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Kongsaree N, Thanyajaroen T, Dechates B, Therawit P, Mahikul W, Ngaosuwan K. Skeletal Effect of Parathyroidectomy on Patients With Primary Hyperparathyroidism: A Systematic Review and Meta-Analysis. J Clin Endocrinol Metab 2024; 109:e1922-e1935. [PMID: 38739762 DOI: 10.1210/clinem/dgae326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 04/22/2024] [Accepted: 05/07/2024] [Indexed: 05/16/2024]
Abstract
CONTEXT Parathyroidectomy (PTX) is recommended for curing primary hyperparathyroidism (PHPT), although uncertainty remains regarding the extent of fracture risk reduction following surgery. OBJECTIVE This work aimed to compare fracture risk and bone mineral density (BMD) changes in patients with PHPT undergoing PTX vs observation (OBS). METHODS We systematically searched PubMed, Embase, and the Cochrane Library until September 2022, including randomized controlled trials (RCTs) and cohort studies, and reviewed citations from previous reviews. Among 1260 initial records, 48 eligible articles from 35 studies (5 RCTs; 30 cohorts) included PHPT patients receiving PTX or OBS interventions with reported fracture events at any site, including the hip, spine, or forearm, and/or BMD changes at each location. Data extraction followed Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines by 2 independent reviewers. RESULTS In 238 188 PHPT patients (PTX: 73 778 vs OBS: 164 410), PTX significantly reduced fractures at any site (relative risk [RR], 0.80; 95% CI, 0.74-0.86) compared to OBS. In 237 217 patients (PTX: 73 458 vs OBS: 163 759), the risk of hip fractures decreased (RR, 0.63; 95% CI, 0.52-0.76). No reduction in forearm and vertebral fractures was observed in 3574 and 3795 patients, respectively. The annual percentage BMD changes from baseline were higher in the PTX group: femoral neck, 1.91% (95% CI, 1.14-2.68); hip, 1.75% (95% CI, 0.58-2.92); radius, 1.75% (95% CI, 0.31-3.18); spine, 2.13% (95% CI, 1.16-3.10). CONCLUSION PTX significantly reduced overall and hip fracture risks in PHPT patients. Despite minimal BMD increase, the substantial decrease in fracture risk suggests additional benefits of PTX beyond mineral content enhancement.
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Affiliation(s)
- Nattanan Kongsaree
- Princess Srisavangavadhana College of Medicine, Chulabhorn Royal Academy, Bangkok 10210, Thailand
| | - Thanaporn Thanyajaroen
- Princess Srisavangavadhana College of Medicine, Chulabhorn Royal Academy, Bangkok 10210, Thailand
| | - Bothamai Dechates
- Endocrinology and Metabolism Unit, Department of Medicine, Chulabhorn Hospital, Chulabhorn Royal Academy, Bangkok 10210, Thailand
| | - Phonthip Therawit
- Endocrinology and Metabolism Unit, Department of Medicine, Chulabhorn Hospital, Chulabhorn Royal Academy, Bangkok 10210, Thailand
| | - Wiriya Mahikul
- Princess Srisavangavadhana College of Medicine, Chulabhorn Royal Academy, Bangkok 10210, Thailand
| | - Kanchana Ngaosuwan
- Princess Srisavangavadhana College of Medicine, Chulabhorn Royal Academy, Bangkok 10210, Thailand
