Improvement in patient-reported physical and mental health after parathyroidectomy for primary hyperparathyroidism

Understanding delays to parathyroidectomy: A mixed-methods approach

BACKGROUND

Patients from ethnic and racial minority groups with primary hyperparathyroidism may have greater time delays to curative parathyroidectomy. Contributing factors are unclear.

METHODS

This was a sequential mixed-methods study. The quantitative phase was a retrospective chart review of adults with primary hyperparathyroidism who underwent parathyroidectomy between 2015 and 2020, collecting demographic and clinical data. Social vulnerability of the patients' residential area, measured with the Social Vulnerability Index, and relevant clinical time intervals were calculated. A multivariable analysis of factors associated with greater time intervals was performed. The qualitative phase involved semistructured interviews with endocrinologists, analyzed inductively for themes.

RESULTS

On chart review of 1,083 patients, the median age was determined to be 61 years and 856 (79%) were female. Six hundred twenty-eight (57.9%) were non-Hispanic White and 456 (42.1%) were Hispanic ethnicity or Asian, Pacific Islander, Black, Native American, Other or Unknown race. Patients of Hispanic ethnicity, or Asian or Pacific Islander, Black, Native American, Other or Unknown race were more likely than non-Hispanic White patients to live in the most socially vulnerable areas (19.3% vs 5.9%, P < .01) and had greater time intervals than non-Hispanic White patients between index hypercalcemia and first parathyroid hormone level, surgical referral, or parathyroidectomy (all P < .05). On multivariable analysis, age (coefficient 7.9, 95% CI 2.8-13.0) and living in the most socially vulnerable areas (coefficient 297.9, 95% CI 87-508.7) were associated with greater days between index hypercalcemia and parathyroidectomy. In the study's qualitative phase, identified themes for reasons for care delays included socioeconomic, nonsocioeconomic patient, and nonsocioeconomic nonpatient factors.

CONCLUSION

Care delays are driven by a combination of socioeconomic and nonsocioeconomic factors.

Improved sexual function after parathyroidectomy in women with primary hyperparathyroidism

BACKGROUND

The study aimed to evaluate whether women with primary hyperparathyroidism (PHPT) experience improvement in their sexual function after parathyroidectomy.

METHODS

Women with PHPT or benign thyroid nodules (controls) undergoing surgery were administered the validated Parathyroidectomy Assessment Score (PAS), Patient-Reported Outcomes Measurement Information System-29 (PROMIS-29) and Female Sexual Function Index (FSFI) pre-operatively, at 3 months and 6 months postoperatively.

RESULTS

Of the 26 PHPT and 18 control patients, PHPT patients were older (53.1 vs 45.3 years, p ​= ​0.008). Post-operatively, both PHPT (pre-op 2.4 vs 3-month 3.0 vs 6-month 2.4, p ​= ​0.022) and control patients (pre-operative 2.4 vs 3-month 3.3 vs 6-month 3.6, p ​= ​0.032) reported increased desire for sexual activities. In addition, PHPT patients experienced increased arousal (pre-operative 2.7 vs 3-month 3.9 vs 6-month 3.6, p ​= ​0.047) and satisfaction (pre-operative 3.0 vs 3-month 4.8 vs 6-month 4.0, p ​= ​0.006).

CONCLUSIONS

The current study indicates that women with PHPT may experience improved sexual function after parathyroidectomy.

Objectively measured cognitive dysfunction in patients with primary hyperparathyroidism improves after parathyroidectomy

BACKGROUND

A relationship between primary hyperparathyroidism (PHPT) and decreased quality of life has been shown using patient-reported outcome measures, including Pasieka's Parathyroid Assessment of Symptoms, SF-36, and PROMIS. Despite this, there remains a paucity of objectively measured data demonstrating cognitive dysfunction in patients with PHPT. We assessed whether parathyroidectomy resulted in quantifiable cognitive improvement.

