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Horowitz G, Leshno M, Izkhakov E, Halpern D, Muhanna N, Greenman Y, Ungar OJ, Carmel-Neidermann NN, Kampel L, Warshavsky A. Revisiting Age Criterion for Surgery in Asymptomatic Primary Hyperparathyroidism. Otolaryngol Head Neck Surg 2023. [PMID: 36808632 DOI: 10.1002/ohn.298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 01/21/2023] [Accepted: 01/27/2023] [Indexed: 02/19/2023]
Abstract
OBJECTIVE To revisit the current age criterion (50 years) for surgical candidacy in patients diagnosed with asymptomatic primary hyperparathyroidism (PHPT). STUDY DESIGN A predictive model relying on past publications using the electronic databases "PubMed," "Embase," "Medline," and "Google Scholar." SETTING Hypothetical large cohort. METHODS A Markov model was constructed, based on relevant literature, to compare 2 potential treatment algorithms for asymptomatic PHPT patients, parathyroidectomy (PTX), and observation. The various potential health states were characterized for the 2 treatment options and included potential surgical complications, end-organ deterioration, and death. A 1-way sensitivity analysis was performed to calculate the quality-adjusted life year (QALY) gains of both strategies. A Monte-Carlo simulation for 30,000 subjects was performed and cycled per annum. RESULTS On the basis of the model's assumptions, the QALY value for the PTX strategy was 19.17 versus 17.82 for the observation strategy. The incremental QALY gains for various ages according to the sensitivity analyses for PTX in comparison to observation were: 2.84 QALY for 40-year-old patients, 2.2 QALY for 50-year-old patients, 1.81 QALY for 55-year-old patients, 1.35 QALY for 60-year-old patients, and 0.86 QALY for 65-year-old patients. The incremental QALY is below 0.5 after the age of 75 years. CONCLUSION This study found PTX to be advantageous for asymptomatic PHPT patients older than the current age criterion of 50 years. The calculated QALY gains support a surgical approach for medically fit patients in their 50s. The current guidelines for the surgical treatment of young asymptomatic PHPT patients should be revisited by the next steering committee.
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Affiliation(s)
- Gilad Horowitz
- Department of Otolaryngology-Head and Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center (Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University), Tel-Aviv, Israel
| | - Moshe Leshno
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel.,Coller School of Management, Tel-Aviv University, Tel-Aviv, Israel
| | - Elena Izkhakov
- The Institute of Endocrinology, Metabolism and Hypertension, Tel-Aviv Sourasky Medical Center, (Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University), Tel-Aviv, Israel
| | - Daniel Halpern
- Department of Otolaryngology-Head and Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center (Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University), Tel-Aviv, Israel
| | - Nidal Muhanna
- Department of Otolaryngology-Head and Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center (Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University), Tel-Aviv, Israel
| | - Yona Greenman
- The Institute of Endocrinology, Metabolism and Hypertension, Tel-Aviv Sourasky Medical Center, (Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University), Tel-Aviv, Israel
| | - Omer J Ungar
- Department of Otolaryngology-Head and Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center (Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University), Tel-Aviv, Israel
| | - Narin N Carmel-Neidermann
- Department of Otolaryngology-Head and Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center (Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University), Tel-Aviv, Israel
| | - Liyona Kampel
- Department of Otolaryngology-Head and Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center (Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University), Tel-Aviv, Israel
| | - Anton Warshavsky
- Department of Otolaryngology-Head and Neck Surgery and Maxillofacial Surgery, Tel-Aviv Sourasky Medical Center (Affiliated to the Sackler Faculty of Medicine, Tel-Aviv University), Tel-Aviv, Israel
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Variation in surgical management of primary hyperparathyroidism in the US Department of Veterans Affairs healthcare system: A 15-year observational study. Surgery 2020; 168:838-844. [DOI: 10.1016/j.surg.2020.05.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 05/04/2020] [Accepted: 05/05/2020] [Indexed: 11/21/2022]
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Ikee R, Yano K, Tsuru T. Constipation in chronic kidney disease: it is time to reconsider. RENAL REPLACEMENT THERAPY 2019. [DOI: 10.1186/s41100-019-0246-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
AbstractConstipation is highly prevalent in patients with chronic kidney disease (CKD) and is primarily characterized by decreased intestinal motility. This chronic disorder affects the quality of life of patients. However, nephrologist and dialysis clinicians have long had a disproportionately limited understanding of constipation. Accumulating evidence has revealed a relationship between constipation and cardiovascular disease and CKD. The pathogenesis of constipation in CKD patients is multifactorial: decreased physical activity, comorbidities affecting bowel movement, such as diabetes mellitus, cerebrovascular disease, and hyperparathyroidism, a restricted dietary intake of plant-based fiber-rich foods, and multiple medications, including phosphate binders and potassium-binding resins, have all been implicated. CKD is associated with alterations in the composition and function of the gut microbiota, so-called gut dysbiosis. Recent studies showed that CKD-related gut dysbiosis decreased intestinal motility via intestinal inflammation or the increased generation of gut-derived uremic toxins, such as indoxyl sulfate and p-cresyl sulfate. Furthermore, the gastrointestinal secretion of mucin was found to be decreased in CKD animal models, which may delay colonic transit by diminished lubrication in the alimentary tract. Thus, CKD-related gut dysbiosis may play a role in constipation, but limited information is currently available. Since constipation is often intractable, particularly in CKD patients, every available means needs to be employed in its treatment. The effects of probiotics, prebiotics, and synbiotics on the composition of the gut microbiota and gut-derived uremic toxins have been increasingly reported. However, their effects on stool consistency or frequency in CKD patients remain unclear. Some laxatives may be beneficial for improving not only bowel habits but also gut dysbiosis. Further studies are required to elucidate the CKD-specific pathogenesis of constipation and develop novel effective treatment options.
