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

Translation into Portuguese (Brazil), cultural adaptation and validation of Parathyroid Assessment of Symptoms (PAS) in patients with chronic kidney disease and hyperparathyroidism

INTRODUCTION

Chronic kidney disease (CKD) is related to high morbidity and mortality and loss of quality of life. Likewise, hyperparathyroidism is associated to progressive loss of renal function, with increased phosphate and decrease calcium levels, which induce the secretion of parathyroid hormone.

OBJECTIVES

To translate into Portuguese (Brazil), culturally adapt and validate the questionnaire Parathyroid Symptoms Assessment (PAS), following reliability and validity criteria in patients with chronic kidney disease and hyperparathyroidism.

METHODS

Methodological and cross-sectional study, carried out at São Lucas Hospital/PUCRS, Porto Alegre, Brazil. The PAS questionnaire validation process followed protocols from previous studies. After translating into Portuguese, it was applied to 100 patients with secondary (SHPT) and tertiary or persistent (THPT) hyperparathyroidism. For PAS validation data, patients responded to the Short Form Health 36 (SF-36) questionnaire. Reliability criteria were evaluated using intraclass correlation coefficient (ICC) and Cronbach's alpha (α-C). Validity was assessed by Spearman's correlation coefficient between PAS and SF-36 values.

RESULTS

Participant's mean age was 55.6 ± 15.6 years, 61% was male, and 68% was diagnosed with SHPT. Among 100 patients, 53% performed a PAS retest (ICC = 0.83). The internal reliability by α-C was 0.86. Negative correlations were observed between PAS questions and SF-36 physical and mental domains, which ranged from 0.3 to 0.7.

CONCLUSION

The Brazilian version of the PAS questionnaire was found to be valid and reliable. The PAS questionnaire can be used to evaluate quality of life in Brazilian patients with hyperparathyroidism who speak Portuguese.

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.

Patient-reported outcome measures for primary hyperparathyroidism: a systematic review of measurement properties

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.

Sex differences in patients with primary hyperparathyroidism

BACKGROUND

Differences in presenting symptoms of primary hyperparathyroidism and outcomes of parathyroidectomy between sexes have been described, but whether these can be assessed by perioperative use of a validated tool, such as the Pasieka Parathyroidectomy Assessment Score, is unknown.

METHOD

All patients with primary hyperparathyroidism were asked to complete symptom assessment at the preoperative and postoperative visits. The assessment included a query for 13 Pasieka Parathyroidectomy Assessment Score parameters evaluated using a visual analog scale as described by Pasieka (summative score 0-1,300), and general quality of life and wellness. A review of a prospectively maintained database of primary hyperparathyroidism patients (January 2016-December 2019) was performed, and those who had a 6-month cure after initial parathyroidectomy were included.

RESULTS

The study cohort was mostly women (77%, 541/701). The median preoperative Pasieka Parathyroidectomy Assessment Score was higher in women (155, 0-1,190) than in men (80.5, 0-855, P < .001), although there were similar rates of asymptomatic primary hyperparathyroidism (Pasieka Parathyroidectomy Assessment Score = 0, 12.5% vs 7%, P = .042). After curative parathyroidectomy, women reported a substantial reduction in symptomatology, with Pasieka Parathyroidectomy Assessment Score declining by 35% at initial postoperative visit (median, 155 vs 100, P < .001), further decreasing to 48% by 6 months (155 vs 80, P < .001). The Pasieka Parathyroidectomy Assessment Score in men did change but to a much smaller degree at both the initial postoperative visit (80.5 vs 70; P = .036) and at 6 months (80.5 vs 57.5; P = .048).

CONCLUSION

When assessed with the Pasieka Parathyroidectomy Assessment Score, improvement in symptoms was clearly demonstrated for women after curative parathyroidectomy. Whether symptom improvement also occurs in men is less apparent but may be due to disparities in the development and validation of outcomes tools in general.

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.

Older Patients With Asymptomatic Primary Hyperparathyroidism: Should Criteria for Surgery Be Expanded?

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.

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.

