Patient Frailty Should Be Used to Individualize Treatment Decisions in Primary Hyperparathyroidism

[Multimorbid patients in endocrine surgery]

Endocrine surgery in multimorbid, frail and geriatric patients is increasing, is often urgent and characterized by special risk constellations. Successful parathyroid gland surgery nearly always results in a marked improvement, irrespective of the specific risk profile of the patient. Except for critical intubation and mediastinal interventions in the risk profile, surgery of the thyroid glands is predominantly beneficial and justifiable even in frail patients. For surgery of the adrenal glands and for gastroenteropancreatic neuroendocrine tumors (GEP-NET), the expected extension of resection, the underlying disease or the grading are decisive for whether alternative treatment measures or surveillance appear to be more beneficial for patients at risk.

The effect of surgical management in mitigating fragility fracture risk among individuals with primary hyperparathyroidism

BACKGROUND

Primary hyperparathyroidism predominately affects women who are postmenopausal and causes complications, including fragility fractures. Its treatment is parathyroidectomy, which is associated with low complication and >95% cure rates. Considering fractures are associated with premature death, we aimed to determine whether the surgical management of individuals with biochemical diagnosis of primary hyperparathyroidism was associated with a reduction in fracture risk.

METHODS

In this population-based cohort study, we used administrative health databases to identify adults ≥18 year old who were biochemically diagnosed with primary hyperparathyroidism between 2007 and 2016 in Ontario. Patients were included if their calcium was ≥2.6 mmol/L (≥10.42 mg/dL) with a concurrent parathyroid hormone of ≥2.2 pmol/L (≥20.75 pg/mL). We followed patients and compared the incidence of fractures between those with and without parathyroidectomy. To control for potential confounding, we used inverse probability of treatment weighting to estimate the average treatment effect in the treated. Fine-Gray competing risk regression models were used to determine the association between surgery and time to fracture.

RESULTS

In a cohort of 28,059 with a biochemical diagnosis of primary hyperparathyroidism, the mean age (standard deviation) was 65 years (14.2 years), and 75% (n = 21,139) were female. Only 12.6% (n = 3,523) underwent parathyroidectomy. Weighted fracture cumulative incidence at 12 years postdiagnosis was 10.17% (n = 182) in surgical patients and 14.04% (n = 2,004) in nonsurgical patients. Parathyroidectomy prevented 1 fracture for every 26 surgeries performed (weighted risk difference, 3.87%, 95% confidence interval, 0.96%-6.62%) and reduced the hazard of fracture by 22% (weighted hazard ratio, 0.78; 95% confidence interval, 0.64-0.95).

CONCLUSION

In a large, publicly funded health system, parathyroidectomy significantly reduced the short- and long-term risk of fragility fractures in patients with primary hyperparathyroidism.

Focus on Non-osteoporotic Post-menopausal Women with Asymptomatic Primary Hyperparathyroidism: A Monocentric Series

OBJECTIVE

Primary Hyperparathyroidism (PHPT) is a common disease, frequently diagnosed in post-menopausal women, among whom Osteoporosis (OP) is a common finding. To date, no study has specifically evaluated the asymptomatic PHPT (aPHPT) patients without OP, in particular post-menopausal women who are exposed to an increased risk of developing OP.

DESIGN

This study involved a retrospective cross-sectional evaluation.

PATIENTS

From our database of 500 consecutive patients diagnosed with PHPT, 178 postmenopausal aPHPT were retrieved.

RESULTS

The clinical, biochemical, and imaging data of the 85 patients without OP were not different from those of the 93 with OP, except for bone alkaline phosphatase (significantly higher in the latter group). Among these 85 patients without OP, the 45 patients meeting surgical criteria for parathyroidectomy had significantly higher values of serum PTH (240 vs. 99 ng/L, p =0.03) and calcium (total, 11.2 ± 0.7 vs. 10.6 ± 0.4 mg/dL, p <0.001; ionized, 1.45 ± 0.12 vs. 1.36 ± 0.8 mmol/L, p =0.044) and lower values of serum phosphate (2.57 ± 0.7 vs. 2.94 ± 0.5 mg/dL, p =0.009) and eGFR (68.5 ± 23.8 vs 80.8 ± 14.4 mL/min/1.73 m2, p =0.006) than the 40 aPHPT patients not meeting surgical criteria, without any difference in densitometric data and calculated fracture risk.

