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

PHQ-9 and GAD-7 Score Response After Parathyroidectomy for Primary Hyperparathyroidism: a Systematic Review and Meta-analysis

OBJECTIVE

Currently, the relationship between parathyroidectomy and objective neuropsychiatric outcomes are not clearly defined. The purpose of this study is to perform the first ever Meta-analysis of preoperative and postoperative PHQ-9 and GAD-7 scores in patients with primary hyperparathyroidism undergoing parathyroidectomy with the goal of identifying a specific psychometric score that could be used as an indication for surgical intervention.

DATA SOURCES

A comprehensive search of the literature was performed using PubMed, Embase, PsycINFO, Web of Science, and Ovid All EBM Reviews.

REVIEW METHODS

Studies met inclusion criteria if they evaluated preoperative and postoperative PHQ-9 and/or GAD-7 scores in patients with primary hyperparathyroidism undergoing parathyroidectomy. Random effects Meta-analyses were used to analyze the compiled data.

RESULTS

The literature search returned 1433 articles for initial review of which 6 (1105 participants) met criteria for inclusion and Meta-analysis. Meta-analysis revealed that primary hyperparathyroidism patients had significantly higher presurgical PHQ-9 scores when compared to control groups. Additionally, patients experienced a statistically significant and sustained decrease in PHQ-9 scores following parathyroidectomy. Notably, there was a dramatic decrease in the percentage of patients with PHQ-9 scores ≥10 (considered clinically significant for depression) following parathyroidectomy.

CONCLUSION

Patients with primary hyperparathyroidism experience a statistically significant and sustained improvement in PHQ-9 scores following parathyroidectomy. Additionally, symptoms of anxiety and suicidal ideation appear to decrease after parathyroidectomy. We propose that a PHQ-9 score ≥10 could potentially be used as an indication for parathyroidectomy in patients with asymptomatic primary hyperparathyroidism.

Improvement of mood and sleep quality in patients with primary hyperparathyroidism after parathyroidectomy: A prospective case-control study

BACKGROUND

Primary hyperparathyroidism can impact patient quality of life with psychopathological symptoms like mood and sleep disturbances. In the latest recommendations published according to the primary hyperparathyroidism surgical consensus, these neuropsychological symptoms continue to be excluded. This study aims to assess the negative effects of mood and sleep on patients with primary hyperparathyroidism compared to healthy controls and analyze their improvement after surgery.

METHODS

Prospective case-control study of patients with primary hyperparathyroidism. The Beck questionnaire and Pittsburgh Sleep Quality Index were used. The control group consisted of healthy people matched by age and sex. Preoperative results were compared with results at 3 and 12 months after surgery and compared with the control group. Statistical analysis consisted of the Kolmogorov-Smirnov test and Student's t test for correlations.

RESULTS

Forty-nine patients who underwent parathyroidectomy were analyzed. In relation to depression, differences were observed between the results of the preoperative period and 3 months after surgery, with a significant decrease in depression score (16.80 ± 9.98 vs 13.08 ± 10.76; P = .001). This improvement was maintained after 1 year (P < .001). Regarding the quality of sleep, there were no differences 3 months after the intervention, but there were differences at 12 months (9.48 ± 4.76 vs 8.27 ± 4.38; P = .032). The dimensions of the Pittsburgh Sleep Quality Index were analyzed, observing significant differences only in daytime dysfunction after 3 months and 12 months after surgery (1.02 ± 0.99 vs 0.69 ± 0.82; P = .01 and 1.04 ± 0.98 vs 0.60 ± 0.76; P = .004).

CONCLUSION

Mood changes and sleep quality improve after primary hyperparathyroidism surgery, although at different postoperative times, with this improvement being more pronounced in mood. This assessment should be taken into account in the preoperative consultation of patients with primary hyperparathyroidism.

Effects of successful parathyroidectomy on neuropsychological and cognitive status in patients with asymptomatic primary hyperparathyroidism

PURPOSE

Besides typical clinical symptoms, primary hyperparathyroidism (pHPT) is associated with impaired quality of life and cognitive status. The aim of this study was to evaluate the quality of life and cognitive impairment in patients with pHPT, before and after parathyroidectomy.

METHODS

We conducted a panel study, which included asymptomatic pHPT patients scheduled for parathyroidectomy. Besides demographic and clinical data, patients' quality of life and cognitive capacity were recorded before, 1 month, and 6 months following parathyroidectomy using the Short Form 36 questionnaire (RAND-36), Beck Depression Inventory (BDI), Depression Anxiety Stress Scales (DASS), Mini-Mental State Examination (MMSE), and Symptom Check List 90-revised version (SCL90R).

RESULTS

During a 2-year follow-up, 101 patients entered the study (88 women), with an average age of 60.7 years. The Global score of RAND-36 test ameliorated by almost 50% 6 months after parathyroidectomy. The most sustained subscores of the RAND-36 test were role functioning/physical and health change, with an improvement of more than 125%. According to the BDI, DASS depression subscore, and SCL90R depression subscore, the extent of depressive symptoms reduction was approximately 60% 6 months postoperatively. The level of anxiety was reduced by 62.4%, measured by both the DASS and SCL90R anxiety subscores. The stress level was almost halved according to the DASS stress subscore (from 10.7 to 5.6 points). The results of the MMSE test showed a significant improvement postoperatively, for 1.2 points (4.4%). A worse preoperative score of each tool was related to the higher magnitude of improvement 6 months after parathyroidectomy.

CONCLUSION

A considerable number of pHPT patients, even without other typical symptoms, show signs of impaired quality of life and neurocognitive status preoperatively. After a successful parathyroidectomy, there is an improvement in quality of life, declined levels of depression, anxiety, and stress, as well as amelioration of cognitive status. Patients with more impaired quality of life and pronounced neurocognitive symptoms may expect more benefits from the surgery.

