diagnosis was associated with significantly increased rates of osteoporosis and hypertension at 3 years after diagnosis compared with those treated within 1 year. CONCLUSIONS AND RELEVANCE Many patients were at high risk for PHP without a documented diagnosis. Complications in these patients, as well as those who received a diagnosis after prolonged workup or time to treatment, resulted in patient harm. System-level interventions are necessary to ensure proper diagnosis and prompt treatment of PHP.
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Affiliation(s)
| | - Francis Beauchamp-Perez
- Department of Otolaryngology–Head and Neck Surgery, Penn State Hershey Medical Center, Hershey, Pennsylvania
| | - Andrea Manni
- Division of Endocrinology and Diabetes, Department of Medicine, Penn State Hershey Medical Center, Hershey, Pennsylvania
| | - Thomas Chung
- Department of Otolaryngology–Head and Neck Surgery, Penn State Hershey Medical Center, Hershey, Pennsylvania
| | - David Goldenberg
- Department of Otolaryngology–Head and Neck Surgery, Penn State Hershey Medical Center, Hershey, Pennsylvania
| | - Neerav Goyal
- Department of Otolaryngology–Head and Neck Surgery, Penn State Hershey Medical Center, Hershey, Pennsylvania
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15
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Lu J, Zheng H, Lai V. Pilot Cross-Sectional Quality of Life Study of a Diverse Endocrine Surgery Patient Population. J Surg Res 2022; 278:257-266. [DOI: 10.1016/j.jss.2022.04.068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 03/19/2022] [Accepted: 04/23/2022] [Indexed: 10/18/2022]
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16
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Dawood NB, Shu ML, Tseng CH, Kim J, Nguyen DT, Leung AM, Yeh MW. An Electronic Medical Record-Based Decision Support Tool for the Diagnosis of Primary Hyperparathyroidism. JAMA Intern Med 2022; 182:1000-1002. [PMID: 35877118 PMCID: PMC9315947 DOI: 10.1001/jamainternmed.2022.2684] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
This cohort study evaluates an electronic medical record–based tool for diagnosis of primary hyperparathyroidism in patients with chronic hypercalcemia.
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Affiliation(s)
| | | | - Chi-Hong Tseng
- Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles
| | - Jiyoon Kim
- Department of Biostatistics, UCLA School of Public Health, Los Angeles
| | - Dalena T Nguyen
- Section of Endocrine Surgery, Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles
| | - Angela M Leung
- Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles.,Division of Endocrinology, Diabetes, and Metabolism, Department of Medicine, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California
| | - Michael W Yeh
- Section of Endocrine Surgery, Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles
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17
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Bunch PM, Nguyen CJ, Johansson ED, Randle RW. Opportunistic Parathyroid Gland Assessment on Routine CT Could Decrease Morbidity from Undiagnosed Primary Hyperparathyroidism. Acad Radiol 2022; 30:881-890. [PMID: 35760712 DOI: 10.1016/j.acra.2022.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 05/20/2022] [Accepted: 05/24/2022] [Indexed: 11/01/2022]
Abstract
RATIONALE AND OBJECTIVES Gaps in primary hyperparathyroidism diagnosis are well-documented. End-organ damage correlates with disease duration and often occurs before diagnosis. We hypothesize that opportunistic parathyroid gland assessment on routine CT could decrease existing diagnosis gaps. Our purpose is to assess for enlarged parathyroid glands on contrast-enhanced CT acquired prior to biochemical screening and subsequent development of related morbidity. MATERIALS AND METHODS This retrospective study included consecutive patients with primary hyperparathyroidism undergoing parathyroidectomy with contrast-enhanced CT including the lower neck and upper chest acquired prior to biochemical screening. One neuroradiologist retrospectively evaluated all CTs for enlarged (estimated weight greater than 60 mg) parathyroid glands. Gold standard operative and pathology reports were correlated with CT findings, and medical records were reviewed for development of primary hyperparathyroidism-related comorbidities. RESULTS The sample comprised 38 patients (30 women, 8 men, median age 60 years) with 70 CTs of interest. The neuroradiologist identified 32 putative enlarged parathyroid glands (median estimated weight 307 mg) in 29 (76%) patients on CTs predating biochemical screening by a median of 30 months. Putative enlarged parathyroid glands on CT corresponded to pathologically proven parathyroid lesions in 26 (90%) patients. Of 26 patients with retrospectively identified pathologically proven parathyroid lesions, 12 (46%) developed at least 1 renal, bone, or neurocognitive comorbidity between CT and subsequent biochemical screening. CONCLUSION Enlarged parathyroid glands are frequently visible on routine CTs acquired years prior to primary hyperparathyroidism diagnosis. Biochemical screening based on enlarged glands could potentially prevent associated morbidity in almost half of such patients.
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18
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Sutton W, Canner JK, Shank JB, Fingeret AL, Karzai S, Segev DL, Prescott JD, Mathur A. The impact of patient age on practice patterns and outcomes for primary hyperparathyroidism. Am J Surg 2022; 224:400-407. [DOI: 10.1016/j.amjsurg.2022.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 02/04/2022] [Accepted: 03/01/2022] [Indexed: 11/26/2022]
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19
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Conroy PC, Hernandez S, Graves CE, Menut KCH, Pearlstein S, Liu C, Shen WT, Gosnell J, Sosa JA, Roman S, Duh QY, Suh I. Screening for Primary Aldosteronism is Underutilized in Patients with Obstructive Sleep Apnea. Am J Med 2022; 135:60-66. [PMID: 34508708 PMCID: PMC9289750 DOI: 10.1016/j.amjmed.2021.07.041] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 06/28/2021] [Accepted: 07/31/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Resistant hypertension is common in patients with primary aldosteronism and in those with obstructive sleep apnea. Primary aldosteronism treatment improves sleep apnea. Despite Endocrine Society guidelines' inclusion of sleep apnea and hypertension co-diagnosis as a primary aldosteronism screening indication, the state of screening implementation is unknown. METHODS All hypertensive adult patients with obstructive sleep apnea (n = 4751) at one institution between 2012 and 2020 were compared with a control cohort without sleep apnea (n = 117,815). We compared the association of primary aldosteronism diagnoses, risk factors, and screening between both groups. Patients were considered to have screening if they had a primary aldosteronism diagnosis or serum aldosterone or plasma renin activity evaluation. RESULTS Obstructive sleep apnea patients were predominantly men and had higher body mass index. On multivariable analysis, hypertensive sleep apnea patients had higher odds of drug-resistant hypertension (odds ratio [OR] 2.70; P < .001) and hypokalemia (OR 1.26; P < .001) independent of body mass index, sex, and number of antihypertensive medications. Overall, sleep apnea patients were more likely to be screened for primary aldosteronism (OR 1.45; P < .001); however, few patients underwent screening whether they had sleep apnea or not (pre-guideline publication 7.8% vs 4.6%; post-guidelines 3.6% vs 4.6%; P < .01). Screening among eligible sleep apnea patients remained low prior to and after guideline publication (4.4% vs 3.4%). CONCLUSIONS Obstructive sleep apnea is associated with primary aldosteronism risk factors without formal diagnosis, suggesting screening underutilization and underdiagnosis. Strategies are needed to increase screening adherence, as patients may benefit from treatment of concomitant primary aldosteronism to reduce sleep apnea severity and its associated cardiopulmonary morbidity.
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Affiliation(s)
| | - Sophia Hernandez
- Department of Surgery; School of Medicine, University of California San Francisco
| | - Claire E Graves
- Department of Surgery, University of California Davis, Sacramento
| | | | | | - Chienying Liu
- Department of Medicine, University of California San Francisco
| | | | | | - Julie A Sosa
- Department of Surgery; Department of Medicine, University of California San Francisco
| | | | | | - Insoo Suh
- Department of Surgery, New York University Langone Health, New York, NY.