METHODS

We examined 59 consecutive patients with PHPT who underwent parathyroidectomy at a single institution between 2019 and 2021. We used BrainCheck, a clinically validated objective measure of neurocognition, to assess pre- and postoperative neurocognitive changes and evaluated associations between BrainCheck scores and parathyroidectomy using the Wilcoxon signed-rank test.

RESULTS

Of the 59 patients with PHPT who underwent parathyroidectomy and rapid cognitive assessment with BrainCheck, 72.9% were female, 49.2% were White, and 30.5% were African American. A total of 44.1% of patients preoperatively showed neurocognitive dysfunction relative to the general population compared to 22% postoperatively, representing an improvement in 53% of the cohort. Postoperative scores for the entire cohort were significantly higher than preoperative scores (Z =2.85, P = .004). This association remained significant when the cohort was stratified by sex, as both males (Z =2.02, P = .044) and females (Z =2.09, P = .037) had a significant increase in scores. Domain sub-analysis demonstrated a significant association between parathyroidectomy and improved executive function (P < .01).

CONCLUSION

Patients with PHPT experience objectively measurable cognitive changes associated with PHPT that can be reversed by parathyroidectomy, with improvements observed as early as 2 weeks after surgery. Further research with a larger cohort is needed to corroborate our findings.

Association of Major Depressive Disorder in Hyperparathyroidism: A Systematic Review

Major depressive disorder (MDD) is a common neuropsychiatry manifestation that is more prevalent lately. Many contributing factors are present (for example, neurochemical, physiological, pathophysiological, and endocrinological factors). Patients with increased serum parathyroid levels are usually linked to psychosis symptoms but not to depressive symptoms. We conducted this systematic review to explore a correlation between depressive disorder and increased serum parathyroid levels, a major endocrinological pathology, and help establish mental wellness in patients suffering from hyperparathyroidism. We conducted a thorough literature search using five major databases, MEDLINE, PubMed, PubMed Central (PMC), ScienceDirect, and Google Scholar, using three keywords-MDD, depression, and hyperparathyroidism. We included mixed method studies, including observational studies, non-randomized controlled trials, case reports, and review articles published in the last ten years, focusing on the adult and geriatric population (>18 years) and on depressive and anxiety symptoms associated with patients with hyperparathyroidism. We included 11 articles (seven observational studies + four case reports) for qualitative synthesis after screening the literature. The reviewed studies showed an association between high serum parathyroid level, high serum calcium level, high serum alkaline phosphatase level, low serum phosphorous level, and increased depressive neurocognitive symptoms. After a patient with hyperparathyroidism is treated for hypercalcemia or undergoes parathyroidectomy and the serum parathyroid levels are lowered, a decrease in severe depressive symptoms is noted. The qualitative analysis of the reviewed literature showed an association between major depressive disorder and hyperparathyroidism. This paper can guide clinicians to assess patients with increased serum parathyroid levels for depressive neuropsychiatric symptoms and plan treatment, as treatment of their hyperparathyroidism can significantly lower their depressive symptoms. More randomized controlled trials should be conducted to find the treatment effectiveness of depression in patients with hyperparathyroidism.

Surgery for primary hyperparathyroidism in Germany, Switzerland, and Austria: an analysis of data from the EUROCRINE registry

PURPOSE

EUROCRINE is an endocrine surgical register documenting diagnostic processes, indication for surgical treatment, surgical procedures, and outcomes. The purpose was to analyse data for PHPT in German speaking countries regarding differences in clinical presentation, diagnostic workup, and treatment.

METHODS

All operations for PHPT performed from 07/2015 to 12/2019 were analysed.

RESULTS

Three thousand two hundred ninety-one patients in Germany (9 centres; 1762 patients), Switzerland (16 centres; 971 patients) and Austria (5 centres; 558 patients) were analysed. Hereditary disease was seen in 36 patients in Germany, 16 patients in Switzerland and 8 patients in Austria. In sporadic disease before primary operation, PET-CT showed the highest sensitivity in all countries. In re-operations, CT and PET-CT achieved the highest sensitivities. The highest sensitivity of IOPTH was seen in Austria (98.1%), followed by Germany (96.4%) and Switzerland (91.3%). Operation methods and mean operative time reached statistical significance (p<0.05). Complication rates are low. Overall, 656 (19.9%) patients were asymptomatic; the remainder showed bone manifestations, kidney stones, fatigue and/or neuropsychiatric symptoms.