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Castellano E, Attanasio R, Borretta G. Letter Regarding: Modern Trends for Primary Hyperparathyroidism: Intervening on Less Biochemically Severe Disease. J Surg Res 2024:S0022-4804(24)00208-7. [PMID: 38926061 DOI: 10.1016/j.jss.2024.04.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 04/10/2024] [Indexed: 06/28/2024]
Affiliation(s)
- Elena Castellano
- Department of Endocrinology, Diabetes and Metabolism, Santa Croce and Carle Hospital, Cuneo, Italy
| | - Roberto Attanasio
- Associazione Medici Endocrinologi, Scientific Committee, Milan, Italy
| | - Giorgio Borretta
- Department of Endocrinology, Diabetes and Metabolism, Santa Croce and Carle Hospital, Cuneo, Italy
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Frey S, Gérard M, Guillot P, Wargny M, Bach-Ngohou K, Bigot-Corbel E, Renaud Moreau N, Caillard C, Mirallié E, Cariou B, Blanchard C. Parathyroidectomy Improves Bone Density in Women With Primary Hyperparathyroidism and Preoperative Osteopenia. J Clin Endocrinol Metab 2024; 109:1494-1504. [PMID: 38152848 DOI: 10.1210/clinem/dgad718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Indexed: 12/29/2023]
Abstract
CONTEXT Osteoporosis and/or bone fractures are indications of parathyroidectomy in primary hyperparathyroidism (PHPT), especially in women. However, the benefit of surgery in patients with osteopenia remains unclear. OBJECTIVE To evaluate bone mineral density (BMD) and bone remodeling biomarkers changes 1 year after parathyroidectomy in women with PHPT. DESIGN In the prospective, monocentric, observational prospective cohort with primary hyperparathyroidism patients (CoHPT) cohort, women operated for sporadic PHPT since 2016 with ≥1 year follow-up were included. BMD (dual-X ray absorptiometry) and bone remodeling biomarkers [cross-linked C-telopeptide (CTX), procollagen type 1 N-terminal propeptide (P1NP), and bone-specific alkaline phosphatases] were assessed before and 1 year after parathyroidectomy. SETTING Referral center. PATIENTS A total of 177 women with PHPT (62.5 ± 13.3 years, 83.1% menopausal, 43.9% osteopenic, and 45.1% osteoporotic) were included. INTERVENTION Parathyroidectomy. MAIN OUTCOME MEASURE BMD change between before and 1 year after parathyroidectomy. RESULTS Parathyroidectomy resulted in significant increase in BMD and decrease in serum bone remodeling biomarker concentrations. In the 72 patients with baseline osteopenia, mean BMD significantly increased at the lumbar spine [+0.05 g/cm2 (95% confidence interval [CI], 0.03-0.07)], the femoral neck [+0.02 g/cm2 (95% CI 0.00-0.04)], the total hip [+0.02 g/cm2 (95% CI 0.01-0.02)], and the forearm [+0.01 (95% CI 0.00-0.02)], comparable to osteoporotic patients. Among osteopenic patients, those with individual BMD gain (>0.03 g/cm2) at ≥1 site had higher preoperative serum CTX, P1NP, and urine calcium concentrations than those without improvement. CONCLUSION Parathyroidectomy significantly improved BMD and remodeling biomarkers in women with osteopenia, thereby supporting the benefit of parathyroidectomy in these patients. Preoperative serum CTX and P1NP concentrations could be useful to predict expected BMD gain.