Cognitive deficits in primary hyperparathyroidism - what we know and what we do not know: A narrative review

Classic symptoms of primary hyperparathyroidism (PHPT) are seen in approximately 20% of patients. While features such as kidney stones and skeletal disease are often highlighted as directly related to the disease, others can be even more prevalent. For example, cognitive dysfunction and reduced quality of life are common complaints in many patients, even among those who are classified as being asymptomatic. The pathophysiology of PHPT involves the impact of excess parathyroid hormone (PTH) on calcium metabolism. Referencing putative neurocognitive issues, many animal studies have illustrated the potential roles of PTH and PTH receptors in the brain. Functional imaging and pre-and post-parathyroidectomy studies have suggested a link between the neuronal impact of elevated PTH levels on specific functional aspects of the central nervous system, such as cognition. Confounding a direct role for PTH are hypercalcemia and vitamin D deficiency, both of which could conceivably alter CNS function in PHPT. The lack of strong evidence that parathyroidectomy improves cognition in patients with PHPT raises the question as to whether parathyroid surgery should be recommended on this basis alone. This narrative review summarizes the available literature on neurocognitive function in PHPT.

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.

The impact of age on quality of life and frailty outcomes after parathyroidectomy in patients with primary hyperparathyroidism

OBJECTIVE

Parathyroidectomy (PTx) improves quality of life (QoL) in patients with primary hyperparathyroidism (PHPT). Whether this effect is modified according to the patients' age is unknown. The aim of this study was to evaluate the impact of age on the effect of PTx on QoL and frailty in patients with PHPT, six months post-PTx.

METHODS

This was a prospective cohort study, including patients with PHPT, admitted from January 2016 to December 2019, divided into two categories: younger (≤ 65 years old) and older (> 65 years old). QoL was assessed with the Pasieka questionnaire (PAS-Q) two days pre- and six months post-operatively. Frailty was also assessed at the same time intervals, with the Frailty Index (FI).

RESULTS

One hundred and thirty-four patients (younger group: 96 patients, mean age 50.4 ± 9.8 years; older group: 38 patients, mean age 72.1 ± 4.9 years) were included. PTx resulted in a significant reduction in PAS-Q score in both groups. Notably, a greater reduction in "mood swings", "irritability", "itchy skin" and "feeling thirsty" PAS-Q domains was observed in the younger group. In contrast, a greater decrease in "bone pain", "tiredness", "weakness", "joint pain", "getting off chair" and "headaches" items was observed in the older group. Moreover, PTx led to a decrease in FI only in this group.

CONCLUSIONS

PTx leads to an improvement in QoL both in older (> 65 years) and younger (≤ 65 years) patients with PHPT, attributed to a differential effect on PAS-Q items. Frailty improves only in the older group.

Quality of Life in Patients With Asymptomatic Primary Hyperparathyroidism After Parathyroidectomy: A 3-Year Longitudinal Study

OBJECTIVE

Impaired quality of life (QoL) is considered as a nonclassical manifestation of primary hyperparathyroidism (PHPT). This study aimed to detect and compare changes in the QoL of patients with asymptomatic PHPT who had successful curative parathyroidectomy (PTX) 3 months and 3 years after the procedure.

METHODS

Patients with diagnosed PHPT were eligible for the study. There were 2 groups: the PTX group, with patients who underwent PTX, and the non-PTX group, with patients who were treated conservatively. QoL was assessed using Pasieka's Parathyroid Assessment of Symptoms Questionnaire (PAS-Q) at baseline, 3 months, and 3 years.

RESULTS

Thirty-eight patients were included in the study: 18 in the PTX group and 20 in the non-PTX group. In the PTX group, the mean PAS-Q total score before PTX was 518, which was reduced significantly at the 3-month (P = .003) and 3-year assessments (P = .001). However, in the non-PTX group, the mean PAS-Q total score was 326 at baseline and increased continuously for 3 years (P = .019). At the 3-year evaluation, the mean total score was significantly higher compared to that of the PTX group (P = .021). Finally, there was a positive correlation between total serum calcium and PAS-Q score in the non-PTX group (r = 0.524, P = .018).

CONCLUSION

QoL of patients with PHPT improved significantly compared to that in conservative surveillance as early as 3 months after successful, curative PTX, and remained improved for 3 years. This finding strengthens, even more, the hypothesis that PTX contributes to better QoL, suggesting that the derangement of QoL may be considered as an individual indication for surgery.

Impact on Quality of Life After Parathyroidectomy for Asymptomatic Primary Hyperparathyroidism

BACKGROUND

Primary hyperparathyroidism (PHPT) is associated with a poorer quality of life. The role of neuropsychiatric symptoms in asymptomatic patients who do not display classical features of PHPT remains undefined. It is unclear whether parathyroidectomy provides immediate benefit beyond the long-term risk reduction of adverse effects. The aim of the study is to assess the effect on quality of life in patients with asymptomatic PHPT undergoing parathyroidectomy.