The Influence of Hyperparathyroidism Patient Profile on Quality of Life After Parathyroidectomy

BACKGROUND

Improvements in quality of life (QoL) after parathyroidectomy in patients with primary hyperparathyroidism (PHPT) is discussed. It has not been analyzed whether these improvements can be influenced by a specific socio-personal or clinical patient profile.

OBJECTIVES

to analyze QoL differences after parathyroidectomy and to determine a socio-personal and clinical profile that influences improvement after parathyroidectomy.

METHODS

A longitudinal prospective cohort study in patients with PHPT. SF-36 and PHPQOL questionnaires were completed by the patients. A comparative preoperatory analysis was carried out, at three and twelve months after surgery. Student's t test was used for the correlations. The size of the effect was assessed using G*Power software. A multivariate analysis was performed to evaluate the socio-personal and clinical variables affecting the improvement in QoL after surgery.

RESULTS

Forty-eight patients were analyzed. Three months after surgery an improvement was found in physical function, general health, vitality, social function, emotional role, mental health and in the patient's declared health assessment. One year after the intervention a general improvement was observed, with a greater effect on mental health and declared health evolution. Patients with bone pain presented with a higher probability of improvement after surgery. Patients with prior psychological disease had a lower associated probability of an improvement and high levels of PTH related to a greater probability of improvement after surgery.

CONCLUSIONS

There is an improvement in the QoL of PHPT patients after parathyroidectomy. Patients with bone pain and high PTH levels prior to the parathyroidectomy present with a greater probability of having a greater improvement in QoL after surgery.

Quality of Life in Primary Hyperparathyroidism

Quality of life is impaired in primary hyperparathyroidism (PHPT), regardless of the severity of the disease. Clinical studies have employed different instruments, including standardized and disease-specific questionnaires, and including patients with different phenotypes of PHPT. Neuropsychiatric symptoms and decline in cognitive status are common in PHPT. Patients may complain of these issues or they can be ascertained by questionnaires; they include depression, anxiety, impaired vitality, social and emotional functions, sleep disturbances, and altered mental function. Randomized controlled trials on the effects of surgical versus non-surgical treatments have collectively shown improvement in quality of life after parathyroidectomy, but results have been heterogeneous.

Long-term Quality of Life After Parathyroidectomy for Primary Hyperparathyroidism: A Systematic Review

Importance

Definitive treatment of primary hyperparathyroidism (pHPT) with curative parathyroidectomy has been shown to improve nonspecific neurocognitive symptoms and may improve long-term quality of life (QOL). However, QOL is not currently routinely assessed preoperatively, and as a result, diminished QOL may be overlooked as an indication for surgery.

Objective

To examine results for measures of long-term QOL after parathyroidectomy in patients with pHPT.

Evidence Review

A systematic, English-language literature review was performed to assess the long-term association of parathyroidectomy, defined as a minimum of 1-year postoperative follow-up, with QOL in patients with pHPT. We conducted a search of PubMed and Scopus using Medical Subject Heading (MeSH) terms for hyperparathyroidism, parathyroid hormone, parathyroidectomy, hypercalcemia, and quality of life. All relevant literature published between June 1998 and February 15, 2021, was included. Study selection was guided by the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) strategy.

Findings

Thirty-one studies conducted in 14 countries with a minimum of 1 year of follow-up were included, comprising 3298 patients with pHPT (2975 underwent parathyroidectomy; 323 were observed), 5445 age- and sex-matched control participants, and 386 control patients with benign thyroid disease. To assess QOL, 21 studies (68%) used a general tool, the 36-item Short Form Survey (SF-36), and 8 (26%) used the disease-specific tool Parathyroidectomy Assessment of Symptoms (PAS). The remaining studies used a combination of 10 additional QOL tools. The median follow-up period was 1 year (range, 1-10 years). Of the 31 studies, 27 (87%) demonstrated significant score improvement in long-term QOL after parathyroidectomy, including 1 study that showed continued improvement in QOL 10 years after parathyroidectomy. The remaining 4 studies (13%) reported mixed results.

Conclusions and Relevance

This systematic review suggests that parathyroidectomy is associated with improved and sustained QOL in patients with pHPT. Patients with pHPT should be screened with a validated QOL tool such as the SF-36 or PAS at the time of diagnosis to guide discussion of these symptoms in the preoperative setting and the potential for long-term improvement after curative parathyroidectomy.

Successful parathyroidectomy improves cognition in patients with primary hyperparathyroidism: A prospective study in a tertiary medical center and comprehensive review of the literature

CONTEXT

The recent American and European guidelines on management of patients with primary hyperparathyroidism (PHPT) did not endorse neurocognitive evaluation as part of standard work-up and did not consider it as a surgery criterion.The neurocognitive deleterious effects of hyperparathyroidism and impact of parathyroidectomy on PHPT patients is yet to be elucidated.

OBJECTIVE

To evaluate specific neurocognitive functions in PHPT patients prior to parathyroidectomy and describe the changes during follow-up with serial evaluations.

DESIGN

A prospective case-control study including parathyroidectomy candidates evaluated at a tertiary teaching university hospital. Thorough neurocognitive evaluation was conducted before and 1- & 6-months following parathyroidectomy: Rey Auditory Verbal Learning Test (RAVLT), Rey-Osterrieth Complex Figure Test (ROCF), Trail Making Test A, Trail Making Test B, Addenbrooke's Cognitive Examination-III (ACE), Frontal Assessment Battery (FAB), Beck Depression Inventory (BDI).