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Affiliation(s)
- Samuel Frey
- Nantes Université, CHU Nantes, Chirurgie Cancérologique, Digestive et Endocrinienne, Institut des Maladies de l'Appareil Digestif, F-44000 Nantes, France
- Nantes Université, CHU Nantes, CNRS, INSERM, l'institut du thorax, F-44000 Nantes, France
| | - Maxime Gérard
- Nantes Université, CHU Nantes, Chirurgie Cancérologique, Digestive et Endocrinienne, Institut des Maladies de l'Appareil Digestif, F-44000 Nantes, France
| | - Pascale Guillot
- Nantes Université, CHU Nantes, Service de Rhumatologie, F-44000 Nantes, France
| | - Matthieu Wargny
- Nantes Université, CHU Nantes, CNRS, INSERM, l'institut du thorax, F-44000 Nantes, France
- Nantes Université, CHU Nantes, Pôle Hospitalo-Universitaire 11: Santé Publique, Clinique des données, INSERM, CIC 1413, F-44000 Nantes, France
| | - Kalyane Bach-Ngohou
- Nantes Université, CHU Nantes, Department of Biochemistry and INSERM, The Enteric Nervous System in Gut and Brain Disorders, IMAD, F-4400 Nantes, France
| | - Edith Bigot-Corbel
- Nantes Université, CHU Nantes, Laboratoire de biochimie, Hôpital Guillaume et René Laennec, F-4400 Nantes, France
| | - Nelly Renaud Moreau
- Nantes Université, CHU Nantes, Chirurgie Cancérologique, Digestive et Endocrinienne, Institut des Maladies de l'Appareil Digestif, F-44000 Nantes, France
| | - Cécile Caillard
- Nantes Université, CHU Nantes, Chirurgie Cancérologique, Digestive et Endocrinienne, Institut des Maladies de l'Appareil Digestif, F-44000 Nantes, France
| | - Eric Mirallié
- Nantes Université, CHU Nantes, Chirurgie Cancérologique, Digestive et Endocrinienne, Institut des Maladies de l'Appareil Digestif, F-44000 Nantes, France
| | - Bertrand Cariou
- Nantes Université, CHU Nantes, CNRS, INSERM, l'institut du thorax, F-44000 Nantes, France
| | - Claire Blanchard
- Nantes Université, CHU Nantes, Chirurgie Cancérologique, Digestive et Endocrinienne, Institut des Maladies de l'Appareil Digestif, F-44000 Nantes, France
- Nantes Université, CHU Nantes, CNRS, INSERM, l'institut du thorax, F-44000 Nantes, France
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Liang G, Kaur MN, Wade CG, Edelen MO, Bates DW, Pusic AL, Liu JB. Patient-reported outcome measures for primary hyperparathyroidism: a systematic review of measurement properties. Health Qual Life Outcomes 2024; 22:31. [PMID: 38566079 PMCID: PMC10988805 DOI: 10.1186/s12955-024-02248-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 03/25/2024] [Indexed: 04/04/2024] Open
Abstract
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.
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Affiliation(s)
- George Liang
- Patient-Reported Outcomes, Value, and Experience (PROVE) Center, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Manraj N Kaur
- Patient-Reported Outcomes, Value, and Experience (PROVE) Center, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | | | - Maria O Edelen
- Patient-Reported Outcomes, Value, and Experience (PROVE) Center, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - David W Bates
- Harvard Medical School, Boston, MA, USA
- Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
- Clinical and Quality Analysis, Information Systems, Mass General Brigham, Boston, MA, USA
| | - Andrea L Pusic
- Patient-Reported Outcomes, Value, and Experience (PROVE) Center, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Division of Plastic Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Jason B Liu
- Patient-Reported Outcomes, Value, and Experience (PROVE) Center, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
- Division of Surgical Oncology, Brigham and Women's Hospital, Boston, MA, USA.
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Krumeich LN, Santos A, Fraker DL, Kelz RR, Wachtel H. Modern Trends for Primary Hyperparathyroidism: Intervening on Less Biochemically Severe Disease. J Surg Res 2024; 296:489-496. [PMID: 38325011 DOI: 10.1016/j.jss.2024.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 12/20/2023] [Accepted: 01/07/2024] [Indexed: 02/09/2024]
Abstract
INTRODUCTION Primary hyperparathyroidism (PHPT) is defined by autonomous parathyroid hormone secretion, which has broad physiologic effects. Parathyroidectomy is the only cure and is recommended for patients demonstrating symptomatic disease and/or end organ damage. However, there may be a benefit to intervening before the development of complications. We sought to characterize institutional trends in the biochemical and symptomatic presentation of PHPT and the associated cure and complication rates. METHODS We performed a retrospective cohort study of 1087 patients undergoing parathyroidectomy for PHPT, evaluating patients at 2-year intervals between 2002 and 2019. We identified signs and symptoms of PHPT based on the 2016 American Association of Endocrine Surgery Guidelines. Trends were evaluated with Kruskal Wallis, Chi-square tests, and Fisher's exact tests. RESULTS Patients with PHPT are presenting with lower parathyroid hormone (P = 0.0001) and calcium (P = 0.001) in the current era. Parathyroidectomy is more commonly performed for borderline guideline concordant patients with osteopenia (40.2%) and modest calciuria (median 246 mg/dL/24 h). 93.7% are cured, with no difference over time or between groups by guideline concordance. CONCLUSIONS Parathyroidectomy is increasingly performed for patients who demonstrate modest bone and renal dysfunction. Patients experience excellent cure rates and rarely experience postoperative hypocalcemia, suggesting a role for broader surgical indications.