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20
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Habib AR, Katz MH. Parathyroidectomy in Elderly Individuals With Primary Hyperparathyroidism: To Operate or Not to Operate. JAMA Intern Med 2022; 182:7-8. [PMID: 34842895 DOI: 10.1001/jamainternmed.2021.6816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Anand R Habib
- Department of Medicine, University of California San Francisco, San Francisco.,Editorial Fellow, JAMA Internal Medicine
| | - Mitchell H Katz
- NYC Health + Hospitals, New York, New York.,Deputy Editor, JAMA Internal Medicine
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21
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Alobuia WM, Meng T, Cisco RM, Lin DT, Suh I, Tamura MK, Trickey AW, Kebebew E, Seib CD. Racial disparities in the utilization of parathyroidectomy among patients with primary hyperparathyroidism: Evidence from a nationwide analysis of Medicare claims. Surgery 2022; 171:8-16. [PMID: 34229901 PMCID: PMC8688157 DOI: 10.1016/j.surg.2021.05.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 04/16/2021] [Accepted: 05/04/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Among patients with primary hyperparathyroidism, parathyroidectomy offers a chance of cure and mitigation of disease-related complications. The impact of race/ethnicity on referral and utilization of parathyroidectomy has not been fully explored. METHODS Population-based, retrospective cohort study using 100% Medicare claims from beneficiaries with primary hyperparathyroidism from 2006 to 2016. Associations of race/ethnicity with disease severity, surgeon evaluation, and subsequent parathyroidectomy were analyzed using adjusted multivariable logistic regression models. RESULTS Among 210,206 beneficiaries with primary hyperparathyroidism, 63,136 (30.0%) underwent parathyroidectomy within 1 year of diagnosis. Black patients were more likely than other races/ethnicities to have stage 3 chronic kidney disease (10.8%) but had lower prevalence of osteoporosis and nephrolithiasis compared to White patients, Black and Hispanic patients were more likely to have been hospitalized for primary hyperparathyroidism-associated conditions (White 4.8%, Black 8.1%, Hispanic 5.8%; P < .001). Patients who were White and met operative criteria were more likely to undergo parathyroidectomy than Black, Hispanic, or Asian patients (White 30.5%, Black 23.0%, Hispanic 21.4%, Asian 18.7%; P < .001). Black and Hispanic patients had lower adjusted odds of being evaluated by a surgeon (odds ratios 0.71 [95% confidence interval 0.69-0.74], 0.68 [95% confidence interval 0.61-0.74], respectively) and undergoing parathyroidectomy if evaluated by a surgeon (odds ratios 0.72 [95% confidence interval 0.68-0.77], 0.82 [95% confidence interval 0.67-0.99]). Asian race was associated with lower adjusted odds of being evaluated by a surgeon (odds ratio 0.64 [95% confidence interval 0.57-0.71]), but no difference in odds of parathyroidectomy. CONCLUSION Racial/ethnic disparities exist in the management of primary hyperparathyroidism among older adults. Determining the factors that account for this disparity require urgent attention to achieve parity in the management of primary hyperparathyroidism.
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Affiliation(s)
- Wilson M. Alobuia
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - Tong Meng
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine, Palo Alto, CA.,Department of Emergency Medicine, Stanford University School of Medicine, Palo Alto, CA
| | - Robin M. Cisco
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - Dana T. Lin
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - Insoo Suh
- Division of Endocrine Surgery, NYU Langone Health, New York, NY
| | - Manjula Kurella Tamura
- Geriatric Research, Education and Clinical Center, Veterans Affairs Palo Alto, Palo Alto, CA.,Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA
| | - Amber W. Trickey
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - Electron Kebebew
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA
| | - Carolyn D. Seib
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA.,Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine, Palo Alto, CA.,Division of General Surgery, Palo Alto Veterans Affairs Health Care System, Palo Alto, CA
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22
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Seib CD, Meng T, Suh I, Harris AHS, Covinsky KE, Shoback DM, Trickey AW, Kebebew E, Tamura MK. Risk of Fracture Among Older Adults With Primary Hyperparathyroidism Receiving Parathyroidectomy vs Nonoperative Management. JAMA Intern Med 2022; 182:10-18. [PMID: 34842909 PMCID: PMC8630642 DOI: 10.1001/jamainternmed.2021.6437] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
IMPORTANCE Primary hyperparathyroidism (PHPT) contributes to the development and progression of osteoporosis in older adults. The effectiveness of parathyroidectomy for reducing fracture risk in older adults is unknown. OBJECTIVE To compare the incidence of clinical fracture among older adults with PHPT treated with parathyroidectomy vs nonoperative management. DESIGN, SETTING, AND PARTICIPANTS This was a population-based, longitudinal cohort study of all Medicare beneficiaries with PHPT from 2006 to 2017. Multivariable, inverse probability weighted Cox proportional hazards and Fine-Gray competing risk regression models were constructed to determine the association of parathyroidectomy vs nonoperative management with incident fracture. Data analysis was conducted from February 17, 2021, to September 14, 2021. MAIN OUTCOMES AND MEASURES The primary outcome was clinical fracture at any anatomic site not associated with major trauma during the follow-up period. RESULTS Among the 210 206 Medicare beneficiaries with PHPT (mean [SD] age, 75 [6.8] years; 165 637 [78.8%] women; 183 433 [87.3%] White individuals), 63 136 (30.0%) underwent parathyroidectomy within 1 year of diagnosis, and 147 070 (70.0%) were managed nonoperatively. During a mean (SD) follow-up period of 58.5 (35.5) months, the unadjusted incidence of fracture was 10.2% in patients treated with parathyroidectomy. During a mean (SD) follow-up of 52.5 (33.8) months, the unadjusted incidence of fracture was 13.7% in patients observed nonoperatively. On multivariable analysis, parathyroidectomy was associated with lower adjusted rates of any fracture (hazard ratio [HR], 0.78; 95% CI, 0.76-0.80]) and hip fracture (HR, 0.76; 95% CI, 0.72-0.79). At 2, 5, and 10 years, parathyroidectomy was associated with adjusted absolute fracture risk reduction of 1.2% (95% CI, 1.0-1.4), 2.8% (95% CI, 2.5-3.1), and 5.1% (95% CI, 4.6-5.5), respectively, compared with nonoperative management. On subgroup analysis, there were no significant differences in the association of parathyroidectomy with fracture risk by age group, sex, frailty, history of osteoporosis, or meeting operative guidelines. Fine-Gray competing risk regression confirmed parathyroidectomy was associated with a lower probability of any fracture and hip fracture when accounting for the competing risk of death (HR, 0.84; 95% CI, 0.82-0.85; and HR, 0.83; 95% CI, 0.80-0.85, respectively). CONCLUSIONS AND RELEVANCE This longitudinal cohort study found that parathyroidectomy was associated with a lower risk of any fracture and hip fracture among older adults with PHPT, suggesting a clinically meaningful benefit of operative management in this population.