RESULTS

18 consecutive patients underwent successful parathyroidectomy. Various neurocognitive functions improved significantly after successful parathyroidectomy: long term auditory memory (RAVLT, p=0.008), short- and long-term visual memory (ROCF, p=0.006 and p=0.002 respectively), visual attention and complex concentration skills (trail making A, p<0.001) and executive abilities (trail making B, p=0.005). No change was identified in frontal-lobe abilities. Depression symptoms were absent or minimal prior to surgery and no significant change was observed after surgery.

CONCLUSIONS

PHPT is associated with significant various neurocognitive dysfunctions when mindfully evaluated before surgery. Successful parathyroidectomy results in several neurocognitive aspect improvements. The data suggest that neurocognitive deterioration may be considered an added parathyroidectomy criterion when surgical decision is not straightforward.

Influence of Parathyroidectomy on Sleep Quality in Primary Hyperparathyroidism

We investigated the impact of parathyroidectomy on sleep quality in patients with primary hyperparathyroidism (pHPT). Thirty consecutive patients with pHPT were enrolled in the study within 1 year. pHPT was diagnosed by typical symptoms accompanied by an elevated level of parathormone. The Pittsburgh Sleep Quality Index (PSQI) was used for the evaluation of sleep 1 day before and 6 months after parathyroidectomy. The mean total PSQI score was elevated to 6.8 ± 0.6 points before surgery, which was in the pathological cut-off of greater than ≥5, indicating impaired sleep quality. After parathyroidectomy, the total score declined insignificantly, amounting to 5.6 ± 0.4 (p > 0.05). Nevertheless, the number of patients with a score of ≥5 before surgery decreased from 21 (70%) to 16 (53%) after surgery. There also was a significant improvement in sleep latency (p = 0.05) and sleep efficiency (p = 0.02) domains of PSQI. We conclude that 70% of patients with untreated pHPT suffered from sleep disorders that improved after parathyroidectomy. The clinical consequence is that patients with pHPT should be questioned about having sleep disorders, which might influence the decision-making concerning parathyroidectomy. With the relation reversed, patients without pHPT but suffering from sleep disturbance should be tested for pHPT.

A Review of the Relationship of the Cerebrospinal Fluid Changes During the Dysregulation of Parathyroid Hormone With Psychiatric or Neurological Manifestations

It is established that normal calcium and vitamin D concentrations are maintained in the body through parathyroid hormone (PTH), a signaling molecule secreted from parathyroid glands. A massive role is played by PTH in increasing calcium levels when they are extremely low in the body through different mechanisms. The dysregulation of this hormone is due to either over functioning of the gland (hyperparathyroidism) or compromised functioning in hypoparathyroidism. A detailed review was done to identify if any changes are happening in the cerebrospinal fluid (CSF) due to any pathology causing the parathormone to be dysregulated enough to, in turn, cause any further pathology in the nervous system. This may then lead to various disabling neuropsychiatric features. The calcium and vitamin D abnormalities are both directly and indirectly connected to psychiatric features like delusions, schizophrenia, disabled cognition, psychosis, coma, mania, and depression of all kinds.

Moreover, their irregularities are also linked to Alzheimer's. During these manifestations, the CSF is altered concentration-wise, where elevated calcium levels inside are observed during different studies. Despite PTH's indirect connection to the CSF modifications, their association hasn't been potently proven yet, considering more observational studies should be conducted in humans and for a more extended period, along with bigger and greater numbers of CSF samples. Suppose there is a possibility of the link of CSF alterations to PTH. In that case, we can consider a pronounced increase of CSF calcium or PTH as a risk factor for debilitating neuropsychiatric diseases. In this review, the possible correlation of CSF and PTH has been discussed.

Evaluation for Primary Hyperparathyroidism in Patients Who Present With Nephrolithiasis

BACKGROUND

The incidence of primary hyperparathyroidism (PHP) is likely underestimated. Nephrolithiasis may indicate PHP with indication for parathyroidectomy. We sought to determine the proportion of patients with an index diagnosis of nephrolithiasis that have serum calcium levels measured, parathyroid hormone (PTH) levels measured if hypercalcemic, and time to referral for definitive management if PHP is diagnosed.

METHODS

A single-institution retrospective review was performed of adult patients presenting with nephrolithiasis between July 1, 2016 and December 31, 2018. Exclusion criteria included currently admitted patients, prior nephrolithiasis, congenital or acquired urinary tract anomalies, and patients on calciuretics. Records were assessed for serum calcium and PTH measurement, as well as referrals. Univariate statistical analysis was performed.

RESULTS

Of 1782 patients with nephrolithiasis screened, 968 met inclusion criteria. Patients were 49.8% female, 88.9% white. Mean age was 53 y. Within this cohort, 620 (64.0%) patients had a calcium measured, with a mean elapsed time from presentation of 27 d (interquartile range [IQR] 0-8). Twelve patients (1.58%) with calcium measured were hypercalcemic and eight (66.7%) had PTH measured with a mean elapsed time from presentation of 183 d (IQR 72-310), all had elevated or non-suppressed PTH. Five (62.5%) were referred to surgeons with mean elapsed referral time of 270 d (IQR 95-492).

CONCLUSIONS

Many with index nephrolithiasis are not assessed for hypercalcemia or hyperparathyroidism. Patients with serum calcium and PTH values indicating PHP diagnosis may have significant delay to parathyroidectomy. Targeted interventions with electronic health record alerts or automated reflex testing may improve care in this domain.

Neuropsychologic changes in primary hyperparathyroidism after parathyroidectomy from a dual-institution prospective study

BACKGROUND

The impact of parathyroidectomy on neuropsychiatric symptoms in primary hyperparathyroidism remains poorly defined. The validated scales Patient Health Questionnaire-9 and Generalized Anxiety Disorder-7 can be used to assess depression and anxiety, respectively. Our aim was to prospectively characterize the changes in neuropsychiatric symptoms after parathyroidectomy.