CONCLUSION

In our series, post-menopausal aPHPT patients without OP accounted for almost a sixth of the whole PHPT series. About half of these patients did not meet surgical criteria, but their T scores and 10-year fracture risk calculated by FRAX were not significantly different from post-menopausal aPHPT without OP meeting surgical criteria.

Sex-Stratified Predictors of Prolonged Operative Time and Hospital Admission in Outpatient Parathyroidectomy

Our retrospective database study investigates sex-stratified predictors of prolonged operative time (POT) and hospital admission following parathyroidectomy for primary hyperparathyroidism (PHPT). The 2016 to 2018 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) was queried for patients with PHPT undergoing parathyroidectomy. Cases analyzed were all outpatient status, arrived from home, coded as non-emergent, and elective. POT was defined by the 75th percentile. Hospital admission was defined as LOS ≥ 1 day. Univariate and multivariable binary logistic regressions were utilized. Of 7442 cases satisfying inclusion criteria, the majority were female (78.0%) and White (78.5%). Median OT (IQR) for females and males was 77 (58-108) and 81 (61-109) minutes, respectively (P = 0.003). 1965 (33.9%) females and 529 (32.3%) males required hospital admission. Independent predictors of POT included ASA class III/IV (aOR 1.342, 95% CI 1.007-1.788) and obesity (aOR 1.427, 95% CI 1.095-1.860) for males (P < 0.05). Independent predictors of hospital admission included age (aOR 1.008, 95% CI 1.002-1.014), ASA class III/IV (aOR 1.490, 95% CI 1.301-1.706), obesity (aOR 1.309, 95% CI 1.151-1.489), dyspnea (aOR 1.394, 95% CI 1.041-1.865), chronic steroid use (aOR 1.674, 95% CI 1.193-2.351), and COPD (aOR 1.534, 95% CI 1.048-2.245) for females (P < 0.05); and ASA class III/IV (aOR 1.931, 95% CI 1.483-2.516) and bleeding disorder (aOR 2.752, 95% CI 1.443-5.247) for males (P < 0.005). In conclusion, predictors of POT and hospital admission following parathyroidectomy for PHPT differed by patient sex. Identifying patients at risk for POT and hospital admission may optimize healthcare resource utilization. Level of Evidence: IV.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-023-04444-3.

Primary Hyperparathyroidism in Older Adults: A Narrative Review of the Most Recent Literature on Epidemiology, Diagnosis and Management

BACKGROUND

Primary hyperparathyroidism (PHPT) is a common endocrine disorder among older adults. The aim of this review is to shed light on PHPT, particularly in this age group, in terms of prevalence, clinical manifestations, medical and surgical management, and post-operative complications.

METHODS

Eligible studies were those considering PHPT exclusively in the older population (main databases: PubMed, Medline, Google Scholar and the University Online database). Articles published in the last 10 years (2013-2023) were considered. Eligibility criteria followed the SPIDER (sample, phenomenon of interest, design, evaluation, research type) tool. The methodological quality of the studies was assessed using the Joanna Briggs Institute critical appraisal tool. A total of 29 studies (mainly observational) matched the inclusion criteria.

RESULTS

The prevalence of PHPT is approximately 1 per 100 in the elderly, and it is more common in females. The clinical presentation varies by age and can include osteoporosis, fractures, and neuropsychiatric symptoms. Conservative management can be an option whenever surgery is not indicated or feasible. However, parathyroidectomy (PTX) remains a safe and effective modality in aging populations with improvement to symptoms, bone mineral density, fracture risk, frailty, quality of life, and metabolic derangements. Complication rates are similar in elderly people compared to younger ones, except for mildly longer length of hospital stay and reoperation for those with higher frailty.

CONCLUSION

PHPT is a common yet overlooked and underdiagnosed condition among the older population. The safety and efficacy of PTX in the older population on different levels is now well demonstrated in the literature.

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.