METHODS

Consecutive patients with PHPT undergoing parathyroidectomy by a single surgeon were recruited from a single center between 2014 and 2019. All patients prospectively completed the validated EQ-5D-3L health status questionnaire preoperatively and postoperatively, comprising two components: (i) five domains including physical and mental health and (ii) visual analog scale (VAS). Biochemical and clinical indices were recorded.

RESULTS

Seventy-eight patients were included, 72% female (n = 56), median age 62 y (interquartile range (IQR): 52-70), and 28 (36%) asymptomatic. A global improvement in health-related quality of life was observed with a VAS score increase from 70 (IQR: 50-80) to 80 (IQR: 70-90); P < 0.001. VAS scores also improved significantly in asymptomatic patients increasing from 77 to 85 (P = 0.014), with an overall improvement in all five domains of quality of life. The symptomatic group showed a significant improvement in anxiety/depression levels (P < 0.01), although this was not the primary complaint in any of the cases.

CONCLUSIONS

Parathyroidectomy is associated with a significant improvement in the quality of life of patients with asymptomatic PHPT. In symptomatic patients, this includes a reduction in anxiety and depression. Benefits are observed as early as 2 mo postoperatively, and results suggest a potentially important cognitive and social aspect of this disease.

Symptoms of Secondary Hyperparathyroidism in Patients Receiving Maintenance Hemodialysis: A Prospective Cohort Study

RATIONALE & OBJECTIVE

Although multiple lines of evidence suggest a negative impact of secondary hyperparathyroidism on patients with kidney failure treated by hemodialysis, it is uncertain whether patients can detect associated symptoms. The objective was to determine whether changes in parathyroid hormone (PTH) levels are associated with changes in symptoms within this patient population.

STUDY DESIGN

Prospective cohort.

SETTING & PARTICIPANTS

165 adults with hyperparathyroidism secondary to kidney failure diagnosed, a range of dialysis vintages, and receiving regular hemodialysis from a US single-provider organization.

EXPOSURE

Change in PTH levels over 24 weeks.

OUTCOMES

19 putative symptoms of secondary hyperparathyroidism measured up to 4 times using a self-administered questionnaire that assessed severity on a 5-level ordinal scale.

ANALYTICAL APPROACH

Longitudinal associations between changes in PTH levels and symptom severity were assessed using generalized additive models.

RESULTS

The 165 participants studied represented 81% of enrollees (N=204) who had sufficiently complete data for analysis. Mean age was 56 years and 54% were women. Increases in PTH levels over time were associated (P<0.1) with worsening of bone aches and stiffness, joint aches, muscle soreness, overall pain, itchy skin, and tiredness, and the effects were more pronounced with larger changes in PTH levels.

LIMITATIONS

Findings may have been influenced by confounding by unmeasured comorbid conditions, concomitant medications, and multiple testing coupled with a P value threshold of 0.10.

CONCLUSIONS

In this exploratory study, we observed that among patients with secondary hyperparathyroidism, increases in PTH levels over time were associated with worsening of 1 or more cluster of symptoms. Replication of these findings in other populations is needed before concluding about the magnitude and shape of these associations. If replicated, these findings could inform clinically useful approaches for measuring patient-reported outcomes related to secondary hyperparathyroidism.

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.

Non classical complications of primary hyperparathyroidism

Several studies suggested that the condition of primary hyperparathyroidism (PHPT) may be associated not only with the classical bone, kidney and gastrointestinal consequences, but also with cardiovascular, neuromuscular and articular complications, impaired quality of life and increased cancer risk. However, the only cardiovascular complications associated with PHPT, which seems to improve after parathyroidectomy, is left ventricular hypertrophy, while, data regarding the reversibility of hypertension, valve calcifications and increased vascular stiffness are inconsistent. Parathyroidectomy seems to ameliorate neuropsychological, cognitive disturbances and quality of life in moderate-severe PHPT, while data in mild PHPT are less clear. At variance, the effect of parathyroidectomy on neuromuscular and articular complications is still unknown, and no studies demonstrated a reduction of cancer risk after recovery from PHPT. Overall, to date, cardiovascular and neuropsychological evaluation are not recommended solely because of PHPT, nor cardiovascular disease, muscle weakness, and neuropsychological complications are indication for parathyroidectomy.