METHODS

Patients undergoing parathyroidectomy and thyroidectomy (control) from two institutions between 2014 and 2019 were prospectively administered a questionnaire assessing neuropsychiatric symptoms before and after surgery. Paired t tests compared preoperative with postoperative neuropsychiatric symptoms and t tests compared differences in neuropsychiatric symptoms between parathyroidectomy and thyroidectomy.

RESULTS

A total of 244 patients underwent parathyroidectomy and 161 underwent thyroidectomy. We observed improvement in neuropsychiatric symptoms after parathyroidectomy (6.2 [5.0-7.4], P < .01). Preoperatively, neuropsychiatric symptoms were more prevalent in patients undergoing parathyroidectomy when compared with thyroidectomy (11.2 ± 11.5 vs 7.5 ± 8.2, P < .01); however, after surgery there was no difference between the two groups (5.1 ± 7.1 vs 5.4 ± 7.2, P = .59). Preoperatively, 27.5% and 18.0% of patients endorsed moderate to severe depression and anxiety, which fell to 8.2% and 5.3%, respectively, (P < .01) after surgery.

CONCLUSION

Patients undergoing parathyroidectomy showed significant improvement in neuropsychiatric symptoms after surgery. Neuropsychiatric symptoms are more prevalent in patients with primary hyperparathyroidism. Neuropsychiatric symptoms should be assessed in all patients with primary hyperparathyroidism and should be considered a relative indication for parathyroidectomy.

Primary hyperparathyroidism

Primary hyperparathyroidism (PHPT) is a condition that affects calcium metabolism due to parathyroid hormone (PTH) hypersecretion leading to hypercalcemia. Manifestations have changed over time, from a symptomatic disease with bone pain, fractures, nephrolithiasis, and muscle weakness, to a condition that is mainly asymptomatic (80-90%). Typical symptoms and signs occur in the bones and kidneys and atypical manifestations are cardiovascular, neuropsychiatric and cognitive, neuromuscular, rheumatological, and gastrointestinal. Diagnosis occurs, in most cases, in asymptomatic patients by a routine calcium measurement with corrected high total calcium associated with high or inappropriately abnormal PTH. If indicated, a search for the location of the involved parathyroid gland should be performed with ultrasound, scintigraphy, or 4D CT. Parathyroidectomy is the gold standard treatment. If surgery cannot be performed, clinical management is indicated. Surgical indications are osteoporosis, hypercalciuria, spine fractures, age <50 years, calcemic values above 1.0 mg/dL threshold value, creatinine clearance ≤60 mL/min, and nephrolithiasis or nephrocalcinosis.

An Atypical Presentation of Primary Hyperparathyroidism in an Adolescent: A Case Report of Hypercalcaemia and Neuropsychiatric Symptoms Due to a Mediastinal Parathyroid Adenoma

Psychiatric disorders are rare clinical manifestations of hypercalcaemia in the pediatric population, are relatively more frequent during adolescence and are often overlooked in cases of severe hypercalcaemia. We described the case of a 17-year-old girl affected by anorexia nervosa, depression and self-harm with incidental detection of moderate hypercalcaemia. Clinical, laboratory and instrumental tests demonstrated that hypercalcaemia was secondary to primary hyperparathyroidism (PHPT) due to a mediastinal parathyroid adenoma in the thymic parenchyma. After parathyroidectomy with robot-assisted surgery, we observed the restoration of calcium and PTH levels in addition to an improvement in psychiatric symptoms. This case demonstrates that serum calcium concentration should be evaluated in adolescents with neurobehavioural symptoms and in cases of hypercalcaemia PHPT should be excluded. Surgery represents the cornerstone of the management of PHPT and may contribute to improving quality of life and psychological function in these patients. However, the complexity of neurological involvement in cases of hypercalcaemia due to PHPT requires further investigations to establish the real impact of this condition on the neurocognitive sphere.

Clinical characteristics and depression score response after parathyroidectomy in primary hyperparathyroidism

OBJECTIVE

Several studies indicate that patients with primary hyperparathyroidism (PHPT) undergoing parathyroid surgery have improvement in mood and neuropsychological functioning. The current analysis aims to examine the relationship between biochemical and clinical variables and the improvement in depression scores and in specific symptoms, after parathyroidectomy.

DESIGN

A prospective observational case-control study at a referral centre.

PATIENTS

Patients with PHPT undergoing parathyroidectomy (n = 88) or thyroid surgery (n = 85).

MEASUREMENTS

The Patient Health Questionnaire-9 (PHQ-9) was utilized to obtain depression scores at enrolment and 12 months after surgery. The changes in PHQ-9 were analysed and correlated with baseline clinical and biochemical parameters.

RESULTS

At enrolment, there was no difference between the groups in the number with a depression diagnosis (PHPT 34.1%, thyroid surgery, 35.5%, P = 0.86). However, baseline PHQ-9 scores were significantly higher in PHPT (median 7.5, range 0-27) than thyroid surgery patients (median 3.0, range 0-18, P < 0.0001). Following surgery, all PHQ-9 scores, total and symptom group (cognitive, somatic) improved and were no longer different between PHPT (total PHQ-9 median 2, range 0-16) and thyroid (median 1, range 0-14, P = 0.31) groups. Baseline parathyroid hormone level, but not calcium, had a weak relationship with change in PHQ-9 score after parathyroid surgery (P = 0.003). Baseline PHQ-9 score was correlated with change in PHQ-9 score at 12 months after parathyroid surgery (P < 0.001).