CONCLUSION

Early postoperative normocalcaemia ranged between 96.8 and 97.1%. Complication rates are low. PET-CT had the highest sensitivity in all three countries in patients undergoing primary operation as well as in Switzerland and Austria in patients undergoing re-operation. PET-CT could be considered a first-line preoperative imaging modality in patients with inconclusive ultrasound examination. The EUROCRINE registry is a beneficial and comprehensive data source for outcome analysis of endocrine procedures on a supranational level.

Social Determinants of Health and Quality of Life in Endocrine Surgery Patients

INTRODUCTION

Quality of life (QoL) of endocrine surgery patients is an important patient outcome but the role of social determinants of health (SDH) on preoperative QoL is understudied.

METHODS

This study used preoperative data of 233 endocrine surgery patients participating in a longitudinal QoL study to examine the influence of SDH (patient-level and environmental) on preoperative QoL. Patient-level SDH was assessed with structured survey questions and environmental SDH with the Social Vulnerability Index. Multiple domains of QoL were assessed with the Patient-Reported Outcomes Measurement Information System-29 (PROMIS-29).

RESULTS

The average age of the sample was 52.9 y and 76.8% were female, 10% were Hispanic, 55.8% were White, 32.6% were Black, 6.9% were Other, and 4.7% were Asian. Patients with patient-level SDH were more likely to have worse preoperative QoL in multiple PROMIS domains. Patients who lived in the most socially vulnerable areas had the same or better QoL scores in the PROMIS-29 domains than those living in less vulnerable areas. Minority race patients were more likely to have patient-level SDH and to live in the most vulnerable areas.

CONCLUSIONS

This study is the first to our knowledge to examine the role of patient-level and environmental SDH on preoperative QoL among endocrine surgery patients. The results identified specific patient-level factors that could be used as the basis for interventions aimed to improve patients' QoL. Future studies that evaluate the role of preoperative SDH on long-term QoL and clinical outcomes would further enhance our understanding of the impact of SDH on patient wellbeing.

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.

Chronic asthenia in patients who have undergone endocrine neck surgery

INTRODUCTION

The impact of chronic asthenia after thyroidectomy has been evaluated in two previous studies comparing total thyroidectomy and hemithyroidectomy. We compared its impact on patients undergoing thyroidectomy, parathyroidectomy for primary hyperparathyroidism, and cholecystectomy.

METHODS

Patients recruited for surgery (233 consecutive total thyroidectomies for non-toxic multinodular goiter, Group I, 43 consecutive parathyroidectomies for primary hyperparathyroidism, group II and a sample of 43 laparoscopic cholecystectomies, group III) were compared at three times: pre-operative, 6 months after surgery, 1 year after surgery. A brief fatigue inventory (BFI) was administered to assess asthenia. We excluded intermediate or high-risk thyroid carcinomas, Grave's disease, obese patients, secondary and tertiary hyperparathyroidism, vitamin D deficiency, and acute cholecystitis. In the postoperative period, patients who had undergone complications of each surgical procedure were also excluded. Demographics, smoking, alcohol abuse, chronic diseases (renal, cardiac, pulmonary, hepatic, and diabetes mellitus), anxiety and depression were noted.

RESULTS

In Group I the significant increase of asthenia during the three periods of detection (p < 0.001) was confirmed. Renal failure further increased the risk of asthenia. In Group II, asthenia after 6 months and 1 year after surgery decreased significantly (p < 0.001). In Group III, the variations in BFI during the three periods were not significant.

CONCLUSIONS

Asthenia is a frequent sequela of total thyroidectomy, also in comparison with other types of surgery. Patients undergoing thyroidectomy must be informed of the possible implications of surgery, which should be calibrated on the strict application of guidelines.