Management of Primary Hyperparathyroidism

Since the last international guidelines were published in 2014 on the evaluation and management of primary hyperparathyroidism (PHPT), new information has become available with regard to evaluation, diagnosis, epidemiology, genetics, classical and nonclassical manifestations, surgical and nonsurgical approaches, and natural history. To provide the most current summary of these developments, an international group, consisting of over 50 experts in these various aspects of PHPT, was convened. This paper provides the results of the task force that was assigned to review the information on the management of PHPT. For this task force on the management of PHPT, two questions were the subject of systematic reviews using the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) methodology. The full report addressing surgical and nonsurgical management of PHPT, utilizing the GRADE methodology, is published separately in this series. In this report, we summarize the results of that methodological review and expand them to encompass a much larger body of new knowledge that did not specifically fit the criteria of the GRADE methodology. Together, both the systematic and narrative reviews of the literature, summarized in this paper, give the most complete information available to date. A panel of experts then considered the last set of international guidelines in light of the newer data and assessed the need for their revision. This report provides the evidentiary background to the guidelines report. In that report, evidence from all task forces is synthesized into a summary statement and revised guidelines for the evaluation and management of PHPT. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Evaluation and Management of Primary Hyperparathyroidism: Summary Statement and Guidelines from the Fifth International Workshop

The last international guidelines on the evaluation and management of primary hyperparathyroidism (PHPT) were published in 2014. Research since that time has led to new insights into epidemiology, pathophysiology, diagnosis, measurements, genetics, outcomes, presentations, new imaging modalities, target and other organ systems, pregnancy, evaluation, and management. Advances in all these areas are demonstrated by the reference list in which the majority of listings were published after the last set of guidelines. It was thus, timely to convene an international group of over 50 experts to review these advances in our knowledge. Four Task Forces considered: 1. Epidemiology, Pathophysiology, and Genetics; 2. Classical and Nonclassical Features; 3. Surgical Aspects; and 4. Management. For Task Force 4 on the Management of PHPT, Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) methodology addressed surgical management of asymptomatic PHPT and non-surgical medical management of PHPT. The findings of this systematic review that applied GRADE methods to randomized trials are published as part of this series. Task Force 4 also reviewed a much larger body of new knowledge from observations studies that did not specifically fit the criteria of GRADE methodology. The full reports of these 4 Task Forces immediately follow this summary statement. Distilling the essence of all deliberations of all Task Force reports and Methodological reviews, we offer, in this summary statement, evidence-based recommendations and guidelines for the evaluation and management of PHPT. Different from the conclusions of the last workshop, these deliberations have led to revisions of renal guidelines and more evidence for the other recommendations. The accompanying papers present an in-depth discussion of topics summarized in this report. © 2022 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Predicting Outcomes in Thyroidectomy and Parathyroidectomy: The Modified Five-Point Frailty Index Versus American Society of Anesthesiologists Classification

INTRODUCTION

Thyroidectomy and parathyroidectomy are relatively safe procedures, with overall morbidity rates of 2%-5%. The increasing age is associated with higher likelihood of poor outcomes. The modified five-point frailty index (mFI-5) is associated with complications, but many surgeons are unfamiliar with mFI-5. We assessed the accuracy of the mFI-5 versus the commonly-used American Society of Anesthesiologists (ASA) classification to predict complications following thyroidectomy and parathyroidectomy.

METHODS

Patients undergoing thyroidectomy or parathyroidectomy in 2015-2018 NSQIP datasets were identified. The mFI-5 scores were calculated by adding the number of the following comorbidities: congestive heart failure, hypertension requiring medication, chronic obstructive pulmonary disease, diabetes, and nonindependent functional status. Receiver operating characteristics curves were plotted for 30-d mortality and serious morbidity (defined as deep surgical site infection, dehiscence, unplanned intubation, failure to wean from the ventilator 48-h postoperatively, acute renal failure, pneumonia, pulmonary embolism, myocardial infarction, cardiac arrest requiring cardiopulmonary resuscitation, sepsis, septic shock, cerebrovascular accident, or reoperation) using mFI-5 and ASA classification. Areas under these curves (AUC) were compared.