CONCLUSIONS

Depression scores improve in both somatic and cognitive domains after parathyroidectomy for PHPT and baseline severity of depression predicts the response.

Primary hyperparathyroidism: should surgery be performed on all patients? Current evidence and residual uncertainties

Primary hyperparathyroidism (pHPT) is the third most common endocrine disease and is characterized by hypercalcaemia and elevated or inappropriately 'normal' levels of the parathyroid hormone (PTH). The main target organs of PTH are the skeletal system and the kidneys. Before the 1970s, pHPT was a rarely detected disease associated with notable morbidity and premature mortality. Introduction of biochemical screening, allowing for a wide range of indications, has contributed to the detection of the full spectrum of the disease. A new entity with an isolated elevation of PTH, normocalcaemic HP, has emerged and is currently being explored. The highest incidence of pHPT, 3-5%, is observed amongst women, and the prevalence increases with age. The female-to-male ratio is 3-4 : 1 except in younger patients where distribution is equal and known hereditary causes account for approximately 10% of the cases. In the last few decades, it has become evident that fewer patients than previously believed are truly asymptomatic. The cause of pHPT is often a benign tumour, a parathyroid adenoma, and the only definite treatment is parathyroidectomy (PTX). No medical treatment, single or combined, can achieve a curing of pHPT. Recent data indicate that PTX, despite being proven to be cost-effective compared to conservative treatment, is underutilized, especially in elderly pHPT patients. The decision of PTX should always be based on a safe diagnosis, and the potential benefits of curative treatment should not be outweighed by the risks of surgery or anaesthesia.

Health-related quality of life improves 1 year after parathyroidectomy in primary hyperparathyroidism: A prospective cohort study

OBJECTIVE

Impaired quality of life (QoL) in primary hyperparathyroidism (PHPT) is commonly present. Patients may complain about nonspecific neurocognitive symptoms which can be difficult to quantify. Two different disease-specific questionnaires have been developed, that is, the parathyroid assessment of symptoms score (PAS) and the primary hyperparathyroidism quality of life (PHPQoL). Using these two questionnaires, we assessed relationship between QoL and biochemical indices in PHPT and effects of parathyroidectomy (PTX).

DESIGN

A prospective cohort study.

METHODS

Patients with PHPT diagnosed from 2015 to 2017 were asked to answer the questionnaires before and 12 months after PTX. Biochemistry was obtained on both occasions.

RESULTS

A total of 104 PHPT patients answered PAS and PHPQoL questionnaires at baseline, with a median age of 64 years (73% females). PHPQoL score correlated inversely with ionized calcium and PTH at baseline (P ˂ 0.04). Total PAS and PHPQoL score did not differ between those with and without osteoporosis, renal calcifications and impaired renal function. Based on levels of ionized calcium, PHPQoL differed significantly between patients with mild- and moderate-severe hypercalcemia (P = 0.01). Fifty-three patients answered PAS and PHPQoL 12 months after PTX showing an improved QoL at follow-up (P_all  ˂ 0.02). Stratifying patients into groups based on levels of ionized calcium showed a significantly improved PHPQoL score in patients with mild (˂1.45 mmol/L) as well as moderate-severe hypercalcemia (≥1.45 mmol/L) at follow-up (P_all  ˂ 0.03).

CONCLUSION

Quality of life improved 12 months after PTX in PHPT patients. Impaired QoL seems to be associated with the degree of hypercalcemia rather than organ manifestations attributable to PHPT.

Neuropsychological Changes in Primary Hyperparathyroidism after Parathyroidectomy

Neuropsychiatric symptoms (NPSs) of sporadic primary hyperparathyroidism (PHPT) are often subtle and effects of parathyroidectomy (PTX) on symptoms remains poorly characterized. Our aim was to evaluate effects of PTX on NPS in patients with PHPT. A prospective questionnaire was distributed to all patients undergoing PTX and to a thyroidectomy (TX) control group. The questionnaire included the validated scales Patient Health Questionnaire-9 (PHQ-9) and Generalized Anxiety Disorder-7 (GAD-7) to assess for depression and anxiety respectively, as well as questions modified from Pasieka's Parathyroid Assessment of Symptoms (M-PAS). Point values were assigned to questionnaire answers to create a score, with a maximum of 63. Fifty-eight patients underwent PTX (58.6%) and 41 TX (41.4%). Mean preoperative scores were greater in PTX versus TX patients in total score, PHQ-9, GAD-7, and M-PAS (all P < 0.05). Post-PTX scores were lower than pre-PTX in total score, PHQ-9, GAD-7, and M-PAS (all P < 0.05), but not in pre- and post-TX. Post-PTX 69.0 and 82.8 per cent of patients showed no symptoms of depression and anxiety, respectively, compared with 37.9 and 56.9 per cent pre-PTX. A total of 16.2 and 10.3 per cent of patients had moderately severe to severe depression and anxiety, which fell to 0 per cent post-PTX. NPSs are more common in patients with PHPT when compared with TX. Patients undergoing PTX have improvements in NPS. NPS scoring should occur in all patients with PHPT and severity of NPS should be considered a relative indication for PTX.

Clinical presentation and management of patients with primary hyperparathyroidism of the Swiss Primary Hyperparathyroidism Cohort: a focus on neuro-behavioral and cognitive symptoms

PURPOSE

To describe the clinical and biochemical profile of patients with primary hyperparathyroidism (PHPT) of the Swiss Hyperparathyroidism Cohort, with a focus on neurobehavioral and cognitive symptoms and on their changes in response to parathyroidectomy.