Analysis of Primary Hyperparathyroidism Screening Among US Veterans With Kidney Stones

Importance

Approximately 3% to 5% of patients with kidney stones have primary hyperparathyroidism (PHPT), a treatable cause of recurrent stones. However, the rate of screening for PHPT in patients with kidney stones remains unknown.

Objectives

To estimate the prevalence of parathyroid hormone (PTH) testing in veterans with kidney stones and hypercalcemia and to identify the demographic, geographic, and clinical characteristics of veterans who were more or less likely to receive PTH testing.

Design, Setting, and Participants

This cohort study obtained Veterans Health Administration (VHA) health records from the Corporate Data Warehouse for veterans who received care in 1 of the 130 VHA facilities across the United States from January 1, 2008, through December 31, 2013. Historical encounters, medical codes, and laboratory data were assessed. Included patients had diagnostic or procedural codes for kidney or ureteral stones, and excluded patients were those with a previous serum PTH level measurement. Data were collected from January 1, 2006, to December 31, 2014. Data analysis was conducted from June 1, 2019, to January 31, 2020.

Exposures

Elevated serum calcium concentration measurement between 6 months before and 6 months after kidney stone diagnosis.

Main Outcomes and Measures

Proportion of patients with a serum PTH level measurement and proportion of patients with biochemical evidence of PHPT who underwent parathyroidectomy.

Results

The final cohort comprised 7561 patients with kidney stones and hypercalcemia and a mean (SD) age of 64.3 (12.3) years. Of these patients, 7139 were men (94.4%) and 5673 were white individuals (75.0%). The proportion of patients who completed a serum PTH level measurement was 24.8% (1873 of 7561). Across the 130 VHA facilities included in the study, testing rates ranged from 4% to 57%. The factors associated with PTH testing included the magnitude of calcium concentration elevation (odds ratio [OR], 1.07 per 0.1 mg/dL >10.5 mg/dL; 95% CI, 1.05-1.08) and the number of elevated serum calcium concentration measurements (OR, 1.08 per measurement >10.5 mg/dL; 95% CI, 1.06-1.10) as well as visits to both a nephrologist and a urologist (OR, 6.57; 95% CI, 5.33-8.10) or an endocrinologist (OR, 4.93; 95% CI, 4.11-5.93). Of the 717 patients with biochemical evidence of PHPT, 189 (26.4%) underwent parathyroidectomy within 2 years of a stone diagnosis.

Conclusions and Relevance

This cohort study found that only 1 in 4 patients with kidney stones and hypercalcemia were tested for PHPT in VHA facilities and that testing rates varied widely across these facilities. These findings suggest that raising clinician awareness to PHPT screening indications may improve evaluation for parathyroidectomy, increase the rates of detection and treatment of PHPT, and decrease recurrent kidney stone disease.

An Institutional experience with primary hyperparathyroidism in the elderly over two decades

BACKGROUND

Parathyroidectomy is the only curative treatment for primary hyperparathyroidism (pHPT) and is associated with low morbidity. This study examined the severity of disease and outcomes of parathyroidectomy based on patient age at a high-volume institution.

METHODS

This is a retrospective review of sporadic pHPT patients who underwent initial parathyroidectomy. To study disease severity over time, patients were divided into timeframes: 1999-2007, 2007-2012, and 2013-2018. Elderly was defined as age ≥75 years.

RESULTS

Over time, the elderly had progressively lower preoperative calcium (11.0, 10.7, 10.7; p = 0.05) and PTH (150.4, 111.9, 107.9; p < 0.001) levels. By age, there was no difference in preoperative calcium (10.8, 10.9; p = 0.91) or in rates of recurrent laryngeal nerve injury, hypoparathyroidism, or persistent/recurrent pHPT.

CONCLUSIONS

Over the 3 time periods of the study, elderly patients had progressively lower calcium and PTH levels. There was no difference in endocrine-specific complications between the age groups, suggesting that parathyroidectomy in the elderly is safe and therefore, age-associated morbidity should not preclude parathyroidectomy.