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Affiliation(s)
- Carolyn D Seib
- Stanford-Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University School of Medicine, Stanford, California.,Department of Surgery, Stanford University School of Medicine, Stanford, California.,Geriatric Research, Education and Clinical Center, Palo Alto Veterans Affairs Health Care System, Palo Alto, California
| | - Tong Meng
- Stanford-Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University School of Medicine, Stanford, California.,Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California
| | - Insoo Suh
- Department of Surgery, New York University Grossman School of Medicine, New York, New York
| | - Alex H S Harris
- Stanford-Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University School of Medicine, Stanford, California.,Center for Innovation to Implementation, Palo Alto Veterans Affairs Health Care System, Palo Alto, California
| | | | - Dolores M Shoback
- Endocrine Research Unit, Department of Medicine, San Francisco Veterans Affairs Medical Center, University of California, San Francisco.,Department of Medicine, University of California, San Francisco
| | - Amber W Trickey
- Stanford-Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Electron Kebebew
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Manjula Kurella Tamura
- Geriatric Research, Education and Clinical Center, Palo Alto Veterans Affairs Health Care System, Palo Alto, California.,Division of Nephrology, Stanford University School of Medicine, Stanford, California
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23
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Park SY, Scotting O, Yen TWF, Evans DB, Wang TS, Dream S. Underdiagnosis of primary hyperparathyroidism in patients with osteoarthritis undergoing arthroplasty. Surgery 2021; 171:731-735. [PMID: 34844753 DOI: 10.1016/j.surg.2021.09.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 08/31/2021] [Accepted: 09/29/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Primary hyperparathyroidism (HPT) is commonly underdiagnosed and undertreated. Joint pain is a nonspecific symptom associated with osteoarthritis or primary HPT. We hypothesize that patients treated for osteoarthritis are underdiagnosed with primary HPT. METHODS Adult patients diagnosed with hip/knee osteoarthritis at the Medical College of Wisconsin from January 2000 to October 2020 were queried. Patients with a calcium level drawn within 1 year of diagnosis of osteoarthritis were included. Patients who had undergone prior parathyroidectomy were excluded. Patients were stratified by serum calcium level, HPT diagnosis, and PTH level. Arthroplasty rates were compared between groups. RESULTS Of 54,788 patients, 9,967 patients (18.2%) had a high serum calcium level, of whom 1,089 (10.9%) had a diagnosis of HPT. Only 76 (7.0%) patients with HPT underwent parathyroidectomy, 208 (19.1%) underwent knee/hip arthroplasty, and 14 (1.3%) underwent both. Arthroplasty was performed in 1,793 patients without evaluation and/or definitive treatment for HPT. There were higher rates of arthroplasty performed in patients with a high serum calcium level compared with those without (21.2% vs 17.4%, P < .001). CONCLUSION Patients with high serum calcium levels were more likely to undergo arthroplasty than those with normocalcemia. Hypercalcemia in the setting of hip or knee osteoarthritis should prompt a full evaluation for primary HPT.
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Affiliation(s)
- Sarah Y Park
- Medical College of Wisconsin, Department of Surgery, Milwaukee, WI
| | - Oliver Scotting
- Medical College of Wisconsin, Department of Orthopedic Surgery, Milwaukee, WI. https://twitter.com/OScotting
| | - Tina W F Yen
- Medical College of Wisconsin, Department of Surgery, Milwaukee, WI
| | - Douglas B Evans
- Medical College of Wisconsin, Department of Surgery, Milwaukee, WI
| | - Tracy S Wang
- Medical College of Wisconsin, Department of Surgery, Milwaukee, WI. https://twitter.com/tracyswangNYMKE
| | - Sophie Dream
- Medical College of Wisconsin, Department of Surgery, Milwaukee, WI.
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24
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Dawood NB, Tseng CH, Nguyen DT, Yan KL, Livhits MJ, Leung AM, Yeh MW. Systems-Level Opportunities in the Management of Primary Hyperparathyroidism: An Informatics-based Assessment. J Clin Endocrinol Metab 2021; 106:e4993-e5000. [PMID: 34313755 DOI: 10.1210/clinem/dgab540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Primary hyperparathyroidism (PHPT), a leading cause of hypercalcemia and secondary osteoporosis, is underdiagnosed. OBJECTIVE This work aims to establish a foundation for an electronic medical record-based intervention that would prompt serum parathyroid hormone (PTH) assessment in patients with persistent hypercalcemia and identify care gaps in their management. METHODS A retrospective cohort study was conducted in a tertiary academic health system of outpatients with persistent hypercalcemia, who were categorized as having classic or normohormonal PHPT. Main outcome measures included the frequencies of serum PTH measurement in patients with persistent hypercalcemia, and their subsequent workup with bone mineral density (BMD) assessment, and ultimately, medical therapy or parathyroidectomy. RESULTS Among 3151 patients with persistent hypercalcemia, 1526 (48%) had PTH measured, of whom 1377 (90%) were confirmed to have classic (49%) or normohormonal (41%) PHPT. PTH was measured in 65% of hypercalcemic patients with osteopenia or osteoporosis (P < .001). At median 2-year follow-up, bone density was assessed in 275 (20%) patients with either variant of PHPT (P = .003). Of women aged 50 years or older with classic PHPT, 95 (19%) underwent BMD assessment. Of patients with classic or normohormonal PHPT, 919 patients (67%) met consensus criteria for surgical intervention, though only 143 (15%) underwent parathyroidectomy. CONCLUSION Within a large academic health system, more than half of patients with confirmed hypercalcemia were not assessed for PHPT, including many patients with preexisting bone disease. Care gaps in BMD assessment and medical or surgical therapy represent missed opportunities to avoid skeletal and other complications of PHPT.
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Affiliation(s)
- Nardeen B Dawood
- UCLA David Geffen School of Medicine, Los Angeles, California, USA
| | - Chi-Hong Tseng
- UCLA David Geffen School of Medicine, Los Angeles, California, USA
| | - Dalena T Nguyen
- Section of Endocrine Surgery, Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, California, USA
| | - Kimberly L Yan
- UCLA David Geffen School of Medicine, Los Angeles, California, USA
| | - Masha J Livhits
- Section of Endocrine Surgery, Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, California, USA
| | - Angela M Leung
- Division of Endocrinology, Diabetes, and Metabolism; Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, California, USA
- Division of Endocrinology, Diabetes, and Metabolism; Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Michael W Yeh
- Section of Endocrine Surgery, Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, California, USA
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25
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Enlarged Parathyroid Glands on Trauma Computed Tomography: Frequency and Assessment for Possible Primary Hyperparathyroidism. J Comput Assist Tomogr 2021; 45:926-931. [PMID: 34407058 DOI: 10.1097/rct.0000000000001214] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The aims of the study were to determine the frequency of enlarged parathyroid glands among patients undergoing trauma computed tomography (CT) who fall within the typical primary hyperparathyroidism (PHPT) age range and to assess for evidence of PHPT. METHODS For this retrospective study of 336 emergency department patients, concurrent cervical spine CT and neck CT angiography (CTA) examinations were reviewed for visible parathyroid glands. When visible, estimated weight was calculated, and a PHPT likelihood category was assigned after medical record review. RESULTS At least 1 parathyroid gland was visible in 17 patients (5%) and enlarged (estimated weight > 60 mg) in 11 (3%). Patients classified as "highly likely" or "likely" of having PHPT exhibited larger glands (median, 355 mg) than those classified as "unlikely" or "highly unlikely" (median, 47 mg; P = 0.01). CONCLUSIONS Parathyroid glands were enlarged in 3% of our cohort. Although PHPT likelihood seems to increase with gland size, definitive determination requires both serum calcium and serum parathyroid hormone.