METHODS

From June 2007 to September 2012, 332 patients were enrolled in the Swiss PHPT Cohort Study, a nationwide prospective and non-interventional project collecting clinical, biochemical, and outcome data in newly diagnosed patients. Neuro-behavioral and cognitive status were evaluated annually using the Mini-Mental State Examination, the Hospital Anxiety and Depression Scale, and the Clock Drawing tests. Follow-up data were recorded every 6 months. Patients with parathyroidectomy had one follow-up visit 3-6 months' postoperatively.

RESULTS

Symptomatic PHPT was present in 43 % of patients. Among asymptomatic patients, 69 % (131/189) had at least one of the US National Institutes for Health criteria for surgery, leaving thus a small number of patients with cognitive dysfunction or neuropsychological symptoms, but without any other indication for surgery. At baseline, a large proportion showed elevated depression and anxiety scores and cognitive dysfunction, but with no association between biochemical manifestations of the disease and test scores. In the 153 (46 %) patients who underwent parathyroidectomy, we observed an improvement in the Mini-Mental State Examination (P = 0.01), anxiety (P = 0.05) and depression (P = 0.05) scores.

CONCLUSION

PHPT patients often present elevated depression and anxiety scores and cognitive dysfunction, but rarely as isolated manifestations. These alterations may be relieved upon treatment by parathyroidectomy.

Health-related quality of life is impaired in primary hyperparathyroidism and significantly improves after surgery: a prospective study using the 15D instrument

Health-related quality of life (HRQoL) is frequently impaired in primary hyperparathyroidism (PHPT) but it is unclear if surgery is beneficial. The objective was to prospectively assess HRQoL in PHPT (n=124) with the 15D instrument before and after surgery, to compare it with that of a comparable sample of the general population (n=4295), and search for predictors of HRQoL and its change. HRQoL, and clinical and laboratory parameters were measured before and at 6 and 12 months after surgery. Regression techniques were used to search for predictors of HRQoL and gains from treatment. Before surgery, PHPT patients had significantly lower mean 15D score compared to controls (0.813 vs 0.904, P<0.001). Excretion, mental function, discomfort and symptoms, distress, depression, vitality, and sexual activity were most impaired (all P<0.001). Number of medications (P=0.001) and subjective symptoms (P<0.05) but not calcium or parathyroid hormone (PTH) predicted impaired HRQoL. Serum 25-hydroxyvitamin D (25OHD) was of borderline significance (P=0.051). Compared to baseline, mean 15D score improved significantly 6 months after surgery (0.813 vs 0.865, P<0.001) and the effect sustained at 1 year (0.878, P<0.001). The improvement was clinically important in 77.4% of patients (P<0.001). Educational level independently predicted improvement (P<0.005). HRQoL is severely impaired in PHPT but improves significantly after surgery. The 15D is a sensitive tool for assessing HRQoL and recognizing patients likely to benefit from surgery.

Long-term prospective evaluation comparing robotic parathyroidectomy with minimally invasive open parathyroidectomy for primary hyperparathyroidism

BACKGROUND

Targeted parathyroidectomy is a popular technique for localized pathology. No single technique is established as superior. The purpose of this study was to compare robotic-assisted parathyroidectomy (RAP) with the most common approach.

METHODS

This was a prospective, nonrandomized study. Fifteen consecutive patients who underwent RAP were compared to 15 matched controls undergoing focused lateral parathyroidectomy (FLP).

RESULTS

Biochemical cure occurred in 29 of 30 patients (97%). No major complications occurred, although there was 1 robotic conversion. RAP demonstrated a significant time reduction (R(2)  = 0.436; p = .01) but took much longer to perform than FLP (119 minutes vs 34 minutes; p = .001). RAP was associated with less initial postoperative pain (p = .036) and higher satisfaction with scar cosmesis (p = .002) until 6 months. Quality of life (QOL) improved in both groups (p = .007).

CONCLUSION

RAP provides superior early cosmesis with equivalent global health improvement compared to FLP. The high cost and learning curve may preclude widespread adoption. Further evaluation is necessary to establish its clinical efficacy regarding scar cosmesis. © 2015 Wiley Periodicals, Inc. Head Neck 38: E300-E7, 2016.

Cinacalcet normalizes serum calcium in a double-blind randomized, placebo-controlled study in patients with primary hyperparathyroidism with contraindications to surgery

OBJECTIVE

Primary hyperparathyroidism (PHPT) is diagnosed by the presence of hypercalcemia and elevated or nonsuppressed parathyroid hormone (PTH) levels. Although surgery is usually curative, some individuals fail or are unable or unwilling to undergo parathyroidectomy. In such individuals, targeted medical therapy may be of value. Cinacalcet normalized calcium level and lowered PTH in patients with PHPT in several phase 2 and open-label studies. We compared cinacalcet and placebo in subjects with PHPT unable to undergo parathyroidectomy.

DESIGN

Phase 3, double-blind, multi centere, randomized, placebo-controlled study.

METHODS

Sixty-seven subjects (78% women) with moderate PHPT were randomized (1:1) to cinacalcet or placebo for ≤28 weeks.

MAIN OUTCOME MEASURE

Achievement of a normal mean corrected total serum calcium concentration of ≤10.3 mg/dl (2.575 mmol/l).

RESULTS

Baseline median (quartile 1 (Q1), Q3) serum PTH was 164.0 (131.0, 211.0) pg/ml and mean (s.d.) serum Ca was 11.77 (0.46) mg/dl. Serum Ca normalized (≤10.3 mg/dl) in 75.8% of cinacalcet- vs 0% of placebo-treated subjects (P<0.001). Corrected serum Ca decreased by ≥1.0 mg/dl from baseline in 84.8% of cinacalcet- vs 5.9% of placebo-treated subjects (P<0.001). Least squares mean (s.e.m.) plasma PTH change from baseline was -23.80% (4.18%) (cinacalcet) vs -1.01% (4.05%) (placebo) (P<0.001). Similar numbers of subjects in the cinacalcet and placebo groups reported adverse events (AEs) (27 vs 20) and serious AEs (three vs four). Most commonly reported AEs were nausea and muscle spasms.