A Pilot Study of Patient-Reported Outcome Measures Across a Broad Sample of Surgical Patients

BACKGROUND

Patient-reported outcomes (PROs) have the potential to aid in surgical decision-making, predict surgical outcomes, assess recovery, and evaluate long-term success. We performed a pilot study testing the ability to use PROs in a broad surgical population in preparation for wide spread use.

MATERIAL AND METHODS

Surgical patients completed five Patient-Reported Outcome Measurement Information System (PROMIS) measures during their preoperative encounter in the preanesthesia clinic and again postoperatively via emailed link. Preoperative to postoperative changes in PROMIS scores, factors related to completion of postoperative measures, intercorrelations between PROMIS measures, and numbers of patients with normal function, and mild, moderate, and severe deficits in PROMIS scores were analyzed.

RESULTS

A total of 393 patients undergoing surgery in 8 specialties completed preoperative PROMIS measures; 239 (60.8%) completed them postoperatively. Physical function (P < 0.0001), pain (P < 0.0001), and cognitive function (P = 0.03) PROMIS scores significantly worsened after surgery but not mental PROMIS scores (P = 0.48). Hispanic and sicker patients had lower completion rates of postoperative measures. Intercorrelations were very high (>0.80) among the physical function and self-efficacy for activities of daily living PROMIS measures. Physical function and pain PROMIS measures had the largest number of patients in the "severe" range after surgery.

CONCLUSIONS

Patients across a broad surgical population completed PROMIS measures successfully, both preoperatively and postoperatively, although the postoperative completion rate was lower than other studies reported in the literature. PROMIS scores were reflective of the effects of surgery. Some of the PROMIS measures were highly correlated suggesting that some measures could be eliminated or replaced with measures assessing other important effects of surgery. Consideration could be made to alert health care providers about patients having PROs in the "severe" range for potential intervention.

Evaluation for Primary Hyperparathyroidism in Patients Who Present With Nephrolithiasis

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Diagnostic and treatment delay in primary hyperparathyroidism. A pending issue

INTRODUCTION

Primary hyperparathyroidism (PHPT) remains underdiagnosed among patients with hypercalcemia, potentially causing increased morbidity.

OBJECTIVE

To identify in surgically operated patients the presence of overlooked hypercalcemia and patients with criteria for surgery (CFS) for PHPT at least one year prior to referral to Endocrinology, and to determine whether this diagnostic delay leads to increased morbidity.

METHODS

An observational study was carried out in 116 consecutive patients. We evaluated electronic medical records registered at least 12 months prior to referral and divided them in four groups: hypercalcemia with CFS (group 1), hypercalcemia without CFS (group 2), normocalcemia (group 3), and cases without previous biochemical evaluation (group 4).

RESULTS

A total of 84 patients (72.4%) had a previous measurement of serum calcium at a time interval of ≥ 12 months. Sixty-six (56.9%) had hypercalcemia and 43 of them (37%) had ≥ 1 CFS, with an average delay of 57 months in receiving proper evaluation. Almost half of the calcemia measurements in group 1 had been made in the emergency room. Patients from group 1 were younger, and had a greater frequency of nephrolithiasis and renal impairment than patients in group 4. The serum calcium values at referral were similar in both groups and higher than the values found in patients from the other two groups.

DISCUSSION

In patients with PHPT and CFS, referral to an endocrinologist is made with an average delay of almost 5 years. The identified causes of this delay, which conditions more kidney disease, are unrecognized hypercalcemia and/or unawareness of the surgical criteria, while calcium elevations promote referral. Interventions are needed to avoid this delay in the diagnosis and resolution of PHPT.

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

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

Effects of surgery on the patient-reported outcomes of primary hyperparathyroidism patients with mild hypercalcemia without classic symptoms: a systematic review of the literature

PURPOSE

To establish if parathyroidectomy is beneficial for patient-reported outcomes (PROs), including quality of life (QoL), of patients with mild hypercalcemia ( < 1.0 mg/dl above the upper limit of reference ranges) caused by primary hyperparathyroidism without classic symptoms (mild PHPT).