RESULTS

Ninety-two thousand, six hundred and ninety-one patients were studied. The mFI-5 and ASA were fair predictors of 30-d mortality (AUC 0.75 and 0.82, respectively) and good predictors of serious morbidity (AUC 0.61 and 0.64). After stratification by age, ASA was superior to mFI-5 in predicting mortality for patients aged 65, 70, 80 y, and older, for the entire population and for thyroidectomy and parathyroidectomy separately.

CONCLUSIONS

The ASA classification is a better predictor of mortality and serious morbidity than mFI-5 among patients undergoing thyroidectomy or parathyroidectomy and may be a better prognostic indicator to use when counseling patients before low-risk neck surgery.

Risk of Fracture Among Older Adults With Primary Hyperparathyroidism Receiving Parathyroidectomy vs Nonoperative Management

Importance

Primary hyperparathyroidism (PHPT) contributes to the development and progression of osteoporosis in older adults. The effectiveness of parathyroidectomy for reducing fracture risk in older adults is unknown.

Objective

To compare the incidence of clinical fracture among older adults with PHPT treated with parathyroidectomy vs nonoperative management.

Design, Setting, and Participants

This was a population-based, longitudinal cohort study of all Medicare beneficiaries with PHPT from 2006 to 2017. Multivariable, inverse probability weighted Cox proportional hazards and Fine-Gray competing risk regression models were constructed to determine the association of parathyroidectomy vs nonoperative management with incident fracture. Data analysis was conducted from February 17, 2021, to September 14, 2021.

Main Outcomes and Measures

The primary outcome was clinical fracture at any anatomic site not associated with major trauma during the follow-up period.

Results

Among the 210 206 Medicare beneficiaries with PHPT (mean [SD] age, 75 [6.8] years; 165 637 [78.8%] women; 183 433 [87.3%] White individuals), 63 136 (30.0%) underwent parathyroidectomy within 1 year of diagnosis, and 147 070 (70.0%) were managed nonoperatively. During a mean (SD) follow-up period of 58.5 (35.5) months, the unadjusted incidence of fracture was 10.2% in patients treated with parathyroidectomy. During a mean (SD) follow-up of 52.5 (33.8) months, the unadjusted incidence of fracture was 13.7% in patients observed nonoperatively. On multivariable analysis, parathyroidectomy was associated with lower adjusted rates of any fracture (hazard ratio [HR], 0.78; 95% CI, 0.76-0.80]) and hip fracture (HR, 0.76; 95% CI, 0.72-0.79). At 2, 5, and 10 years, parathyroidectomy was associated with adjusted absolute fracture risk reduction of 1.2% (95% CI, 1.0-1.4), 2.8% (95% CI, 2.5-3.1), and 5.1% (95% CI, 4.6-5.5), respectively, compared with nonoperative management. On subgroup analysis, there were no significant differences in the association of parathyroidectomy with fracture risk by age group, sex, frailty, history of osteoporosis, or meeting operative guidelines. Fine-Gray competing risk regression confirmed parathyroidectomy was associated with a lower probability of any fracture and hip fracture when accounting for the competing risk of death (HR, 0.84; 95% CI, 0.82-0.85; and HR, 0.83; 95% CI, 0.80-0.85, respectively).

Conclusions and Relevance

This longitudinal cohort study found that parathyroidectomy was associated with a lower risk of any fracture and hip fracture among older adults with PHPT, suggesting a clinically meaningful benefit of operative management in this population.

Safety of parathyroidectomy in older vs. younger patients with primary hyperparathyroidism

BACKGROUND

Primary hyperparathyroidism is a prevalent endocrinopathy for which surgery is the only curative option. Parathyroidectomy is primarily recommended in younger and symptomatic patients, while there are still concerns regarding surgical complications in older patients. We therefore assessed the association of age with surgical outcomes in patients undergoing parathyroidectomy in a large population in Switzerland.

METHODS

Population-based cohort study of adult patients with primary hyperparathyroidism undergoing parathyroidectomy in Switzerland between 2012 and 2018. The cohort was divided into four age groups (<50 years, 50-64 years, 65-74 years, ≥75 years). The primary outcome was a composite of in-hospital postoperative complications. Secondary outcomes were intensive care unit (ICU) admission, unplanned 30-day-readmission, and prolonged length of hospital stay.