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26
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Huang SY, Burchette R, Chung J, Haigh PI. Parathyroidectomy for nephrolithiasis in primary hyperparathyroidism: Beneficial but not a panacea. Surgery 2021; 171:29-34. [PMID: 34364687 DOI: 10.1016/j.surg.2021.03.077] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 03/14/2021] [Accepted: 03/19/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND Nephrolithiasis is a classic indication for parathyroidectomy in primary hyperparathyroidism patients; however, the effects of parathyroidectomy on nephrolithiasis recurrence are not well studied. The aim was to determine effect of parathyroidectomy on time to first nephrolithiasis recurrence and recurrence rate per patient-years. METHODS A retrospective cohort study of patients diagnosed with primary hyperparathyroidism and at least one episode of nephrolithiasis was performed. The patients were divided into observation, presurgery, and postsurgery groups. Endpoints were time to first recurrence of nephrolithiasis and average recurrence rate per patient-years. RESULTS The cohort was comprised of 1,252 patients. In addition, 334 (27%) patients underwent parathyroidectomy and 918 (73%) were observed. The surgical and nonsurgical groups differed significantly in age, sex, Charlson, calcium, and primary hyperparathyroidism level. Overall recurrence rate was 31.3%. The 5-, 10-, and 15-year recurrence-free survival rates were 74.4%, 56.3%, 49.5%, respectively (presurgery), 82.4%, 70.9%, 62.8%, respectively (postsurgery; P < .0001), and 86.3%, 77.7%, and 70.6%, respectively (observation). The presurgery group had an increased risk of first recurrence compared with the observation group (hazard ratio 1.89; 95% confidence interval, 1.44-2.47). The average recurrence rates among all surgical patients who recurred were 1 event per 4.3 patient-years presurgery versus 1 event per 6.7 patient-years postsurgery (P = .0001). CONCLUSION Recurrent nephrolithiasis is a significant problem in patients with primary hyperparathyroidism. Parathyroidectomy prolongs the time to first recurrence and decreases the number of re-recurrences over time but does not eliminate recurrences. Observation may also be a reasonable approach in selected patients.
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Affiliation(s)
- Siu-Yuan Huang
- Department of Surgery, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA
| | - Raoul Burchette
- Department of Research and Evaluation, Southern California Permanente Medical Group, Los Angeles, CA
| | - Joanie Chung
- Department of Research and Evaluation, Southern California Permanente Medical Group, Los Angeles, CA
| | - Philip I Haigh
- Department of Surgery, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA.
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27
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Ejlsmark-Svensson H, Rolighed L, Harsløf T, Rejnmark L. Risk of fractures in primary hyperparathyroidism: a systematic review and meta-analysis. Osteoporos Int 2021; 32:1053-1060. [PMID: 33527175 DOI: 10.1007/s00198-021-05822-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 01/04/2021] [Indexed: 12/13/2022]
Abstract
An increased risk of fractures in primary hyperparathyroidism (PHPT) has been reported in a number of relatively small studies. Performing a systematic literature search, we identified available studies and calculated common estimates by pooling results from the individual studies in a meta-analysis. Searching EMBASE and PubMed, we identified published studies reporting the risk of fractures in PHPT compared to a control group. We calculated odds ratio (OR) with 95% confidence interval (CI). A total of 804 studies were identified of which 12 studies were included. Risk of any fracture was increased compared to controls (OR 2.01; 95% CI, 1.61-2.50; I2 46%, 5 studies). Analysis of fracture risk at specific sites showed an increased risk of fracture at the forearm (OR 2.36; 95% CI, 1.64-3.38; I2 0%, 4 studies) and spine (OR 3.00; 95% CI, 1.41, 6.37, I2 88%, 9 studies). Risk estimate for hip fractures was non-significantly increased (OR 1.27; 95% CI, 0.97-1.66; I2 0%, 3 studies). Risk of vertebral fractures (VFx) was also increased if analyses were restricted to only studies with a healthy control group (OR 5.76; 95% CI, 3.86-8.60; I2 29%, 6 studies), studies including patients with mild PHPT (OR 4.22; 95% CI, 2.20-8.12; I2 57%, 4 studies) or studies including postmenopausal women (OR 8.07; 95% CI, 4.79-13.59; I2 0%, 3 studies). PHPT is associated with an increased risk of fractures. Although a number of studies are limited-it seems that the risk is increased across different skeletal sites including patients with mild PHPT and postmenopausal women.
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Affiliation(s)
- H Ejlsmark-Svensson
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Palle Juul-Jensen Boulevard, 8200, Aarhus, Denmark.
| | - L Rolighed
- Department of Otorhinolaryngology, Head and Neck Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - T Harsløf
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Palle Juul-Jensen Boulevard, 8200, Aarhus, Denmark
| | - L Rejnmark
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Palle Juul-Jensen Boulevard, 8200, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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28
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Seib CD, Suh I, Meng T, Trickey A, Smith AK, Finlayson E, Covinsky KE, Kurella Tamura M, Kebebew E. Patient Factors Associated With Parathyroidectomy in Older Adults With Primary Hyperparathyroidism. JAMA Surg 2021; 156:334-342. [PMID: 33404646 DOI: 10.1001/jamasurg.2020.6175] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance Parathyroidectomy provides definitive management for primary hyperparathyroidism (PHPT), reducing the risk of subsequent fracture, nephrolithiasis, and chronic kidney disease (CKD), but its use among older adults in the US is unknown. Objective To identify patient characteristics associated with the use of parathyroidectomy for the management of PHPT in older adults. Design, Setting, and Participants This population-based, retrospective cohort study used 100% Medicare claims from beneficiaries with an initial diagnosis of PHPT from January 1, 2006, to December 31, 2016. Patients were considered to meet consensus guideline criteria for parathyroidectomy based on diagnosis codes indicating osteoporosis, nephrolithiasis, or stage 3 CKD. Multivariable logistic regression was used to identify patient characteristics associated with parathyroidectomy. Data were analyzed from February 11, 2020, to October 8, 2020. Main Outcomes and Measures The primary outcome was parathyroidectomy within 1 year of diagnosis. Results Among 210 206 beneficiaries with an incident diagnosis of PHPT (78.8% women; mean [SD] age, 75.3 [6.8] years), 63 136 (30.0%) underwent parathyroidectomy within 1 year of diagnosis. Among the subset of patients who met consensus guideline criteria for operative management (n = 131 723), 38 983 (29.6%) were treated with parathyroidectomy. Patients treated operatively were younger (mean [SD] age, 73.5 [5.7] vs 76.0 [7.1] years) and more likely to be White (90.1% vs 86.0%), to be robust or prefrail (92.1% vs 85.7%), and to have fewer comorbidities (Charlson Comorbidity Index score of 0 or 1, 54.6% vs 44.1%), in addition to being more likely to live in socioeconomically disadvantaged (46.9% vs 40.3%) and rural (18.1% vs 13.6%) areas (all P < .001). On multivariable analysis, increasing age had a strong inverse association with parathyroidectomy among patients aged 76 to 85 years (unadjusted rate, 25.9%; odds ratio [OR], 0.68 [95% CI, 0.67-0.70]) and older than 85 years (unadjusted rate, 11.2%; OR, 0.27 [95% CI, 0.26-0.29]) compared with those aged 66 to 75 years (unadjusted rate, 35.6%), as did patients with moderate to severe frailty (unadjusted rate, 18.9%; OR, 0.60 [95% CI, 0.56-0.64]) compared with robust patients (unadjusted rate, 36.1%) and those with a Charlson Comorbidity Index score of 2 or greater (unadjusted rate, 25.9%; OR, 0.77 [95% CI, 0.75-0.79]) compared with a Charlson Comorbidity Index score of 0 (unadjusted rate, 37.0%). With regard to operative guidelines, a history of nephrolithiasis increased the odds of parathyroidectomy (OR, 1.43 [95% CI, 1.39-1.47]); stage 3 CKD decreased the odds of parathyroidectomy (OR, 0.71 [95% CI, 0.68-0.74]); and osteoporosis showed no association (OR, 1.01 [95% CI, 0.99-1.03]). Conclusions and Relevance In this cohort study, most older adults with PHPT did not receive definitive treatment with parathyroidectomy. Older age, frailty, and multimorbidity were associated with nonoperative management, and guideline recommendations had minimal effect on treatment decisions. Further research is needed to identify barriers to surgical care and develop tools to target parathyroidectomy to older adults most likely to benefit.