CONCLUSIONS

These results demonstrate that cinacalcet normalizes serum calcium in this PHPT population and appears to be well tolerated.

Timing of symptom improvement after parathyroidectomy for primary hyperparathyroidism

BACKGROUND

The timing of symptom improvement after parathyroidectomy for primary hyperparathyroidism (PHPT) has not been well characterized.

METHODS

This prospective study involved administering a questionnaire to patients with PHPT who underwent curative parathyroidectomy over an 11-month period. The questionnaire evaluated the frequency of 18 symptoms of PHPT on a 5-point Likert scale and was administered preoperatively and 1 week, 6 weeks, and 6 months postoperatively.

RESULTS

Of 197 eligible patients, 132 (67%) participated in the study. The questionnaires were completed at a rate of 91%, 92%, and 86% at 1 week, 6 weeks, and 6 months postoperatively, respectively. The most commonly reported preoperative symptoms were fatigue (98%), muscle aches (89%), and bone/joint pain (87%). Improvement in symptom severity occurred across all symptoms and was separated into three categories based on the timing of improvement. Fatigue and bone/joint pain demonstrated "Immediate Improvement" (>50% of patients reporting improvement by post-operative week 1), whereas the majority of symptoms showed peak improvement at 6 weeks ("Delayed Improvement"). Symptoms categorized as "Continuous Improvement" were those showing progressive improvement up to 6 months postoperatively (polydipsia, headaches, and nausea/vomiting).

CONCLUSION

Symptom improvement was most prominent 6 weeks postparathyroidectomy, although some symptoms showed continued improvement at 6 months.

Cost-efficiency of laboratory testing among psychiatric inpatients

BACKGROUND

A set of tests to rule out medical conditions among psychiatric inpatients is still to be defined. A first step in this direction is to determine the utility of lab tests commonly used by psychiatrists.

METHODS

Biochemical tests have been routinely performed on inpatients in a psychiatric hospitalization unit from 2006 to 2009. This study examines the prevalence of abnormal values in 1,278 laboratory tests performed on 894 patients. The number of subjects screened and the direct expenditure needed to find results outside the normal range were computed. Differences in clinical profiles were compared between diagnostic groups according to main diagnosis.

RESULTS

We found high rates of seropositive patients for human immunodeficiency virus (14.3%) and hepatitis B virus (15.7%). Most patients met at least one criteria of metabolic syndrome (67.6%). The detection of hepatic abnormalities was very efficient (65.71%), particularly for patients diagnosed with alcohol use disorders.

CONCLUSIONS

The cost-efficiency of lab tests in psychiatric units is greatly variable. Though results of this study may not be generalized due to the different prevalence of medical conditions, the methodology can be easily implemented across psychiatric services. Cost-effectiveness and costbenefit analyses are warranted.

Development of a new tool for assessing health-related quality of life in patients with primary hyperparathyroidism

BACKGROUND

Several studies in recent years have evaluated Health Related Quality of Life (HRQoL) of patients with primary hyperparathyroidism (PHPT). No disease specific questionnaires are available to assess the impact of the disease. The aim of this research is to describe the development of a new disease specific Quality of Life (QoL) questionnaire for use specifically with PHPT patients.

METHODS

A conceptual model was developed describing the impact of the disease and its symptoms on QoL domains. A literature review was conducted to identify the most relevant domains. A focus group with experts was used to validate the domains; 24 patients were also interviewed to complement the information from the patient's perspective. A content analysis of the interviews was performed to identify items related with the impact of the disease, leading to PHPQoL-V.1 which was presented to a sample of 67 patients. Reliability was assessed by Cronbach's coefficient alpha and item-total score correlations. Validity was assessed by a factor analysis performed to determine the number of domains. Rasch analysis was carried out in order to refine the questionnaire items.

RESULTS

259 items were extracted from the interviews that were subsequently reduced to 34 items. Cronbach's coefficient alpha was 0.92. The factor analysis extracted two domains (physical and emotional). After Rasch analysis the questionnaire PHPQoL-V.2 kept 16 items (9 physical and 7 emotional). The questionnaire was developed in a Spanish population and the final version was translated to English through translation and back-translation.

CONCLUSION

The first disease specific HRQoL questionnaire for PHPT patients (PHPQoL-16) has been developed. Validation studies designed to assess measurement properties of this tool are currently underway.

Article Commentary: Nonclassical Symptoms of Primary Hyperparathyroidism and Their Response to Parathyroidectomy

An estimated 100,000 new patients are diagnosed with primary hyperparathyroidism (PHPT) each year in the United States.1 In the past, patients with PHPT typically presented with “stones, bones, abdominal groans, and psychic moans” but today patients often present with more subtle symptoms and physiologic changes associated with earlier stages of disease. Patients without the classic symptoms of PHPT are often referred to as “asymptomatic.” These patients frequently pose a conundrum for clinicians. Uncertainties remain as to which symptoms truly represent PHPT and which are related to comorbidities or the aging process. To address these uncertainties, we review most recent literature regarding the nonclassical manifestations of PHPT and their response to parathyroidectomy.

Surgery in primary hyperparathyroidism: extensive personal experience

Parathyroidectomy is the optimal treatment for primary hyperparathyroidism (PHPT) and provides a cure in the vast majority of cases. Over the last 2 decades, improvements in preoperative localization and the development of intraoperative parathyroid hormone monitoring have opened the door for new surgical approaches to parathyroidectomy. Minimally invasive parathyroidectomy is performed under regional or local anesthesia. It requires less surgical dissection resulting in decreased trauma to tissues and is more effective and less costly than traditional bilateral cervical exploration. This article reviews our approach reflecting advances in preoperative localization, anesthetic techniques, and intraoperative management of patients undergoing parathyroidectomy for the treatment of PHPT.