RESULTS

We studied 2642 patients with a median (IQR) age of 62 (53-71) years. Overall, 111 patients had complications including surgical re-intervention, hypocalcemia, and vocal cord paresis. As compared to <50 year-old patients, older patients had no increased risk for in-hospital complications after surgery (50-64 years: odds ratio (OR): 0.51 (95% CI, 0.28 to 0.92); 65-74 years: OR: 0.72 (95% CI, 0.39 to 1.33); ≥75 years: OR: 1.03 (95% CI, 0.54 to 1.95), respectively. There was also no association of age and rates of ICU-admission and unplanned 30-day-readmission, but oldest patients had longer hospital stays (OR: 2.38 (95% CI, 1.57 to 3.60)).

CONCLUSION

≥50 year-old patients undergoing parathyroidectomy had comparable risk of in-hospital complications as compared with younger ones. These data support parathyroidectomy in even older patients with primary hyperparathyroidism as performed in clinical routine.

Patient Factors Associated With Parathyroidectomy in Older Adults With Primary Hyperparathyroidism

Importance

Parathyroidectomy provides definitive management for primary hyperparathyroidism (PHPT), reducing the risk of subsequent fracture, nephrolithiasis, and chronic kidney disease (CKD), but its use among older adults in the US is unknown.

Objective

To identify patient characteristics associated with the use of parathyroidectomy for the management of PHPT in older adults.

Design, Setting, and Participants

This population-based, retrospective cohort study used 100% Medicare claims from beneficiaries with an initial diagnosis of PHPT from January 1, 2006, to December 31, 2016. Patients were considered to meet consensus guideline criteria for parathyroidectomy based on diagnosis codes indicating osteoporosis, nephrolithiasis, or stage 3 CKD. Multivariable logistic regression was used to identify patient characteristics associated with parathyroidectomy. Data were analyzed from February 11, 2020, to October 8, 2020.

Main Outcomes and Measures

The primary outcome was parathyroidectomy within 1 year of diagnosis.

Results

Among 210 206 beneficiaries with an incident diagnosis of PHPT (78.8% women; mean [SD] age, 75.3 [6.8] years), 63 136 (30.0%) underwent parathyroidectomy within 1 year of diagnosis. Among the subset of patients who met consensus guideline criteria for operative management (n = 131 723), 38 983 (29.6%) were treated with parathyroidectomy. Patients treated operatively were younger (mean [SD] age, 73.5 [5.7] vs 76.0 [7.1] years) and more likely to be White (90.1% vs 86.0%), to be robust or prefrail (92.1% vs 85.7%), and to have fewer comorbidities (Charlson Comorbidity Index score of 0 or 1, 54.6% vs 44.1%), in addition to being more likely to live in socioeconomically disadvantaged (46.9% vs 40.3%) and rural (18.1% vs 13.6%) areas (all P < .001). On multivariable analysis, increasing age had a strong inverse association with parathyroidectomy among patients aged 76 to 85 years (unadjusted rate, 25.9%; odds ratio [OR], 0.68 [95% CI, 0.67-0.70]) and older than 85 years (unadjusted rate, 11.2%; OR, 0.27 [95% CI, 0.26-0.29]) compared with those aged 66 to 75 years (unadjusted rate, 35.6%), as did patients with moderate to severe frailty (unadjusted rate, 18.9%; OR, 0.60 [95% CI, 0.56-0.64]) compared with robust patients (unadjusted rate, 36.1%) and those with a Charlson Comorbidity Index score of 2 or greater (unadjusted rate, 25.9%; OR, 0.77 [95% CI, 0.75-0.79]) compared with a Charlson Comorbidity Index score of 0 (unadjusted rate, 37.0%). With regard to operative guidelines, a history of nephrolithiasis increased the odds of parathyroidectomy (OR, 1.43 [95% CI, 1.39-1.47]); stage 3 CKD decreased the odds of parathyroidectomy (OR, 0.71 [95% CI, 0.68-0.74]); and osteoporosis showed no association (OR, 1.01 [95% CI, 0.99-1.03]).

Conclusions and Relevance

In this cohort study, most older adults with PHPT did not receive definitive treatment with parathyroidectomy. Older age, frailty, and multimorbidity were associated with nonoperative management, and guideline recommendations had minimal effect on treatment decisions. Further research is needed to identify barriers to surgical care and develop tools to target parathyroidectomy to older adults most likely to benefit.