Comparative efficacy of parathyroidectomy and active surveillance in patients with mild primary hyperparathyroidism: a systematic review and meta-analysis

Counseling for patients with primary hyperparathyroidism (PHPT) and mild hypercalcemia without indications for surgical intervention requires accurate estimates of the potential benefits of parathyroidectomy. We aim to summarize the available evidence regarding the benefits of parathyroidectomy that patients with mild PHPT without indications for surgery experience compared to observation. We searched multiple databases from inception to August 2015. We included randomized controlled trials (RCT) and observational studies that evaluated changes in bone health, quality of life or neuropsychiatric symptoms, or in the risk of nephrolithiasis, cardiovascular events, or death between patients undergoing parathyroidectomy or active surveillance. Eight studies were eligible. Risk differences were not significant, in part due to lack of events (fractures, nephrolithiasis, cardiovascular events, or deaths). No significant differences were observed across measures of bone health, quality of life, and neuropsychiatric symptoms. A single RCT evaluating bone mineral density (BMD) changes at 5 years found a small statistically significant effect favoring parathyroidectomy. Patients with mild PHPT without indications for surgery experience a limited number of adverse consequences during short-term follow-up limiting our ability to estimate the benefit of surgery during this timeframe. This information is helpful as these patients consider surgery versus active surveillance. Long-term data is warranted to determine who benefits in the long run from surgical intervention and the extent to which this benefit affects outcomes that matter to patients.

Quality of Life After Surgery or Surveillance for Asymptomatic Primary Hyperparathyroidism: A Meta-Analysis of Randomized Controlled Trials

A number of studies have investigated the effects of surgery on symptoms and quality of life in patients with hyperparathyroidism. However, the results are inconsistent. We conducted this meta-analysis to quantitatively assess changes in quality of life among patients with asymptomatic primary hyperparathyroidism. Different databases were searched for randomized controlled trials comparing surgery with surveillance. Quality of life was measured by the Short Form-36 general health survey. The pooled random-effects estimates of standardized mean difference (SMD) and 95% confidence intervals (CIs) were calculated. Three trials involving 294 participants were included. At 1 year, patients undergoing parathyroidectomy had significantly better physical role functioning (SMD, 0.31; 95% CI 0.04-0.57; P = 0.02) and emotional role functioning (SMD, 0.29; 95% CI 0.02-0.55; P = 0.03). At 2 years, the surgery group had significantly better emotional role functioning (SMD, 0.35; 95% CI 0.02-0.67; P = 0.04) than the surveillance group. Furthermore, compared with baseline, emotional role functioning improved after surgery (SMD, 0.31; 95% CI 0.02-0.60; P = 0.04), whereas emotional role functioning tended to get worse in patients assigned to medical surveillance (SMD, -0.27; 95% CI -0.55 to 0.02; P = 0.07). Although Short Form-36 is a generic instrument, our results suggest that parathyroidectomy may be associated with better quality of life, especially in the emotional aspects of well-being.

No beneficial effects of vitamin D supplementation on muscle function or quality of life in primary hyperparathyroidism: results from a randomized controlled trial

CONTEXT

Impairments of muscle function and strength in patients with primary hyperparathyroidism (PHPT) are rarely addressed, although decreased muscle function may contribute to increased fracture risk.

OBJECTIVE

We aimed to assess the changes in muscle strength, muscle function, postural stability, quality of life (QoL), and well-being during treatment with vitamin D or placebo before and after parathyroidectomy (PTX) in PHPT patients.

DESIGN

A randomized placebo-controlled trial.

PATIENTS

We included 46 PHPT patients, mean age 58 (range 29-77) years and 35 (76%) were women.

INTERVENTIONS

Daily treatment with 70 μg (2800 IU) cholecalciferol or placebo for 52 weeks. Treatment was administered 26 weeks before PTX and continued for 26 weeks after PTX.

MAIN OUTCOME MEASURES

Changes in QoL and measures of muscle strength and function.

RESULTS

Preoperatively, 25-hydroxyvitamin D (25OHD) increased significantly (50-94 nmol/l) compared with placebo (57-52 nmol/l). We did not measure any beneficial effects of supplementation with vitamin D compared with placebo regarding well-being, QoL, postural stability, muscle strength, or function. In all patients, we measured marked improvements in QoL, well-being (P<0.01), muscle strength in the knee flexion and extension (P<0.001), and muscle function tests (P<0.01) after surgical cure. Postural stability improved during standing with eyes closed (P<0.05), but decreased with eyes open (P<0.05).