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Affiliation(s)
- Lauren N Krumeich
- Department for Surgery, University of Michigan, Ann Arbor, Michigan; Department for Surgery, University of Michigan Medical School, Ann Arbor, Michigan.
| | - Angelica Santos
- Department for Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Douglas L Fraker
- Department for Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rachel R Kelz
- Department for Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Heather Wachtel
- Department for Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
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Wang X, Shi G, Li G, Tang G. Systematic review of the risk of urolithiasis following parathyroidectomy in patients with primary hyperparathyroidism. Int Urol Nephrol 2024; 56:1217-1225. [PMID: 38038823 DOI: 10.1007/s11255-023-03882-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 11/04/2023] [Indexed: 12/02/2023]
Abstract
OBJECTIVE Parathyroidectomy (PTX) is the conclusive therapy for primary hyperparathyroidism (PHPT), but its effect on the risk of urolithiasis is inconclusive. We comprehensively reviewed the currently available research to investigate the impact of PTX on the likelihood of urolithiasis among individuals suffering PHPT. METHODS Internet-based articles in English language released on Cochrane, PubMed, Scopus, Web of knowledge, and Embase up to September, 2023 were comprehensively reviewed. Each publication in contrast to the incidence, occurrence, or recurrence of urolithiasis after PTX versus medical treatment in PHPT patients was included. The outcome with pooled relative risks (RRs) and corresponding 95% confidence intervals (CIs) was examined employing DerSimonian and Laird's model of random effects. To determine the range of the real effect size of a future study in 95% of all populations, a prediction interval (PI) was also established. RESULTS Finally, ten studies involving 74,190 patients were included. Results from randomized-controlled trials (RCTs) and observational studies (OSs) both revealed that PTX did not substantially lessen the vulnerability of urolithiasis among individuals with PHPT (RCTs: pooled relative risk [RR] 0.42, 95%CI 0.13-1.41, p = 0.163; OSs: pooled RR 1.37, 95%CI 0.96 to 1.97, p = 0.084). The PI (RCT: 0.03 to 5.96; OSs: 0.44-4.20) containing 1.0 suggested the possibility of consistent results in future studies. Subgroup and sensitivity analyses supported the above findings, and no evidence showed publication bias. CONCLUSION Our analysis from the available RCTs or OSs did not give adequate or exact proof that the average effect of PTX lowers the incidence of urolithiasis among PHPT persons based on the random-effects model. Future research shall take into account the common effect of PTX as well as the prerequisites of preventive stone procedures, which will further help us assess the effectiveness of PTX in reducing kidney calculus comorbidity and develop techniques to avoid stone sequelae in these individuals.
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Affiliation(s)
- Xingmu Wang
- Clinical Laboratory Center, Shaoxing People's Hospital, Shaoxing, Zhejiang, People's Republic of China
| | - Ge Shi
- Clinical Laboratory Center, Shaoxing People's Hospital, Shaoxing, Zhejiang, People's Republic of China
| | - Gangfeng Li
- Clinical Laboratory Center, Shaoxing People's Hospital, Shaoxing, Zhejiang, People's Republic of China
| | - Guiliang Tang
- Department of Urology, Shaoxing People's Hospital, No. 568, Zhongxing North Road, Yuecheng District, Shaoxing, 312000, Zhejiang, People's Republic of China.