Frailty is More Predictive than Age for Complications After Thyroidectomy for Multinodular Goiter

BACKGROUND

Risks of thyroidectomy for multinodular goiter (MNG) in older and frail patients are unclear, particularly regarding hematoma and recurrent laryngeal nerve (RLN) palsy.

METHODS

MNG patients undergoing total thyroidectomy were reviewed in the ACS-NSQIP procedure-targeted database (2016-2017). Outcomes were analyzed between adult (age <65), older-adult (age ≥65 and <80), and oldest-old (age ≥80) patients. Five-factor modified frailty index (mFI-5) was calculated based on functional status, diabetes, COPD, CHF, and hypertension, and used in comparative analyses.

RESULTS

A total of 2189 adult, 635 older-adult, and 59 oldest-old patients were included. Compared to adult patients, older-adult and oldest-old patients had higher mFI-5 ≥0.4 rates (14% vs. 22% vs. 31%, respectively, p < 0.001). The overall complication rate was 17.0% and similar between groups; however, oldest-old patients had higher rates of surgical site infection (3.4% vs. 0.3% vs. 0.4%), pneumonia (5.1% vs. 0.3% vs. 0.2%), and readmission (10.2% vs. 2.4% vs. 2.6%) compared to older-adult and adult patients, respectively (p < 0.05). On multivariable analyses of thyroidectomy-specific complications, mFI-5 ≥0.4 (OR 2.5, 95%-CI 1.4-4.4) and bleeding disorder (OR 4.6, 95%-CI 1.3-16.3) were predictive of hematoma, whereas vessel-sealant device usage (OR 0.4, 95%-CI 0.3-0.7) was protective. mFI-5 ≥ 0.4 (OR 1.5, 95%-CI 1.1-2.2), bleeding disorder (OR 2.8, 95%-CI 1.04-7.8), parathyroid autotransplantation (OR 1.7, 95%-CI 1.2-2.6), and prolonged operative time (OR 1.4, 95%-CI 1.02-1.8) were predictive of RLN palsy. Age was not a significant predictor of hematoma or RLN palsy.

CONCLUSIONS

Patients ≥80 years old are at increased risk for systemic complications and readmission after thyroidectomy for MNG. Frailty index better risk-stratifies patients than age for thyroidectomy-specific complications.

Undertreatment of primary hyperparathyroidism in a privately insured US population: Decreasing utilization of parathyroidectomy despite expanding surgical guidelines

BACKGROUND

Primary hyperparathyroidism is associated with substantial morbidity, including osteoporosis, nephrolithiasis, and chronic kidney disease. Parathyroidectomy can prevent these sequelae but is poorly utilized in many practice settings.

METHODS

We performed a retrospective cohort study using the national Optum de-identified Clinformatics Data Mart Database. We identified patients aged ≥35 with a first observed primary hyperparathyroidism diagnosis from 2004 to 2016. Multivariable logistic regression was used to determine patient/provider characteristics associated with parathyroidectomy.

RESULTS

Of 26,522 patients with primary hyperparathyroidism, 10,101 (38.1%) underwent parathyroidectomy. Of the 14,896 patients with any operative indication, 5,791 (38.9%) underwent parathyroidectomy. Over time, there was a decreasing trend in the rate of parathyroidectomy overall (2004: 54.4% to 2016: 32.4%, P < .001) and among groups with and without an operative indication. On multivariable analysis, increasing age and comorbidities were strongly, inversely associated with parathyroidectomy (age 75-84, odds ratio 0.50 [95% confidence interval 0.45-0.55]; age ≥85, odds ratio 0.21 [95% confidence interval 0.17-0.26] vs age 35-49; Charlson Comorbidity Index ≥2 vs 0 odds ratio 0.62 [95% confidence interval 0.58-0.66]).

CONCLUSION

The majority of US privately insured patients with primary hyperparathyroidism are not treated with parathyroidectomy. Having an operative indication only modestly increases the likelihood of parathyroidectomy. Further research is needed to address barriers to treatment and the gap between guidelines and clinical care in primary hyperparathyroidism.