METHODS

We conducted a systematic review of the literature. Prospective studies were selected if PROs were measured before and after surgery and if the subpopulation of mild PHPT was clearly defined. Selected studies were appraised for their designs, PRO measures, and potential biases, as well as findings. Effect sizes were estimated to evaluate the extent of the benefits, if possible.

RESULTS

Four randomized controlled trials and six observational studies were included in this analysis. Seven studies used the SF-36 to measure QoL and the other three used different scales. Quantitative data on outcomes were provided in the four observational studies, but effect sizes could not be estimated. A placebo effect of surgery was discussed in five studies. Statistically significant improvements in PROs were observed in all studies, but the clinical importance of the changes was not discussed in detail.

CONCLUSIONS

The surgical treatment of mild PHPT may be associated with improved PROs, but the clinical significance of the changes is not yet confirmed.

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

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

Validation of a novel patient-reported outcome measure for parathyroid and thyroid disease (PROMPT)

BACKGROUND

Patient-reported outcome measures are being used increasingly to assess disease severity and response to surgery. The purpose of this study was to create and validate a patient-reported outcome measure for symptoms of thyroid enlargement and hyperparathyroidism, 2 conditions where the presence of preoperative symptoms and response to surgery is often questioned.

METHODS

A questionnaire reviewing common symptoms was developed from a literature review and expert opinion. Internal validity, reliability, and initial responsiveness to surgery were evaluated.

RESULTS

Patient-Reported Outcome Measure for Parathyroid and Thyroid Disease (PROMPT) consists of 30 items: 10 compressive items and 20 hyperparathyroidism items; we evaluated 302 surveys collected over 10 months. PROMPT showed high internal consistency for compressive and hyperparathyroid constructs (Cronbach's α 0.84 and 0.95). Constructs were scored from 0-100, with greater scores corresponding to increased severity of symptoms. Preoperatively, patients with a goiter demonstrated greater compressive scores compared with other thyroid patients and hyperparathyroid patients (goiter, 47.5; nodule/other, 38.4; hyperparathyroid, 29.8; P < .0001). PROMPT demonstrated high test-retest reliability with acceptable intraclass correlation coefficients for both compressive score and hyperparathyroid score (0.840 and 0.646). Hyperparathyroid scores improved 2 weeks after (48.6 postop, 44.0 preop, P = .0470).

CONCLUSION

We validated a novel measure for symptoms of hyperparathyroidism and goiter. PROMPT demonstrates high internal consistency, test-retest reliability, and preliminary analysis, which suggests that it is sensitive to change after surgery.

Quality of life in multiple endocrine neoplasia type 2A compared with normative and disease populations

BACKGROUND

Patient-reported outcomes are measured in chronic disease states to inform intervention and management decisions while minimizing negative outcomes. We hypothesized that health-related quality of life in patients with multiple endocrine neoplasia type 2A would be worse than the general US population but similar to other chronic diseases.

METHODS

Adults ≥18 years with multiple endocrine neoplasia type 2A were recruited to complete the Patient-Reported Outcomes Measurement Information System 29-item questionnaire (n = 45). Scores based on the Patient-Reported Outcomes Measurement Information System T-score metric were compared with the general US population and with cohorts with low back pain, cancer, congestive heart failure, chronic obstructive pulmonary disease, major depressive disorder, rheumatoid arthritis, neuroendocrine tumors, primary hyperparathyroidism, and MEN1.

RESULTS

Compared with US normative data, multiple endocrine neoplasia type 2A patients reported worse anxiety (58.2 ± 12.0, P < .0001), depression (55.4 ± 12.0, P < .01), fatigue (61.4 ± 10.8, P < .0001), pain interference (54.0 ± 11.5, P < .05), and sleep disturbance (56.9 ± 2.7, P < .001), as well as significantly lower physical functioning (45.7 ± 9.3, P < .01) and ability to participate in social roles (46.4 ± 9.7, P < .05). Multiple endocrine neoplasia type 2A patients reported greater fatigue than patients with cancer (P < .0001), chronic obstructive pulmonary disease (P = .01), rheumatoid arthritis (P = .0002), neuroendocrine tumors (P = .0007), and primary hyperparathyroidism (P < .0001) but higher physical functioning compared with patients with rheumatoid arthritis (P = .02), low back pain, congestive heart failure, and chronic obstructive pulmonary disease (P < .0001).