CONCLUSIONS

Patients with PHPT and 25OHD levels around 50 nmol/l did not benefit from vitamin D supplementation concerning muscle strength, muscle function, postural stability, well-being, or QoL. Independent of preoperative 25OHD levels, PTX improved these parameters.

Health-related quality of life after successful surgery for primary hyperparathyroidism: no additive effect from vitamin D supplementation: results of a double-blind randomized study

OBJECTIVE

Vitamin D insufficiency is common in primary hyperparathyroidism (pHPT). Patients with pHPT frequently have a reduced health-related quality of life (HRQoL). Our objectives were to evaluate whether HRQoL in pHPT is associated with vitamin D insufficiency and whether vitamin D supplementation after parathyroidectomy (PTX) could improve HRQoL.

DESIGN

A randomized, double-blind study (ClinicalTrials.gov identifier: NCT00982722).

METHODS

The study included 150 pHPT patients randomized, 6 weeks after PTX, to daily treatment with either cholecalciferol 1600 IU and calcium carbonate 1000 mg (D+) or calcium carbonate alone (D-). HRQoL was estimated with SF-36 before and after PTX and after 12 months of study medication.

RESULTS

Three-quarters (77%) of the pHPT patients had vitamin D insufficiency, defined as 25OHD <50 nmol/l. The pHPT patients scored lower than a reference population in all domains of SF-36. A total of 135 patients completed the entire study period. Improvements in nearly all domains were registered at the follow-up 6 weeks after PTX. At the end of the study medication period, the D+ group had a significantly higher median serum (s-) 25OHD concentration (76 (65; 93) (lower; upper interquartile ranges) vs 48 (40; 62) nmol/l, P<0.001) and a lower plasma (p-) parathyroid hormone concentration (40 (34; 52) vs 49 (38; 66) ng/l, P=0.01) than the D- group. The improvements in HRQoL remained unchanged at the follow-up 1 year after PTX. Postoperative vitamin D supplementation had no obvious effect on HRQoL.

CONCLUSION

PTX resulted in significant improvements in HRQoL. Despite a high prevalence of vitamin D insufficiency, 1 year of postoperative vitamin D supplementation had no obvious beneficial effect on HRQoL.

The extent of improvement of health-related quality of life as assessed by the SF36 and Paseika scales after parathyroidectomy in patients with primary hyperparathyroidism--a systematic review and meta-analysis

BACKGROUND

Previous studies have shown that parathyroidectomy for primary hyperparathyroidism (PHPT) improve the function and quality of life of patients. The aim of this systematic review and meta-analysis is to determine the health-related quality of life outcomes among those having surgical management for PHPT.

METHODS

Several databases were searched (MEDLINE, EMBASE, PubMed, Current Contents) for studies in which health-related quality of life was measured by reliable and validated instruments (SF-36 and Paseika Questionnaire) before and after parathyroidectomy for patients with primary hyperparathyroidism (PHPT). For the SF-36, score differences greater than 5 points indicate clinically relevant changes.

RESULTS

There were six studies with quality of life data. The SF-36 data was derived from 238 patients, with a mean age of 59 years and 71% were females. The range of follow up after surgery was 6 months to one year. The pre- and post-parathyroidectomy SF-36 quality of life scale scores were vitality (44 vs. 60, p<0.001), physical functioning (51 vs. 69, p<0.001), bodily pain (50 vs. 65, p<0.001), general health (54 vs. 64, p<0.001), role physical (34 vs. 52, p<0.001), role emotional (43 vs. 59, p<0.001), role social (60 vs. 74, p<0.001), and mental health (55 vs. 71, p<0.001). The Paseika data was derived from 203 patients, with a mean age of 54 years and 67% were females. The pre- and post-parathyroidectomy Paseika scores were feeling tired (51 vs. 19, p<0.001), feeling thirsty (29 vs. 12, p<0.001), mood swings (33 vs. 12, p<0.001), joint pains (32 vs. 14, p<0.001), irritability (31 vs. 10, p<0.001), feeling blue (31 vs. 14, p<0.001), feeling weak (37 vs. 15, p<0.001), itchy (17 vs. 7, p<0.001), forgetful (27 vs. 16, p<0.001), headache (18 vs. 5, p<0.001), abdominal pain (19 vs. 8, p<0.001), bone pain (38 vs. 17, p<0.001), ability to move off chair (27 vs. 11, p<0.001).

CONCLUSION

Parathyroidectomy significantly improves the short to medium-term health-related quality of life of patients suffering from primary hyperparathyroidism.