Changes in bone mineral density after parathyroidectomy in patients with moderate to severe primary hyperparathyroidism

OBJECTIVE

Primary hyperparathyroidism (PHPT) is relatively common in China and results in severe damage to the skeletal system. This study aimed to investigate changes in bone mineral density (BMD) over 2 years in patients with PHPT after parathyroidectomy.

METHODS

This retrospective cohort study included patients with PHPT who underwent parathyroidectomy between January 2010 and December 2015. BMD and T-scores and Z-scores of the lumbar spine (L1, L2, L3, and L4) and total hip (femoral neck, great trochanter, and Ward's triangle) at baseline and 2 years after surgery were measured by dual-energy X-ray absorptiometry.

RESULTS

Thirty patients with moderate to severe PHPT (17 men and 13 women) aged 38.90±15.48 years were included. BMD, and T-score and Z-score values at the lumbar spine and total hip at 6 months, 1 year, and 2 years after parathyroidectomy were significantly improved compared with preoperative values. Improvement in BMD was largest at L4 (46.7%) and smallest at L1 (37.4%) in the lumbar spine 2 years after parathyroidectomy. For the total hip, the increase in BMD was largest at Ward's triangle (42.6%) and smallest at the femoral neck (37.5%).

CONCLUSIONS

BMD of the lumbar spine and total hip is improved after parathyroidectomy in patients with PHPT.

Surgical Management of Primary Hyperparathyroidism-Clinicopathologic Study of 1019 Cases from a Single Institution

BACKGROUND

Primary hyperparathyroidism (pHPT) is an endocrine disorder characterized by hypercalcemia and caused by the presence of disordered parathyroid glands. Parathyroidectomy is the only curative therapy for pHPT, but despite its high cure rate of 95-98%, there are still cases where hypercalcemia persists after this surgical procedure. The aim of this study was to present the results of a surgical treatment of patients due to primary hyperparathyroidism and failures related to the thoracic location of the affected glands.

METHODS

We present a retrospective analysis of 1019 patients who underwent parathyroidectomy in our department in the period 1983-2018.

RESULTS

Among the group of 1019 operated-on patients, treatment failed in 19 cases (1.9%). In 16 (84.2%) of them, the repeated operation was successful. In total, 1016 patients returned to normocalcemia.

CONCLUSIONS

Our results confirm that parathyreoidectomy is the treatment of choice for patients with primary hyperparathyroidism. The ectopic position of the parathyroid gland in the mediastinum is associated with an increased risk of surgical failure. Most parathyroid lesions in the mediastinum can be safely removed from the cervical access.

Non-surgical management of primary hyperparathyroidism in the aging population

Primary hyperparathyroidism (PHPT) is commonly observed in the aging population, and the average age at diagnosis has increased in the last 20 years. Parathyroidectomy, the only definitive cure for PHPT, is indicated in symptomatic and asymptomatic older PHPT patients with skeletal and renal disease. It is as effective in older patients as it is in younger patients. Nevertheless, older patients may present with comorbidities and greater frailty, leading to the possibility of more complications, higher morbidity and mortality after surgery. This review focuses on the non-surgical clinical management of PHPT in elderly patients. We also summarize the most recent literature regarding the pharmacological management of PHPT to reduce serum calcium levels, to improve bone mineral density or to do both in the aging population.

Recent advances in the understanding and management of primary hyperparathyroidism

Primary hyperparathyroidism is a hormonal disorder whose prevalence is approximately 1–2% in the United States of America. The disease has become more recognizable to clinicians in an earlier phase and, at present, patients can be diagnosed with “classic”, “normocalcemic”, “normohormonal”, or “mild, asymptomatic” primary hyperparathyroidism. Surgery, with a focused parathyroidectomy when possible, or a four-gland exploration, is the only way to cure the disease. Cure is determined by use of intra-operative parathyroid hormone monitoring with long-term cure rates ranging from 90–95%. Newer adjuncts to surgery include CT or PET imaging and near-infrared immunofluorescence. This article highlights updates in parathyroid disease and advances in parathyroid surgery; it does not provide a comprehensive summary of the disease process or a review of surgical indications, which can be found in the AAES guidelines or NIH Symposium on primary hyperparathyroidism.