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Affiliation(s)
- Carolyn D Seib
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Stanford University School of Medicine, Stanford, California.,Department of Surgery, Stanford University School of Medicine, Stanford, California.,Division of General Surgery, Palo Alto Veterans Affairs Health Care System, Palo Alto, California
| | - Insoo Suh
- Department of Surgery, University of California, San Francisco
| | - Tong Meng
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Stanford University School of Medicine, Stanford, California.,Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California
| | - Amber Trickey
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Stanford University School of Medicine, Stanford, California
| | | | - Emily Finlayson
- Department of Surgery, University of California, San Francisco
| | | | - Manjula Kurella Tamura
- Geriatric Research, Education and Clinical Center, Veterans Affairs Palo Alto, Palo Alto, California.,Division of Nephrology, Stanford University School of Medicine, Stanford, California
| | - Electron Kebebew
- Department of Surgery, Stanford University School of Medicine, Stanford, California
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29
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Pandzic Jaksic V, Majic A, Rezic T, Andric J, Jaksic O, Zrilic A, Marusic S. PRIMARY HYPERPARATHYROIDISM DETECTED BY PARATHYROID INCIDENTALOMA: CLINICAL FEATURES, WORK-UP AND MANAGEMENT. ACTA ENDOCRINOLOGICA (BUCHAREST, ROMANIA : 2005) 2021; 17:219-225. [PMID: 34925571 PMCID: PMC8665247 DOI: 10.4183/aeb.2021.219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
CONTEXT With the widespread use of neck ultrasound, parathyroid incidentaloma (PI) emerges as an additional opportunity for incidental detection of primary hyperparathyroidism (PHPT). OBJECTIVE AND DESIGN This study aimed to investigate PHPT cases detected by PI and to compare them with other PHPT patients. A retrospective analysis of newly diagnosed PHPT patients between 2014 and 2020 was conducted in our hospital. SUBJECTS AND METHODS The cohort of 124 subjects was divided in two groups: 22 (17.7%) PHPT patients detected by PI (PI PHPT group) and the rest of 102 PHPT patients (non-PI PHPT group). Overall, 21 PIs were discovered on ultrasound and one was found during thyroid surgery. Clinical features, work-up and management of two study groups were compared. RESULTS The PI PHPT group had lower ionized calcium at diagnosis (p=0.034), lower peak serum calcium during follow-up (p<0.01), less fractures (p=0.022) and was less likely to meet the international criteria for parathyroidectomy (p<0.01). Positive sestamibi scan (p=0.022) and confirmed concordant localization in at least two different parathyroid imaging techniques (p=0.033) were more likely in the PI PHPT group. The frequency of surgical management did not differ between groups. CONCLUSIONS PHPT detected by PI is clinically relevant and mostly comparable to PHPT in other patients with some features that correspond more often to a mild disease. Higher rate of positive preoperative localization in PHPT detected by PI might encourage parathyroidectomy even without the international criteria met.
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Affiliation(s)
| | - A. Majic
- Dubrava Clinical Hospital, Zagreb, Croatia
| | - T. Rezic
- Dubrava Clinical Hospital, Zagreb, Croatia
| | - J. Andric
- Dubrava Clinical Hospital, Zagreb, Croatia
| | - O. Jaksic
- University of Zagreb School of Medicine, Zagreb, Croatia
| | - A. Zrilic
- Dubrava Clinical Hospital, Zagreb, Croatia
| | - S. Marusic
- Dubrava Clinical Hospital, Zagreb, Croatia
- University of Zagreb School of Medicine, Zagreb, Croatia
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30
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Ganesan C, Weia B, Thomas IC, Song S, Velaer K, Seib CD, Conti S, Elliott C, Chertow GM, Kurella Tamura M, Leppert JT, Pao AC. Analysis of Primary Hyperparathyroidism Screening Among US Veterans With Kidney Stones. JAMA Surg 2021; 155:861-868. [PMID: 32725208 DOI: 10.1001/jamasurg.2020.2423] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Importance Approximately 3% to 5% of patients with kidney stones have primary hyperparathyroidism (PHPT), a treatable cause of recurrent stones. However, the rate of screening for PHPT in patients with kidney stones remains unknown. Objectives To estimate the prevalence of parathyroid hormone (PTH) testing in veterans with kidney stones and hypercalcemia and to identify the demographic, geographic, and clinical characteristics of veterans who were more or less likely to receive PTH testing. Design, Setting, and Participants This cohort study obtained Veterans Health Administration (VHA) health records from the Corporate Data Warehouse for veterans who received care in 1 of the 130 VHA facilities across the United States from January 1, 2008, through December 31, 2013. Historical encounters, medical codes, and laboratory data were assessed. Included patients had diagnostic or procedural codes for kidney or ureteral stones, and excluded patients were those with a previous serum PTH level measurement. Data were collected from January 1, 2006, to December 31, 2014. Data analysis was conducted from June 1, 2019, to January 31, 2020. Exposures Elevated serum calcium concentration measurement between 6 months before and 6 months after kidney stone diagnosis. Main Outcomes and Measures Proportion of patients with a serum PTH level measurement and proportion of patients with biochemical evidence of PHPT who underwent parathyroidectomy. Results The final cohort comprised 7561 patients with kidney stones and hypercalcemia and a mean (SD) age of 64.3 (12.3) years. Of these patients, 7139 were men (94.4%) and 5673 were white individuals (75.0%). The proportion of patients who completed a serum PTH level measurement was 24.8% (1873 of 7561). Across the 130 VHA facilities included in the study, testing rates ranged from 4% to 57%. The factors associated with PTH testing included the magnitude of calcium concentration elevation (odds ratio [OR], 1.07 per 0.1 mg/dL >10.5 mg/dL; 95% CI, 1.05-1.08) and the number of elevated serum calcium concentration measurements (OR, 1.08 per measurement >10.5 mg/dL; 95% CI, 1.06-1.10) as well as visits to both a nephrologist and a urologist (OR, 6.57; 95% CI, 5.33-8.10) or an endocrinologist (OR, 4.93; 95% CI, 4.11-5.93). Of the 717 patients with biochemical evidence of PHPT, 189 (26.4%) underwent parathyroidectomy within 2 years of a stone diagnosis. Conclusions and Relevance This cohort study found that only 1 in 4 patients with kidney stones and hypercalcemia were tested for PHPT in VHA facilities and that testing rates varied widely across these facilities. These findings suggest that raising clinician awareness to PHPT screening indications may improve evaluation for parathyroidectomy, increase the rates of detection and treatment of PHPT, and decrease recurrent kidney stone disease.