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Abstract
Primary hyperparathyroidism (PHPT), the most common cause of hypercalcemia, is most often identified in postmenopausal women with hypercalcemia and parathyroid hormone (PTH) levels that are either frankly elevated or inappropriately normal. The clinical presentation of PHPT includes three phenotypes: target organ involvement of the renal and skeletal systems; mild asymptomatic hypercalcemia; and more recently, high PTH levels in the context of persistently normal albumin-corrected and ionized serum calcium values. The factors that determine which of these three clinical presentations is more likely to predominate in a given country include the extent to which biochemical screening is employed, the prevalence of vitamin D deficiency, and whether a medical center or practitioner tends to routinely measure PTH levels in the evaluation of low bone density or frank osteoporosis. When biochemical screening is common, asymptomatic primary hyperparathyroidism is the most likely form of the disease. In countries where vitamin D deficiency is prevalent and biochemical screening is not a feature of the health care system, symptomatic disease with skeletal abnormalities is likely to predominate. Finally, when PTH levels are part of the evaluation for low bone mass, the normocalcemic variant is seen. Guidelines for surgical removal of hyperfunctioning parathyroid tissue apply to all three clinical forms of the disease. If guidelines for surgery are not met, parathyroidectomy can also be an appropriate option if there are no medical contraindications to surgery. In settings where either the serum calcium or bone mineral density is of concern, and surgery is not an option, pharmacological approaches are available and effective. Referencing in this article the most current published articles, we review the different presentations of PHPT, with particular emphasis on recent advances in our understanding of target organ involvement and management.
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Affiliation(s)
- Barbara C Silva
- Division of Endocrinology, Felicio Rocho and Santa Casa Hospital, Belo Horizonte, Brazil
| | - Natalie E Cusano
- Division of Endocrinology, Lenox Hill Hospital, New York, NY, USA
| | - John P Bilezikian
- Division of Endocrinology, College of Physicians and Surgeons, Columbia University, New York, NY, USA.
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Milat F, Ramchand SK, Herath M, Gundara J, Harper S, Farrell S, Girgis CM, Clifton-Bligh R, Schneider HG, De Sousa SMC, Gill AJ, Serpell J, Taubman K, Christie J, Carroll RW, Miller JA, Grossmann M. Primary hyperparathyroidism in adults-(Part I) assessment and medical management: Position statement of the endocrine society of Australia, the Australian & New Zealand endocrine surgeons, and the Australian & New Zealand bone and mineral society. Clin Endocrinol (Oxf) 2024; 100:3-18. [PMID: 34931708 DOI: 10.1111/cen.14659] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 11/30/2021] [Accepted: 12/09/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To formulate clinical consensus recommendations on the presentation, assessment, and management of primary hyperparathyroidism (PHPT) in adults. METHODS Representatives from relevant Australian and New Zealand Societies used a systematic approach for adaptation of guidelines (ADAPTE) to derive an evidence-informed position statement addressing nine key questions. RESULTS PHPT is a biochemical diagnosis. Serum calcium should be measured in patients with suggestive symptoms, reduced bone mineral density or minimal trauma fractures, and in those with renal stones. Other indications are detailed in the manuscript. In patients with hypercalcaemia, intact parathyroid hormone, 25-hydroxy vitamin D, phosphate, and renal function should be measured. In established PHPT, assessment of bone mineral density, vertebral fractures, urinary tract calculi/nephrocalcinosis and quantification of urinary calcium excretion is warranted. Parathyroidectomy is the only definitive treatment and is warranted for all symptomatic patients and should be considered for asymptomatic patients without contraindications to surgery and with >10 years life expectancy. In patients who do not undergo surgery, we recommend annual evaluation for disease progression. Where the diagnosis is not clear or the risk-benefit ratio is not obvious, multidisciplinary discussion and formulation of a consensus management plan is appropriate. Genetic testing for familial hyperparathyroidism is recommended in selected patients. CONCLUSIONS These clinical consensus recommendations were developed to provide clinicians with contemporary guidance on the assessment and management of PHPT in adults. It is anticipated that improved health outcomes for individuals and the population will be achieved at a decreased cost to the community.