Patients with surgically cured primary hyperparathyroidism have a reduced quality of life compared with population-based healthy sex-, age-, and season-matched controls

OBJECTIVE

Primary hyperparathyroidism (PHPT) is associated with feelings of fatigue and depression, as well as limitation to physical and mental functioning. These quality of life (QoL) characteristics improve after parathyroidectomy. However, whether former patients fully regain QoL compared with healthy controls is largely unknown.

DESIGN AND PATIENTS

Cross-sectional study. Fifty-one former PHPT patients, successfully treated by surgery (mean time since parathyroidectomy 7.4 (range 5-15) years), and 51 sex- and age-matched healthy controls.

METHODS

The 36-item Short-Form Health Survey version 2 and the WHO-Five Well-being Index. The surveys included questions on overall physical and mental health, functioning, and limitation in daily life activities.

RESULTS

Former patients scored significantly lower compared with controls in physical functioning (P=0.01), role limitation caused by emotional problems (P=0.01), vitality (P<0.001), and general health (P=0.01). Compared with the controls, cases had a lower median (interquartile range) score of physical component summary (PCS; 54.9 (47.9-58.7) vs 49.6 (45.2-55.9), P=0.03) and mental component summary (MCS; 55.4 (49.7-58.1) vs 52.5 (44.7-55.5), P=0.04). There was no association between time since operation and PCS or MCS. Compared with controls, cases had higher body mass index (BMI; 26.0±4.7 vs 28.8±6.0 kg/m(2), P<0.001) and a higher frequency of cardiovascular diseases (CVD; 41.2 vs 62.7%, P=0.03). After adjustment for differences in BMI and CVD, PCS did no longer differ between groups. However, adjustments did not change the finding of a lower MCS in cases compared with controls.

CONCLUSION

Even though QoL may improve substantially after surgery, former PHPT patients still have reduced QoL compared with healthy controls.

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

OBJECTIVE

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Hyperparathyroidism, an emerging disease

A retrospective study based on 35 years of personal experience was done. Up to today 2,175 patients were operated, 1,318 for primary hyperparathyroidism (HPT) and 857 for secondary and tertiary HPT. Considering recent years (1999 to July 2010), 918 patients were operated for primary HPT. Preoperatively all the patients performed a cervical ultrasound and/or a sestamibi scan. Open mininvasive procedure was preferred: it is an easily reproducible and costless technique. Using magnifying glasses up to 2.5, an excellent three-dimensional vision was obtained. The operating time is short and if there are any doubts it is possible to extend the exploration to the other side of the neck. Immediate and long-term results were excellent, with a cure rate greater than 99%. Complications in the treatment of a single adenoma are around 0.3%. Patients can be discharged 24-48 h after the operation. Regarding reoperations, a correct diagnostic and therapeutic approach is essential. CT, MRI and SPECT must correlate with the information given by ultrasound and scintigraphy. The intraoperative PTH assay (io-PTH) is required and the approach should be limited to the area where the missed gland probably is. The functionality of the autotransplantation (AT) performed immediately was good. The functionality of the cryopreserved tissue is better for the HPT I in comparison with HPT II. Considering HPT I or HPT II the use of io-PTH is helpful. MIBI scanning is helpful but not essential, except in reoperations. Surgeon experience is another very important factor for good results.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Neurocognitive dysfunction: a predictor of parathyroid hyperplasia

BACKGROUND

To determine whether a symptomatic presentation was associated with parathyroid hyperplasia, we retrospectively examined pre-operative symptom profiles of patients who underwent parathyroidectomy.

METHODS

From October 2007 to July 2008, 111 patients with primary hyperparathyroidism completed a preoperative symptom questionnaire prior to parathyroidectomy. The symptom profiles of patients with and without hyperplasia were compared.

RESULTS

Neurocognitive symptoms occurred in 51.4% of patients. Patients with 1 neurocognitive symptom had a 25% risk of parathyroid hyperplasia. Additional neurocognitive symptoms increased the risk of hyperplasia linearly, with hyperplasia occurring in 38% of patients reporting 2 neurocognitive symptoms (P < .001) and 61% of patients reporting 3 or more of these symptoms (P < .001). A negative sestamibi scan was associated with a 33% risk of hyperplasia. Coupled with at least 1 neurocognitive symptom, the risk of hyperplasia was 53.3% (P < .001). Of patients with 3 or more neurocognitive symptoms and a negative localizing scan, 100% were found to have parathyroid hyperplasia (P < .001).

CONCLUSION

The presence of neurocognitive dysfunction in a patient with hyperparathyroidism may be used as a predictor of hyperplastic disease. Three or more of these symptoms, coupled with a negative sestamibi scan, was 100% predictive of parathyroid hyperplasia in our cohort.

Cinacalcet reduces serum calcium concentrations in patients with intractable primary hyperparathyroidism

CONTEXT

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

OBJECTIVE

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

DESIGN

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

SETTING

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

PATIENTS

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

INTERVENTION

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

MAIN OUTCOME MEASURE

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

RESULTS

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

CONCLUSIONS

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

Neuropsychological features in primary hyperparathyroidism: a prospective study

CONTEXT

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

OBJECTIVE

This study evaluated psychological symptoms and cognitive function in PHPT.

DESIGN

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

SETTINGS

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

PARTICIPANTS

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

INTERVENTION

Participants with PHPT underwent parathyroidectomy.

OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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