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Affiliation(s)
- Calyani Ganesan
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Benjamin Weia
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - I-Chun Thomas
- Division of Nephrology, Department of Urology, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Shen Song
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California
| | - Kyla Velaer
- Department of Urology, Stanford University School of Medicine, Palo Alto, California
| | - Carolyn D Seib
- Department of Surgery, Stanford University School of Medicine, Palo Alto, California
| | - Simon Conti
- Department of Urology, Stanford University School of Medicine, Palo Alto, California
| | - Chris Elliott
- Department of Urology, Santa Clara Valley Medical Center, San Jose, California
| | - Glenn M Chertow
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California.,Department of Epidemiology and Population Health, Stanford University School of Medicine, Palo Alto, California
| | - Manjula Kurella Tamura
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California.,Division of Nephrology, Department of Urology, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - John T Leppert
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California.,Division of Nephrology, Department of Urology, Veterans Affairs Palo Alto Health Care System, Palo Alto, California.,Department of Urology, Stanford University School of Medicine, Palo Alto, California
| | - Alan C Pao
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California.,Division of Nephrology, Department of Urology, Veterans Affairs Palo Alto Health Care System, Palo Alto, California.,Department of Urology, Stanford University School of Medicine, Palo Alto, California
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Cormier C, Koumakis E. Bones and Primary Hyperparathyroidism. Joint Bone Spine 2021; 89:105129. [PMID: 33484857 DOI: 10.1016/j.jbspin.2021.105129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2020] [Indexed: 10/22/2022]
Abstract
Primary hyperparathyroidism (PHPT) is a disease caused by excessive and inappropriate secretion of parathyroid hormone resulting in hypercalcemia. It is usually diagnosed incidentally in the face of hypercalcemia, a complication such as osteoporosis or, more rarely, a renal complication with lithiasis. The clinical presentation reflects hypercalcemia and involves several organs, mainly the cardiovascular system, bones, and kidneys. However, most patients with PHPT are asymptomatic. The diagnosis is made based on laboratory tests. It is easy when serum calcium and parathyroid hormone levels are high, but difficult when one of these two values is normal. Normocalcemic PHPT can be diagnosed only after ruling out all causes of secondary hyperparathyroidism. Parathyroid imaging cannot diagnose it but guides the surgeon and rules out an associated thyroid abnormality. The reference treatment is surgery. The surgical indication is based on the presence or risk of complications, and it is the only treatment that prevents fractures. Pharmaceutical treatments have only limited effects on complications and are reserved for cases where surgery is contraindicated. After parathyroid surgery, the use of bisphosphonates must be avoided as they seem to interfere with the parathyroidectomy's fracture-preventing effects. If surgery is not indicated, a plan for monitoring laboratory values, bone density, and renal function will be established.
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Affiliation(s)
- Catherine Cormier
- Service de Rhumatologie Hôpital Cochin, APHP, Université Paris Descartes Centre de Référence des Maladies du Métabolisme du Calcium et du Phosphate 27 Rue du Faubourg St Jacques, 75679 PARIS Cedex 14, France.
| | - Eugénie Koumakis
- Service de Rhumatologie Hôpital Cochin, APHP, Université Paris Descartes Centre de Référence des Maladies du Métabolisme du Calcium et du Phosphate 27 Rue du Faubourg St Jacques, 75679 PARIS Cedex 14, France
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Sheehan MT, Li YH, Doi SA, Onitilo AA. Frequency of Parathyroid Hormone Assessment in the Evaluation of Hypercalcemia. A Comparison Between Patients With and Without a History of Malignancy in a 20-year Dataset of 20,954 Patients. Clin Med Insights Endocrinol Diabetes 2021; 14:11795514211059494. [PMID: 34866958 PMCID: PMC8637696 DOI: 10.1177/11795514211059494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 10/22/2021] [Indexed: 11/18/2022] Open
Abstract
Background: The purpose of this study was to evaluate whether a prior diagnosis of
malignancy affected the assessment of parathyroid hormone (PTH) in
hypercalcemic patients and whether the rate of this assessment changed over
time. Methods: A retrospective cohort study was designed that included adult patients with
hypercalcemia with and without a history of malignancy between January 1,
2000 and December 31, 2019 in the Marshfield Clinic Health System (MCHS).
The overall and annual rates of PTH assessment in each group was determined.
In patients with a PTH assessment, duration of time and number of elevated
serum calcium levels between the first documentation of hypercalcemia and
the assessment of PTH were recorded, as was the degree of hypercalcemia. Results: Approximately a quarter (23%) of the patients in each group had a PTH
assessment. The rate of PTH assessment initially increased over time but
later declined significantly. Although a more severe degree of hypercalcemia
predicted a greater probability of PTH assessment, the rate of assessment
declined with all degrees of hypercalcemia in the last 5 years. While most
patients who had a PTH assessed did so within a few months of the first
documentation of hypercalcemia, less than half (40%) had a delay of more
than 2 years before a PTH level was drawn. Conclusion: This lack of appropriate and timely assessment may have significant health
consequences in both groups of patients. Better education of providers about
the appropriate and timely assessment of PTH in the evaluation of
hypercalcemia is urgently needed.
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Affiliation(s)
- Michael T Sheehan
- Department of Endocrinology, Marshfield Clinic Health System, Weston, WI, USA
| | - Ya-Huei Li
- Cancer Care and Research Center, Marshfield Clinic Research Institute, Marshfield, WI, USA
| | - Suhail A Doi
- Department of Population Medicine, College of Medicine, Doha, Qatar
| | - Adedayo A Onitilo
- Department of Oncology, Marshfield Clinic Health System, Weston, WI, USA
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Seib CD, Meng T, Suh I, Cisco RM, Lin DT, Morris AM, Trickey AW, Kebebew E. Undertreatment of primary hyperparathyroidism in a privately insured US population: Decreasing utilization of parathyroidectomy despite expanding surgical guidelines. Surgery 2021; 169:87-93. [PMID: 32654861 PMCID: PMC7736152 DOI: 10.1016/j.surg.2020.04.066] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2020] [Revised: 03/29/2020] [Accepted: 04/29/2020] [Indexed: 01/21/2023]
Abstract
BACKGROUND Primary hyperparathyroidism is associated with substantial morbidity, including osteoporosis, nephrolithiasis, and chronic kidney disease. Parathyroidectomy can prevent these sequelae but is poorly utilized in many practice settings. METHODS We performed a retrospective cohort study using the national Optum de-identified Clinformatics Data Mart Database. We identified patients aged ≥35 with a first observed primary hyperparathyroidism diagnosis from 2004 to 2016. Multivariable logistic regression was used to determine patient/provider characteristics associated with parathyroidectomy. RESULTS Of 26,522 patients with primary hyperparathyroidism, 10,101 (38.1%) underwent parathyroidectomy. Of the 14,896 patients with any operative indication, 5,791 (38.9%) underwent parathyroidectomy. Over time, there was a decreasing trend in the rate of parathyroidectomy overall (2004: 54.4% to 2016: 32.4%, P < .001) and among groups with and without an operative indication. On multivariable analysis, increasing age and comorbidities were strongly, inversely associated with parathyroidectomy (age 75-84, odds ratio 0.50 [95% confidence interval 0.45-0.55]; age ≥85, odds ratio 0.21 [95% confidence interval 0.17-0.26] vs age 35-49; Charlson Comorbidity Index ≥2 vs 0 odds ratio 0.62 [95% confidence interval 0.58-0.66]). CONCLUSION The majority of US privately insured patients with primary hyperparathyroidism are not treated with parathyroidectomy. Having an operative indication only modestly increases the likelihood of parathyroidectomy. Further research is needed to address barriers to treatment and the gap between guidelines and clinical care in primary hyperparathyroidism.