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Affiliation(s)
- Frances Milat
- Department of Endocrinology, Monash Health, Victoria, Australia
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Victoria, Australia
- Department of Medicine, Nursing & Health Sciences, Monash University, Victoria, Australia
| | - Sabashini K Ramchand
- Department of Endocrinology, Austin Health, Victoria, Australia
- Department of Medicine, Austin Health, University of Melbourne, Victoria, Australia
| | - Madhuni Herath
- Department of Endocrinology, Monash Health, Victoria, Australia
- Centre for Endocrinology and Metabolism, Hudson Institute of Medical Research, Victoria, Australia
- Department of Medicine, Nursing & Health Sciences, Monash University, Victoria, Australia
| | - Justin Gundara
- Department of Surgery, Redland Hospital, Metro South and Faculty of Medicine, University of Queensland, Australia
- Department of Surgery, Logan Hospital, Metro South and School of Medicine and Dentistry, Griffith University, Queensland, Australia
| | - Simon Harper
- Department of General Surgery, Wellington Regional Hospital, Wellington, New Zealand
- Department of Surgery, University of Otago, Wellington, New Zealand
| | - Stephen Farrell
- Department of Surgery, St Vincent's Hospital, Victoria, Australia
- Department of Surgery, Austin Hospital, Victoria, Australia
- Department of Surgery, Royal Children's Hospital, Victoria, Australia
- Department of Surgery, University of Melbourne, Victoria, Australia
| | - Christian M Girgis
- Department of Diabetes and Endocrinology, Westmead Hospital, New South Wales, Australia
- Department of Endocrinology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- Faculty of Medicine and Health, University of Sydney, New South Wales, Australia
| | - Roderick Clifton-Bligh
- Department of Endocrinology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- Faculty of Medicine and Health, University of Sydney, New South Wales, Australia
- Kolling Institute, University of Sydney, New South Wales, Australia
| | - Hans G Schneider
- Clinical Biochemistry Unit, Alfred Pathology Service, Alfred Health, Victoria, Australia
- Department of Endocrinology, Alfred Hospital, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Victoria, Australia
| | - Sunita M C De Sousa
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, Australia
- South Australian Adult Genetics Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Adelaide Medical School, Faculty of Health and Medical Sciences, University of Adelaide, South Australia, Australia
| | - Anthony J Gill
- Faculty of Medicine and Health, University of Sydney, New South Wales, Australia
- Cancer Diagnosis and Pathology Group, Kolling Institute of Medical Research, Royal North Shore Hospital, St Leonards, New South Wales, Australia
- NSW Health Pathology, Department of Anatomical Pathology, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Jonathan Serpell
- Department of General Surgery, The Alfred Hospital, Victoria, Australia
- Monash University Department of Endocrine Surgery, Victoria, Australia
| | - Kim Taubman
- Department of Medical Imaging, St Vincent's Hospital, Victoria, Australia
- Department of Endocrinology, St Vincent's Hospital, Victoria, Australia
- Department of Medicine, University of Melbourne, Victoria, Australia
| | | | - Richard W Carroll
- Endocrine, Diabetes, and Research Centre, Wellington Regional Hospital, Wellington, New Zealand
| | - Julie A Miller
- Department of Surgery, University of Melbourne, Victoria, Australia
- Department of Surgery, The Royal Melbourne Hospital, Victoria, Australia
- Epworth Hospital Network, Victoria, Australia
| | - Mathis Grossmann
- Department of Endocrinology, Austin Health, Victoria, Australia
- Department of Medicine, Austin Health, University of Melbourne, Victoria, Australia
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Broekhuis JM, Cote MP, Collins RA, Gomez-Mayorga JL, Chaves N, James BC. Association of patient-practitioner sex concordance with specialist referral in primary hyperparathyroidism. Surgery 2024; 175:19-24. [PMID: 37925258 DOI: 10.1016/j.surg.2023.08.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 07/14/2023] [Accepted: 08/17/2023] [Indexed: 11/06/2023]