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Alore EA, Suliburk JW, Ramsey DJ, Massarweh NN, Balentine CJ, Singh H, Awad SS, Makris KI. Diagnosis and Management of Primary Hyperparathyroidism Across the Veterans Affairs Health Care System. JAMA Intern Med 2019; 179:1220-1227. [PMID: 31305864 PMCID: PMC6632180 DOI: 10.1001/jamainternmed.2019.1747] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Untreated primary hyperparathyroidism impairs quality of life and incurs substantial costs. Parathyroidectomy is a low-risk, high-success, definitive intervention. OBJECTIVES To determine the appropriateness of diagnostic evaluation for primary hyperparathyroidism in patients with hypercalcemia and the use of parathyroidectomy for the treatment of primary hyperparathyroidism across the Veterans Affairs (VA) health care system. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study of veterans with hypercalcemia and primary hyperparathyroidism was conducted from January 1, 2000, through September 30, 2015, using the VA Corporate Data Warehouse, a national electronic health record-based repository. The study included 371 370 veterans with chronic hypercalcemia and 47 158 veterans with biochemical evidence of primary hyperparathyroidism diagnosed by hypercalcemia, elevated serum parathyroid hormone levels, and near-normal serum creatinine levels. Statistical analysis was performed from April 21, 2017, to April 10, 2019. MAIN OUTCOMES AND MEASURES The proportion of veterans with hypercalcemia who have parathyroid hormone levels evaluated, the proportion of veterans with hyperparathyroidism who are treated surgically, and the factors associated with parathyroidectomy using generalized linear latent and mixed model regression. RESULTS Of 371 370 patients with chronic hypercalcemia, 86 887 (23.4%) received further testing with parathyroid hormone level. Of 47 158 patients meeting diagnostic criteria for primary hyperparathyroidism (42 737 men [90.6%] and 4421 women [9.4%]; mean [SD] age, 67.3 [11.8] years), 6048 (12.8%) underwent parathyroidectomy. Of 5793 patients with primary hyperparathyroidism presenting with a serum calcium level more than 1 mg/dL above the upper limit of normal, 1501 (25.9%) underwent parathyroidectomy. There was a decreasing trend in the use of parathyroidectomy over time. Factors positively associated with parathyroidectomy were nephrolithiasis (odds ratio [OR], 2.23; 95% CI, 1.90-2.61) and non-Hispanic white race/ethnicity (OR, 1.31; 95% CI, 1.17-1.46), while age (OR, 0.95; 95% CI, 0.95-0.96), Elixhauser Comorbidity Index score (OR, 0.76; 95% CI, 0.72-0.80), decreased estimated glomerular filtration rate (OR, 0.52; 95% CI, 0.45-0.60), and diagnosis of osteoporosis (OR, 0.65; 95% CI, 0.52-0.80) were inversely related to surgery. CONCLUSIONS AND RELEVANCE From this study's findings, parathyroid hormone level is infrequently tested in patients with hypercalcemia, suggesting underdiagnosis of primary hyperparathyroidism. Patients meeting diagnostic criteria for primary hyperparathyroidism are undertreated with recommended parathyroidectomy. Similar gaps have previously been observed in non-VA care of primary hyperparathyroidism, suggesting the need for a systematic evaluation of barriers to diagnosis and treatment that informs intervention design.