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Affiliation(s)
- Carolyn D Seib
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine, CA; Department of Surgery, Stanford University School of Medicine, CA; Division of General Surgery, Palo Alto Veterans Affairs Health Care System, CA.
| | - Tong Meng
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine, CA; Department of Emergency Medicine, Stanford University School of Medicine, CA
| | - Insoo Suh
- Department of Surgery, University of California, San Francisco, CA
| | - Robin M Cisco
- Department of Surgery, Stanford University School of Medicine, CA
| | - Dana T Lin
- Department of Surgery, Stanford University School of Medicine, CA
| | - Arden M Morris
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine, CA; Department of Surgery, Stanford University School of Medicine, CA
| | - Amber W Trickey
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine, CA
| | - Electron Kebebew
- Department of Surgery, Stanford University School of Medicine, CA
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34
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Variation in surgical management of primary hyperparathyroidism in the US Department of Veterans Affairs healthcare system: A 15-year observational study. Surgery 2020; 168:838-844. [DOI: 10.1016/j.surg.2020.05.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 05/04/2020] [Accepted: 05/05/2020] [Indexed: 11/21/2022]
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Duh QY, Suh I, Stoller ML. Underdiagnosis of Primary Hyperparathyroidism-The Need for a System-Level Fix. JAMA Surg 2020; 155:868-869. [PMID: 32725177 DOI: 10.1001/jamasurg.2020.2448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Quan-Yang Duh
- Department of Surgery, University of California, San Francisco.,Surgical Service, Veterans Health Administration Medical Center, San Francisco, California
| | - Insoo Suh
- Department of Surgery, University of California, San Francisco.,Surgical Service, Veterans Health Administration Medical Center, San Francisco, California
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Quilao RJ, Greer M, Stack BC. Investigating the potential underdiagnosis of primary hyperparathyroidism at the University of Arkansas for Medical Sciences. Laryngoscope Investig Otolaryngol 2020; 5:773-777. [PMID: 32864451 PMCID: PMC7444768 DOI: 10.1002/lio2.415] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 04/03/2020] [Accepted: 05/19/2020] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION Primary hyperparathyroidism (PHPT) is a condition in which one or more parathyroid glands secrete excess amounts of parathyroid hormone (PTH). In short, PHPT is characterized by hypercalcemia/hypercalciuria with concurrent elevated PTH levels. This condition is known to increase the risk of cardiovascular disease, osteoporosis, psychiatric disturbances, and renal complications. As of now, the disease typically runs a long course before being identified and treated. At present, surgery is the only viable treatment option for patients with this disease. Publications from other tertiary centers have identified a large-scale underdiagnosis of PHPT. The aim of this study is to determine if similar trends exist at the University of Arkansas for Medical Sciences (UAMS). Moreover, this study was seen as a first step to developing a machine learning strategy to diagnose PHPT in large clinical data sets. METHODS To evaluate for potential underdiagnosis of PHPT at UAMS, all patients from 2006 to 2018 with hypercalcemia and/or hypercalciuria (excluding those with known malignancies or other possible causes of excess serum calcium) were identified in electronic medical records. Then, it was evaluated whether these hypercalcemic/hypercalciuric patients received subsequent measurement of PTH levels necessary to confirm the diagnosis of HPT. RESULTS At UAMS between 2006 and 2018, 28 831 patients were identified as having hypercalcemia and/or hypercalciuria. Of these patients, only 7984 ever had subsequent PTH levels tested. Therefore, 20 847 (72.3%) of these patients never had PTH labs drawn. CONCLUSIONS These findings may represent a significant patient population in which PHPT remains undiagnosed due to lack of follow-up. PHPT is often a silent disease with an insidious onset. At the point of diagnosis, typically the treatment is surgical removal of the offending parathyroid gland(s) (parathyroidectomy). Identification of underdiagnosis is the first step for subsequent improvement in the diagnosis of PHPT. Detection of this disease in its earlier stages may open the door for medical and lifestyle interventions, thereby decreasing long-term sequelae of the disease, such as osteoporosis, myocardial infarction, or stroke.
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Affiliation(s)
- Raymond J. Quilao
- University of Arkansas for Medical Sciences, Class of 2020, College of MedicineLittle RockArkansasUSA
| | - Melody Greer
- Department of Biomedical InformaticsUniversity of Arkansas for Medical SciencesLittle RockArkansasUSA
| | - Brendan C. Stack
- Department of Otolaryngology – Head and Neck SurgerySouthern Illinois University School of MedicineSpringfieldIllinoisUSA
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Balentine C. ASO Author Reflections: Race and Gender Disparities in Access to Parathyroidectomy: A Need to Change Processes for Diagnosis and Referral to Surgeons. Ann Surg Oncol 2020; 27:785-786. [PMID: 32542564 DOI: 10.1245/s10434-020-08723-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Courtney Balentine
- Department of Surgery and Division of Endocrine Surgery, VA North Texas Healthcare System and University of Texas Southwestern, Dallas, TX, USA.
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Mallick R, Xie R, Kirklin JK, Chen H, Balentine CJ. Race and Gender Disparities in Access to Parathyroidectomy: A Need to Change Processes for Diagnosis and Referral to Surgeons. Ann Surg Oncol 2020; 28:476-483. [PMID: 32542566 DOI: 10.1245/s10434-020-08707-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND Hyperparathyroidism substantially impairs quality of life, and effective treatment depends on timely referral to surgeons. We hypothesized that there would be race and gender disparities in the time from initial diagnosis of hyperparathyroidism to treatment with parathyroidectomy. METHODS We reviewed administrative data on 2289 patients with hypercalcemia (calcium > 10.5 mg/dL) and abnormal parathyroid hormone levels who were seen at a tertiary referral center from 2011 to 2016. We used two-phase parametric hazard modeling to identify predictors of time from index abnormal calcium until parathyroidectomy. RESULTS The median age of our cohort was 63 years, and 1685 (74%) were women. Of the total patients, 1301 (57%) were Caucasian, and 946 (41%) were African-American. Only 490 (21%) patients underwent parathyroidectomy. Among patients undergoing surgery, time from index high calcium to surgical treatment was longest for African-American men, who waited a median of 13.6 months (interquartile range IQR 2-28), compared with 2.9 months (IQR 1-8) for Caucasian males (p < 0.05). African-American women waited a median of 6.7 months (IQR 2-16) versus 3.5 months (IQR 2-14) for Caucasian women (p < 0.05). At 1 year after the index abnormal calcium, only 6% of black men underwent surgery compared with 20% of white males (p < 0.05). Similarly, 13% of black women underwent surgery versus 20% of white women (p < 0.05). These differences remained significant after adjusting for age, calcium levels, insurance, and comorbidities. CONCLUSIONS African-Americans face substantial delays in access to parathyroidectomy after diagnosis with hyperparathyroidism that could impair quality of life and increase health care costs. We must improve systems of diagnosis and referral to ensure timely treatment of hyperparathyroidism.
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Affiliation(s)
- Reema Mallick
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Rongbing Xie
- Department of Surgery, University of Alabama-Birmingham, Birmingham, AL, USA.,Kirklin Institute for Research in Surgical Outcomes, University of Alabama-Birmingham, Birmingham, AL, USA
| | - James K Kirklin
- Department of Surgery, University of Alabama-Birmingham, Birmingham, AL, USA.,Kirklin Institute for Research in Surgical Outcomes, University of Alabama-Birmingham, Birmingham, AL, USA
| | - Herbert Chen
- Department of Surgery, University of Alabama-Birmingham, Birmingham, AL, USA
| | - Courtney J Balentine
- North Texas VA Health Care System, Dallas, TX, USA. .,Department of Surgery, The University of Texas Southwestern Medical Center, Dallas, TX, USA.