Current issues in the presentation of asymptomatic primary hyperparathyroidism: proceedings of the Fourth International Workshop

OBJECTIVE

This report summarizes data on traditional and nontraditional manifestations of primary hyperparathyroidism (PHPT) that have been published since the last International Workshop on PHPT.

PARTICIPANTS

This subgroup was constituted by the Steering Committee to address key questions related to the presentation of PHPT. Consensus was established at a closed meeting of the Expert Panel that followed.

EVIDENCE

Data from the 5-year period between 2008 and 2013 were presented and discussed to determine whether they support changes in recommendations for surgery or nonsurgical follow-up.

CONSENSUS PROCESS

Questions were developed by the International Task Force on PHPT. A comprehensive literature search for relevant studies was undertaken. After extensive review and discussion, the subgroup came to agreement on what changes in the recommendations for surgery or nonsurgical follow-up of asymptomatic PHPT should be made to the Expert Panel.

CONCLUSIONS

1) There are limited new data available on the natural history of asymptomatic PHPT. Although recognition of normocalcemic PHPT (normal serum calcium with elevated PTH concentrations; no secondary cause for hyperparathyroidism) is increasing, data on the clinical presentation and natural history of this phenotype are limited. 2) Although there are geographic differences in the predominant phenotypes of PHPT (symptomatic, asymptomatic, normocalcemic), they do not justify geography-specific management guidelines. 3) Recent data using newer, higher resolution imaging and analytic methods have revealed that in asymptomatic PHPT, both trabecular bone and cortical bone are affected. 4) Clinically silent nephrolithiasis and nephrocalcinosis can be detected by renal imaging and should be listed as a new criterion for surgery. 5) Current data do not support a cardiovascular evaluation or surgery for the purpose of improving cardiovascular markers, anatomical or functional abnormalities. 6) Some patients with mild PHPT have neuropsychological complaints and cognitive abnormalities, and some of these patients may benefit from surgical intervention. However, it is not possible at this time to predict which patients with neuropsychological complaints or cognitive issues will improve after successful parathyroid surgery.

Perioperative changes in cortical excitability, mood, and quality of life in patients with primary hyperparathyroidism: a pilot study using transcranial magnetic stimulation

OBJECTIVE

Serum calcium (Ca(2)(+)) and parathyroid hormone (PTH), amongst others, modify cortical excitability. Alterations in cortical excitability were shown in patients with epilepsy as well as hyper- or hypoparathyroidism. In patients with primary hyperparathyroidism (pHPT), preoperative elevated serum calcium and parathyroidectomy (PTx) may affect mood and quality of life. We hypothesized that perioperative changes in Ca(2)(+) and PTH in pHPT will affect cortical excitability and improve subjective health.

DESIGN AND METHODS

Transcranial magnetic stimulation (TMS) was performed before and after surgery in 15 pHPT patients. We measured resting motor threshold, cortical silent period (CSP), short intracortical inhibition, and intracortical facilitation. Health questionnaires were administered before, 1 day and 6 months after PTx, along with the disease-specific Pasieka's parathyroid assessment of symptoms (PAS), which was, to our knowledge, its first use in German.

RESULTS

SURGERY WAS SUCCESSFUL IN ALL PATIENTS. TMS-MEASUREMENTS REMAINED UNCHANGED WHEN ANALYZING ALL PATIENTS IN THIS PILOT STUDY. POSTOPERATIVELY, DEPRESSION DECLINED (P=0.05) AND QUALITY OF LIFE IMPROVED SIGNIFICANTLY (P=0.001) IN THE SF-36-SUBSCALES: vitality, social functioning, mental health and subjective health transition (post-hoc analysis). The PAS proved early relief of disease-specific symptoms (P<0.001).

CONCLUSIONS

We found unchanged cortical excitability comparing pre- and post-PTx in this pilot study. Mood and quality of life improved postoperatively. The German PAS is valuable in detecting disease-specific changes early after PTx.

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.

Parathyroidectomy improves symptomatology and quality of life in patients with secondary hyperparathyroidism

BACKGROUND

The parathyroidectomy assessment of symptoms (PAS) score was designed initially for primary hyperparathyroidism to provide a specific symptom assessment and was validated later in secondary and tertiary hyperparathyroidism. The aim of our study was to evaluate changes in the PAS scores and quality of life before and after parathyroidectomy for secondary hyperparathyroidism.