Abstract
BACKGROUND Prior research has demonstrated barriers to the workup and management of primary hyperparathyroidism. As recent data have suggested that patient and practitioner sex concordance is associated with lower surgical complications, we sought to evaluate the effect of sex concordance on referral for primary hyperparathyroidism. METHODS We queried an institutional database for patients with first-incident hypercalcemia and subsequent biochemical evidence of primary hyperparathyroidism between 2010 and 2018. Primary care practitioner and endocrinologist sex, laboratory values, and complications of primary hyperparathyroidism were collected. Sex concordance (male patient/male practitioner or female patient/female practitioner) was evaluated as a binary predictor of specialist evaluation using logistic regression and Cox proportional hazards modeling. RESULTS Among 1,100 patients, mean age was 62.5 (standard deviation 13.6), and 74% were female sex. Primary care practitioner sex was 52% female, and 63% of patients had sex concordance with their primary care practitioner. Endocrinologist sex was 59% female, and 45% of patients had sex concordance with their endocrinologist. Patients with sex concordance with their primary care practitioner (70 vs 80%, P = .001) and endocrinologist (71 vs 82%, P < .001) were less likely to be female sex compared to those with discordance. After adjusting for demographics and clinical covariates, those patients with primary care practitioner sex concordance had 32% higher odds of endocrinologist evaluation (odds ratio 1.32, 95% confidence interval 1.003-1.734, P = .047). Similarly, those patients with endocrinologist sex concordance had a 48% higher rate of surgeon evaluation (hazard ratio 1.48, confidence interval 1.1-2.0, P = .009). Stratified analysis revealed that sex discordance reduced the rate of surgeon referral for female patients (hazard ratio 0.63, confidence interval 0.44-0.89, P = .008) but not male patients (hazard ratio 1.06, CI 0.58-1.93, P = .861). CONCLUSION Sex discordance between patients and their health care professionals may contribute to under-referral in primary hyperparathyroidism. Further evaluation of the effect of patient and practitioner identities on communication and decision-making in surgery are needed.
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Affiliation(s)
- Jordan M Broekhuis
- Harvard Medical School, Boston, MA; Division of Surgical Oncology, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Maria P Cote
- Division of Surgical Oncology, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Reagan A Collins
- Division of Surgical Oncology, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA; Division of Surgical Oncology, Department of Surgery, Massachusetts General Hospital, Boston, MA; Institute for Technology Assessment, Massachusetts General Hospital, Boston, MA
| | - Jorge L Gomez-Mayorga
- Division of Surgical Oncology, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Natalia Chaves
- Harvard Medical School, Boston, MA; Division of Surgical Oncology, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Benjamin C James
- Harvard Medical School, Boston, MA; Division of Surgical Oncology, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA.
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Febrero B, Ruiz-Manzanera JJ, Ros-Madrid I, Hernández-Martínez AM, Rodríguez JM. The Influence of Hyperparathyroidism Patient Profile on Quality of Life After Parathyroidectomy. World J Surg 2023; 47:2197-2205. [PMID: 37210692 DOI: 10.1007/s00268-023-07066-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2023] [Indexed: 05/22/2023]
Abstract
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.
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Affiliation(s)
- Beatriz Febrero
- Department of Endocrine Surgery, General Surgery Service, Virgen de La Arrixaca University Hospital, Murcia, Spain
- Biomedical Research Institute of Murcia (IMIB-Arrixaca), Murcia, Spain
| | - Juan José Ruiz-Manzanera
- Department of Endocrine Surgery, General Surgery Service, Virgen de La Arrixaca University Hospital, Murcia, Spain.