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Duskin-Bitan H, Nemirovsky N, Slutzky-Shraga I, Gorshtein A, Masri-Iraqi H, Robenshtok E, Diker-Cohen T, Singer J, Shimon I, Hirsch D, Tsvetov G. Hyperparathyroidism in patients over 75: Clinical characteristics and outcome. Is conservative treatment a safe alternative? Maturitas 2020; 135:47-52. [PMID: 32252964 DOI: 10.1016/j.maturitas.2020.02.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 02/19/2020] [Accepted: 02/28/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE With the current aging of the world's population, primary hyperparathyroidism (PHPT) is increasingly detected in the elderly. Yet data on the presentation and outcome of PHPT in this group are scarce. The objective was to describe a cohort of patients aged 75 years or more with PHPT observed in our endocrine clinic. STUDY DESIGN A retrospective analysis of medical records in an endocrine clinic at a tertiary hospital. We evaluated 182 patients with PHPT, aged 75 years or more at their last follow-up, all diagnosed at age 65 or more. Laboratory data were compared at diagnosis and last follow-up. RESULTS Mean age at diagnosis was 73 ± 4 years, last follow-up was at 83 ± 4 years, and mean follow-up was 11.3 ± 5.5 years. Osteoporosis, fractures, and nephrolithiasis were diagnosed in 114(63 %), 84(46 %), and 43(24 %) patients, respectively. Overall, 150 patients had an indication for surgery; of them, the 29 who underwent parathyroidectomy were younger than the non-operated patients and had higher rates of hypercalciuria. During the follow-up of the 141 patients who did not undergo operation, serum and urinary calcium levels significantly had decreased, and vitamin D level had increased at last visit (10.4 ± 0.5 mg/dl, 161 ± 70 mg/24 h, 69 ± 17 nmol/l, p < 0.01 respectively) compared with levels at diagnosis (10.6 ± 0.2 mg/dl, 223 ± 95 mg/24 h, 53 ± 15 nmol/l, respectively, p = 0.001). Overall, 38 of the 182 patients (20 %) died during follow-up; these patients were significantly older at diagnosis (76 ± 5 vs. 72 ± 4 years) but there were no differences in laboratory variables. CONCLUSIONS While most patients had a formal indication for surgery, few underwent parathyroidectomy. Serum and urinary calcium significantly decreased during follow-up in patients who did not undergo surgery. Our data are reassuring and support at least the consideration of conservative treatment for these patients.
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Affiliation(s)
- Hadar Duskin-Bitan
- Institute of Endocrinology, Diabetes and Metabolism, Rabin Medical Center, Petah-Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | | | - Ilana Slutzky-Shraga
- Institute of Endocrinology, Diabetes and Metabolism, Rabin Medical Center, Petah-Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Alexander Gorshtein
- Institute of Endocrinology, Diabetes and Metabolism, Rabin Medical Center, Petah-Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Hiba Masri-Iraqi
- Institute of Endocrinology, Diabetes and Metabolism, Rabin Medical Center, Petah-Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eyal Robenshtok
- Institute of Endocrinology, Diabetes and Metabolism, Rabin Medical Center, Petah-Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Talia Diker-Cohen
- Institute of Endocrinology, Diabetes and Metabolism, Rabin Medical Center, Petah-Tikva, Israel; Medicine A, Rabin Medical Center, Petah-Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Joelle Singer
- Institute of Endocrinology, Diabetes and Metabolism, Rabin Medical Center, Petah-Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ilan Shimon
- Institute of Endocrinology, Diabetes and Metabolism, Rabin Medical Center, Petah-Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Dania Hirsch
- Institute of Endocrinology, Diabetes and Metabolism, Rabin Medical Center, Petah-Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gloria Tsvetov
- Institute of Endocrinology, Diabetes and Metabolism, Rabin Medical Center, Petah-Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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40
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Affiliation(s)
- Catherine Y Zhu
- Department of Surgery, Section of Endocrine Surgery, UCLA David Geffen School of Medicine, Los Angeles, California
| | - Cord Sturgeon
- Department of Surgery, Section of Endocrine Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Michael W Yeh
- Department of Surgery, Section of Endocrine Surgery, UCLA David Geffen School of Medicine, Los Angeles, California
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Paja-Fano M, Martínez-Martínez AL, Monzón-Mendiolea A. Diagnostic and treatment delay in primary hyperparathyroidism. A pending issue. ACTA ACUST UNITED AC 2020; 67:357-363. [PMID: 31982385 DOI: 10.1016/j.endinu.2019.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Revised: 11/06/2019] [Accepted: 11/08/2019] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Primary hyperparathyroidism (PHPT) remains underdiagnosed among patients with hypercalcemia, potentially causing increased morbidity. OBJECTIVE To identify in surgically operated patients the presence of overlooked hypercalcemia and patients with criteria for surgery (CFS) for PHPT at least one year prior to referral to Endocrinology, and to determine whether this diagnostic delay leads to increased morbidity. METHODS An observational study was carried out in 116 consecutive patients. We evaluated electronic medical records registered at least 12 months prior to referral and divided them in four groups: hypercalcemia with CFS (group 1), hypercalcemia without CFS (group 2), normocalcemia (group 3), and cases without previous biochemical evaluation (group 4). RESULTS A total of 84 patients (72.4%) had a previous measurement of serum calcium at a time interval of ≥ 12 months. Sixty-six (56.9%) had hypercalcemia and 43 of them (37%) had ≥ 1 CFS, with an average delay of 57 months in receiving proper evaluation. Almost half of the calcemia measurements in group 1 had been made in the emergency room. Patients from group 1 were younger, and had a greater frequency of nephrolithiasis and renal impairment than patients in group 4. The serum calcium values at referral were similar in both groups and higher than the values found in patients from the other two groups. DISCUSSION In patients with PHPT and CFS, referral to an endocrinologist is made with an average delay of almost 5 years. The identified causes of this delay, which conditions more kidney disease, are unrecognized hypercalcemia and/or unawareness of the surgical criteria, while calcium elevations promote referral. Interventions are needed to avoid this delay in the diagnosis and resolution of PHPT.
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Affiliation(s)
- Miguel Paja-Fano
- Hospital Universitario Basurto. Servicio de Endocrinología, Osakidetza, OSI Bilbao-Basurto, Bilbao, España.
| | | | - Andoni Monzón-Mendiolea
- Hospital Universitario Basurto. Servicio de Endocrinología, Osakidetza, OSI Bilbao-Basurto, Bilbao, España
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42
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Bertocchio JP. Diagnosis and Management of Hyperparathyroidism. JAMA Intern Med 2019; 179:1732. [PMID: 31790524 DOI: 10.1001/jamainternmed.2019.5084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Jean-Philippe Bertocchio
- Department of Genitourinary Medical Oncology Research, The University of Texas MD Anderson Cancer Center, Houston
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43
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Gaschen P, Almekdash MH, Peiris A. Diagnosis and Management of Hyperparathyroidism. JAMA Intern Med 2019; 179:1732. [PMID: 31790529 DOI: 10.1001/jamainternmed.2019.5129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Paul Gaschen
- Texas Tech University Health Sciences Center, Lubbock
| | - Mhd Hasan Almekdash
- Clinical Research Institute, Texas Tech University Health Sciences Center, Lubbock
| | - Alan Peiris
- Clinical Research Institute, Department of Internal Medicine, Texas Tech University Health Sciences Center, Lubbock
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44
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Alore EA, Ramsey DJ, Makris KI. Diagnosis and Management of Hyperparathyroidism-Reply. JAMA Intern Med 2019; 179:1733-1734. [PMID: 31790533 DOI: 10.1001/jamainternmed.2019.5087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Elizabeth A Alore
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - David J Ramsey
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Health Services Research and Development Center of Innovation, Houston, Texas
| | - Konstantinos I Makris
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Health Services Research and Development Center of Innovation, Houston, Texas.,Michael E. DeBakey Department of Surgery, VA Medical Center, Houston, Texas
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45
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Error in Title of Table 2 and Rewording of Conflict of interest Disclosures. JAMA Intern Med 2019; 179:1304. [PMID: 31476002 PMCID: PMC6724158 DOI: 10.1001/jamainternmed.2019.4281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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