METHODS

This prospective study included 49 consecutive patients who underwent parathyroidectomy for secondary hyperparathyroidism. The PAS and Short Form (SF)-36 questionnaires were completed before parathyroidectomy and at 12 months postoperatively.

RESULTS

All 13 symptoms included in the PAS score improved significantly. The mean ± standard deviation PAS score decreased from 545 ± 263 to 284 ± 201 (P < .0001) after parathyroidectomy. Quality of life was enhanced in both physical (40.3 ± 17.1 to 59.0 ± 14.9; P < .0001) and mental (47.6 ± 17.1 to 63.7 ± 13.0; P < .0001) components. The PAS score was inversely correlated with the SF-36 global score preoperatively and postoperatively (r(2) = 0.48 and 0.25; P < .001). The change in PAS score also correlated with the change in SF-36 global score (r(2) = 0.29; P < .001). Multiple linear regression analysis showed that preoperative PAS score and bone mineral density T-score were predictors of the decrease in PAS score. Preoperative SF-36 global score and intact parathyroid hormone levels were predictors of the increment in SF-36 score.

CONCLUSION

The symptom burden of secondary hyperparathyroidism has a negative impact on a patient's quality of life. Parathyroidectomy is associated with a marked improvement in symptoms and quality of life.

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.

Long-term outcome in patients with primary hyperparathyroidism who underwent minimally invasive parathyroidectomy

BACKGROUND

Minimally invasive parathyroidectomy (MIP) has become a well-accepted treatment for selected patients with primary hyperparathyroidism (PHPT). However, few studies have evaluated long-term outcomes for this operative approach. We therefore chose to examine both the long-term symptom resolution and biochemical cure following MIP for PHPT.

METHODS

A total of 460 PHPT patients who underwent a MIP between 2004 and 2009 were successfully mailed a questionnaire that assessed preoperative and postoperative Parathyroidectomy Assessment of Symptoms (PAS) scores, most recent calcium and parathyroid hormone (PTH) levels, and information about any reoperation for PHPT. Long-term evaluation of symptomatic and biochemical cure was performed.

RESULTS

A total of 200 patients (43.5%) responded to our correspondence. The mean age of the patients was 58.7 ± 11.9 years, 74.5% were female, and 78.5% were Caucasian. The mean follow-up was 37 ± 19 months. The mean PAS scores fell by 117 ± 14 at long-term follow-up after MIP (P < 0.0001). All 13 symptoms comprising the PAS score diminished, of which ten did so significantly (P < 0.01). There was a significant drop in the mean serum calcium (preop. 11.1 mg/dl, postop. 9.6 mg/dl; P < 0.0001) and PTH (preop. 130.9 pg/ml, postop. 45.7 pg/ml; P < 0.0001) at long-term follow-up. Five patients (2.5%) developed recurrent disease (calcium > 10.5 mg/dl), and one (0.5%) underwent a reoperation for persistent disease and was subsequently cured.

CONCLUSIONS

This study demonstrates that MIP has long-term benefits in terms of excellent symptom resolution and a high biochemical cure rate (97%) in selected patients who have PHPT, preoperative localization with sestamibi scans, and assessment of intraoperative PTH level.

Primary hyperparathyroidism: Skeletal and non-skeletal effects, diagnosis and management

Primary hyperparathyroidism (PHPT) is the third most common endocrinopathy seen today, and is most frequently found in the 6th to 7th decade of life. PHPT can present with various degrees of symptoms, and can affect many organ systems, including the skeletal, renal, central nervous system and cardiovascular system. Despite this, the most common presentation of hyperparathyroidism is "asymptomatic" with the diagnosis being made incidentally with the initial finding of hypercalcemia on routine laboratory studies, leading to further investigation. Surgical versus medical management is usually based on factors such as age and complications related to hyperparathyroidism (i.e. the presence of renal stones, renal insufficiency and bone loss and significant increases in serum calcium). Treatment options include parathyroidectomy, bisphosphonates, calcitonin and calcimimetics. In this review, we discuss primary hyperparathyroidism in detail with a focus on clinical manifestations particularly in the elderly population. We highlight the indications for surgical versus medical management and compare some of the uses of newer therapeutic agents relative to traditional ones.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

The long-term benefit of parathyroidectomy in primary hyperparathyroidism: a 10-year prospective surgical outcome study

BACKGROUND

Previously, utilizing a disease-specific outcome tool (Parathyroidectomy Assessment Of Symptoms or PAS scores) for hyperparathyroidism (HPT), parathyroidectomy was shown to decrease many of the vague nonspecific symptoms associated with HPT. The purpose of this study was to assess whether this improvement persists in the long term.