CONCLUSIONS

This study is the first to use the Patient-Reported Outcomes Measurement Information System to compare patient-reported outcomes between multiple endocrine neoplasia type 2A and other chronic conditions. Individuals with multiple endocrine neoplasia type 2A reported worse health-related quality of life in all 7 domains compared with US normative data. Multiple endocrine neoplasia type 2A patients reported greater fatigue but greater physical function compared with several other conditions. Prospective longitudinal evaluation of patient-reported outcomes in multiple endocrine neoplasia type 2A should be conducted to identify treatments associated with the highest health-related quality of life.

Primary Hyperparathyroidism: Effects on Bone Health

Primary hyperparathyroidism (PHPT) is the most common cause of chronic hypercalcemia. With the advent of routine calcium screening, the classic presentation of renal and osseous symptoms has been largely replaced with mild, asymptomatic disease. In hypercalcemia caused by PHPT, serum parathyroid hormone levels are either high, or inappropriately normal. A single-gland adenoma is responsible for 80% of PHPT cases. Less frequent causes include 4-gland hyperplasia and parathyroid carcinoma. Diminished bone mineral density and nephrolithiasis are the major current clinical sequelae. Parathyroidectomy is the only definitive treatment for PHPT, and in experienced hands, cure rates approach 98%.

Substitution of Usual Perioperative Care by eHealth to Enhance Postoperative Recovery in Patients Undergoing General Surgical or Gynecological Procedures: Study Protocol of a Randomized Controlled Trial

Background

Due to the strong reduction in the length of hospital stays in the last decade, the period of in-hospital postoperative care is limited. After discharge from the hospital, guidance and monitoring on recovery and resumption of (work) activities are usually not provided. As a consequence, return to normal activities and work after surgery is hampered, leading to a lower quality of life and higher costs due to productivity loss and increased health care consumption.

Objective

With this study we aim to evaluate whether an eHealth care program can improve perioperative health care in patients undergoing commonly applied abdominal surgical procedures, leading to accelerated recovery and to a reduction in costs in comparison to usual care.

Methods

This is a multicenter randomized, single-blinded, controlled trial. At least 308 patients between 18 and 75 years old who are on the waiting list for a laparoscopic cholecystectomy, inguinal hernia surgery, or laparoscopic adnexal surgery for a benign indication will be included. Patients will be randomized to an intervention or control group. The intervention group will have access to an innovative, perioperative eHealth care program. This intervention program consists of a website, mobile phone app, and activity tracker. It aims to improve patient self-management and empowerment by providing guidance to patients in the weeks before and after surgery. The control group will receive usual care and will have access to a nonintervention (standard) website consisting of the digital information brochure about the surgical procedure being performed. Patients are asked to complete questionnaires at 5 moments during the first 6 months after surgery. The primary outcome measure is time to return to normal activities based on a patient-specific set of 8 activities selected from the Patient-Reported Outcomes Measurement Information System (PROMIS) physical functioning item bank version 1.2. Secondary outcomes include social participation, self-rated health, duration of return to work, physical activity, length of recovery, pain intensity, and patient satisfaction. In addition, an economic evaluation alongside this randomized controlled trial will be performed from the societal and health care perspective. All statistical analyses will be conducted according to the intention-to-treat principle.

Results

The enrollment of patients started in September 2015. The follow-up period will be completed in February 2017. Data cleaning and analyses have not begun as of the time this article was submitted.

Conclusions

We hypothesize that patients receiving the intervention program will resume their normal activities sooner than patients in the control group and costs will be lower.

ClinicalTrial

Netherlands Trial Registry NTC4699; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=4699 (Archived by WebCite at http://www.webcitation.org/6mcCBZmwy)