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Affiliation(s)
- Elizabeth A Alore
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - James W Suliburk
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Health Services Research and Development Center of Innovation, Houston, Texas
| | - David J Ramsey
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Health Services Research and Development Center of Innovation, Houston, Texas
| | - Nader N Massarweh
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Health Services Research and Development Center of Innovation, Houston, Texas.,Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Courtney J Balentine
- Department of Surgery, University of Texas Southwestern, Dallas.,Veterans Affairs North Texas Health Care System, Dallas
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Health Services Research and Development Center of Innovation, Houston, Texas.,Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas.,Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Samir S Awad
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Konstantinos I Makris
- Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Texas.,Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Health Services Research and Development Center of Innovation, Houston, Texas.,Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
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Minisola S, Gianotti L, Bhadada S, Silverberg SJ. Classical complications of primary hyperparathyroidism. Best Pract Res Clin Endocrinol Metab 2018; 32:791-803. [PMID: 30665547 DOI: 10.1016/j.beem.2018.09.001] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Traditionally, classical complications of primary hyperparathyroidism are mainly represented by skeletal, kidney and gastrointestinal involvement. The old picture of osteitis fibrosa cystica is no longer commonly seen, at least in the western world. However, new imagining techniques have highlighted deterioration of skeletal tissue in patients with primary hyperparathyroidism not captured by traditional DXA measurement. Concerning the kidney, the most common consequences of excessive parathyroid hormone secretion are hypercalciuria and kidney stones; however, the exact pathogenesis of urinary stone formation is still unknown. The 2013 International Congress on the management of Asymptomatic Primary Hyperparathyroidism, emphasized the role of imaging techniques for early discovery of both skeletal and renal complications in asymptomatic patients. Gastrointestinal manifestations include acid-peptic disease, constipation, pancreatitis and gall stone disease. More studies are needed in this area to find the exact pathophysiological mechanism underlying these manifestations and the effect of parathyroid surgery.
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Affiliation(s)
- Salvatore Minisola
- Department of Internal Medicine and Medical Disciplines, "Sapienza", Rome University, Italy.
| | - Laura Gianotti
- SC Endocrinologia Diabetologia e Metabolismo, Azienda Ospedaliera S. Croce e Carle, Cuneo, Italy.
| | - Sanjay Bhadada
- Department of Endocrinology, Postgraduate Institute of Medical Education and Research, Chandigarh 160 012, India.
| | - Shonni J Silverberg
- Columbia University Medical College of Physicians & Surgeons, New York, USA.
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Abstract
In this Review, we describe the pathogenesis, diagnosis and management of primary hyperparathyroidism (PHPT), with a focus on recent advances in the field. PHPT is a common endocrine disorder that is characterized by hypercalcaemia and elevated or inappropriately normal serum levels of parathyroid hormone. Most often, the presentation of PHPT is asymptomatic in regions of the world where serum levels of calcium are routinely measured. In addition to mild hypercalcaemia, PHPT can manifest with osteoporosis and hypercalciuria as well as with vertebral fractures and nephrolithiasis, both of which can be asymptomatic. Other clinical forms of PHPT, such as classical disease and normocalcaemic PHPT, are less common. Parathyroidectomy, the only curative treatment for PHPT, is recommended in patients with symptoms and those with asymptomatic disease who are at risk of progression or have subclinical evidence of end-organ sequelae. Parathyroidectomy results in an increase in BMD and a reduction in nephrolithiasis. Various medical therapies can increase BMD or reduce serum levels of calcium, but no single drug can do both. More data are needed regarding the neuropsychological manifestations of PHPT and the pathogenetic mechanisms leading to sporadic PHPT, as well as on risk factors for complications of the disorder. Future work that advances our knowledge in these areas will improve the management of the disorder.
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Affiliation(s)
- Marcella D Walker
- Division of Endocrinology, Department of Medicine, Columbia University, College of Physicians and Surgeons, New York, New York 10032, USA
| | - Shonni J Silverberg
- Division of Endocrinology, Department of Medicine, Columbia University, College of Physicians and Surgeons, New York, New York 10032, USA
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Pepe J, Piemonte S, Cipriani C, Cilli M, Minisola S. Emerging data on cardiovascular risk in primary hyperparathyroidism. Endocrine 2014; 47:345-7. [PMID: 25205449 DOI: 10.1007/s12020-014-0415-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Accepted: 08/30/2014] [Indexed: 11/26/2022]
Affiliation(s)
- Jessica Pepe
- Department of Internal Medicine and Medical Disciplines, Sapienza University, Viale del Policlinico 155, 00161, Rome, Italy
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Abstract
Due to the wide use of screening tests for serum calcium, the prevalence rate of primary hyperparathyroidism (PHPT) has become higher and higher lately. PHPT has become the third largest endocrine system disease after diabetes and hyperthyroidism. Most of the patients diagnosed with PHPT in China had obvious clinical manifestations. Acute pancreatitis (AP), peptic ulcer and chronic constipation were its main digestive tract symptoms, which result in hypercalcemia and high parathyroid hormone (PTH). These digestive tract symptoms will disappear with the cure of PHPT. PHPT has an obvious correlation with AP, peptic ulcer and chronic constipation.In order to reduce the misdiagnosis rate and get better clinical effect, clinicians should fully recognize its clinical characters to get a better understanding of this disease. To reduce misdiagnosis, screening of high-risk patients is also necessary. In this paper, by searching the literature, we summarize the digestive tract symptoms of PHPT and make relevant analysis and discussion.
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