METHODS

PAS Scores and quality of life (QOL) measures were mailed to patients previously enrolled in the primary HPT study, including the thyroidectomy comparison group. Data were compared pre-operatively, 1 and 10 years after operation.

RESULTS

Of the original 122 HPT patients, 78 (64%) and 39/58 (68%) of the thyroidectomy patients participated. The pre-operative PAS score in the HPT group was 318; this decreased to 177 at 1 year and 189 at 10 years (P < .05). In contrast, thyroidectomy had PAS scores of 170 pre-operatively, 190 at 1 year, and 174 at 10 years (P = .1). HPT patients were more symptomatic pre-operatively compared to the thyroidectomy group (318 vs 170; P < .05), yet at 1 and 10 years, there were no differences. QOL was better in the HPT group at 10 years compared to pre-operatively (P < .05).

CONCLUSION

This prospective study demonstrates the long-term benefit of parathyroidectomy in primary HPT patients. Decrease of their pre-operative symptoms appears to have contributed to their improved QOL at 10 years.

Parathyroidectomy is safe and improves symptoms in elderly patients with primary hyperparathyroidism (PHPT)

OBJECTIVE

Parathyroidectomy for primary hyperparathyroidism (PHPT) is curative in over 95% of cases. Although PHPT affects up to 2% of the elderly population, whose life expectancy may be a decade or more, such patients may be denied surgery because of perceived risk. This study investigates the outcomes of surgery for PHPT in the elderly.

DESIGN AND PATIENTS

Consecutive patients with PHPT treated at a tertiary referral centre over 5 years.

MEASUREMENTS

A prospective database recorded clinical, biochemical and pathological information. Pasieka's parathyroid symptom scores were obtained pre-operatively and post-operatively, from a recent subgroup of 70 consecutive patients. Deaths during follow-up were identified using the NHS Strategic Tracing Service. Statistical analysis was performed with spss v12.0.

RESULTS

Between November 2002 and October 2007, 224 patients (17-89 years) underwent surgery for PHPT. In the subgroup comprising patients aged >75 years there was a significantly greater proportion of women (47/56 vs. 52/81, P < 0.05). Pre-operative indices of these patients were similar to younger patients, as were proportions undergoing minimally invasive parathyroidectomy (n = 134) or bilateral neck exploration (n = 90). Patients >75 years had a longer hospital stay (1.6 vs. 0.8 days, P = 0.003). Pasieka's symptom scores improved significantly at 3-6 months postoperatively in all age groups. During a minimum median follow-up of 22 months, there were seven patients with persistent/recurrent disease. Median 2-year survival of those aged 60-74 and those over 75 ranged from 85-90%.

CONCLUSION

Parathyroidectomy is safe in the elderly and is associated with a significant improvement in symptoms. As survival after operation is similar to younger patients, surgery should be considered in all elderly patients with PHPT.

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

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

Surgery for asymptomatic primary hyperparathyroidism: proceedings of the third international workshop

CONTEXT

An international workshop on primary hyperparathyroidism (PHPT) was convened on May 13, 2008, to review and update the previous summary statement on the management of asymptomatic PHPT published in 2002.

EVIDENCE ACQUISITION

Electronic literature sources were systematically reviewed, addressing critical aspects of the surgical issues pertaining to the indications, imaging, surgical treatment, and cost-effective management of patients with PHPT.

EVIDENCE SYNTHESIS

The surgical group concluded that many patients with "asymptomatic" PHPT have neurocognitive symptoms that may be unmasked after successful parathyroidectomy. Furthermore, reduced bone density and increased fracture risk can be improved with parathyroidectomy. When PHPT is symptomatic, it may be associated with nephrolithiasis, increased cardiovascular disease, and decreased survival. Preoperative imaging studies should only be performed to help plan the operation, and negative imaging should never preclude surgical referral. Noninvasive localization studies including ultrasound and sestamibi scans are often employed, especially in anticipation of focused explorations. Invasive localization studies should be reserved for remedial explorations where noninvasive imaging has been unsuccessful.

CONCLUSIONS

When performed by expert parathyroid surgeons, parathyroid surgery is safe, cost-effective, and associated with very low perioperative morbidity. Minimally invasive approaches to parathyroid surgery appear to be as effective as the classic bilateral cervical exploration approach.

Preserving function and quality of life after thyroid and parathyroid surgery

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