- Biomedical Research Institute of Murcia (IMIB-Arrixaca), Murcia, Spain.
| | - Inmaculada Ros-Madrid
- Biomedical Research Institute of Murcia (IMIB-Arrixaca), Murcia, Spain
- Department of Endocrinology and Nutrition, Virgen de La Arrixaca University Hospital, Murcia, Spain
| | - Antonio-Miguel Hernández-Martínez
- Biomedical Research Institute of Murcia (IMIB-Arrixaca), Murcia, Spain
- Department of Endocrinology and Nutrition, Virgen de La Arrixaca University Hospital, Murcia, Spain
| | - José M Rodríguez
- Department of Endocrine Surgery, General Surgery Service, Virgen de La Arrixaca University Hospital, Murcia, Spain
- Biomedical Research Institute of Murcia (IMIB-Arrixaca), Murcia, Spain
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11
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Bartz-Kurycki MA, Dream S, Yen TW, Doffek K, Shaker J, Evans DB, Wang TS. Older Patients With Asymptomatic Primary Hyperparathyroidism: Should Criteria for Surgery Be Expanded? J Endocr Soc 2023; 7:bvad098. [PMID: 37873505 PMCID: PMC10590644 DOI: 10.1210/jendso/bvad098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Indexed: 10/25/2023] Open
Abstract
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.
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Affiliation(s)
| | - Sophie Dream
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Tina W Yen
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Kara Doffek
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Joseph Shaker
- Division of Endocrinology, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Douglas B Evans
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Tracy S Wang
- Division of Surgical Oncology, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI 53226, USA
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12
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Zhu CY, Zhou HX, Tseng CH, Fackelmayer OJ, Haigh PI, Adams AL, Yeh MW. Long-term effects of primary hyperparathyroidism and parathyroidectomy on kidney function. Eur J Endocrinol 2023; 189:115-122. [PMID: 37449311 DOI: 10.1093/ejendo/lvad081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 04/10/2023] [Accepted: 06/23/2023] [Indexed: 07/18/2023]
Abstract
IMPORTANCE Limited evidence supports kidney dysfunction as an indication for parathyroidectomy in asymptomatic primary hyperparathyroidism (PHPT). OBJECTIVE To investigate the natural history of kidney function in PHPT and whether parathyroidectomy alters renal outcomes. DESIGN Matched control study. SETTING A vertically integrated health care system serving 4.6 million patients in Southern California. PARTICIPANTS 6058 subjects with PHPT and 16 388 matched controls, studied from 2000 to 2016. EXPOSURES Biochemically confirmed PHPT with varying serum calcium levels. MAIN OUTCOMES Estimated glomerular filtration rate (eGFR) trajectories were compared over 10 years, with cases subdivided by severity of hypercalcemia: serum calcium 2.62-2.74 mmol/L (10.5-11 mg/dL), 2.75-2.87 (11.1-11.5), 2.88-2.99 (11.6-12), and >2.99 (>12). Interrupted time series analysis was conducted among propensity-score-matched PHPT patients with and without parathyroidectomy to compare eGFR trajectories postoperatively. RESULTS Modest rates of eGFR decline were observed in PHPT patients with serum calcium 2.62-2.74 mmol/L (−1.0 mL/min/1.73 m2/year) and 2.75-2.87 mmol/L (−1.1 mL/min/1.73 m2/year), comprising 56% and 28% of cases, respectively. Compared with the control rate of −1.0 mL/min/1.73 m2/year, accelerated rates of eGFR decline were observed in patients with serum calcium 2.88-2.99 mmol/L (−1.5 mL/min/1.73 m2/year, P < .001) and >2.99 mmol/L (−2.1 mL/min/1.73 m2/year, P < .001), comprising 9% and 7% of cases, respectively. In the propensity score–matched population, patients with serum calcium >2.87 mmol/L exhibited mitigation of eGFR decline after parathyroidectomy (−2.0 [95% CI: −2.6 to −1.5] to −0.9 [95% CI: −1.5 to 0.4] mL/min/1.73 m2/year). CONCLUSIONS AND RELEVANCE Compared with matched controls, accelerated eGFR decline was observed in the minority of PHPT patients with serum calcium >2.87 mmol/L (11.5 mg/dL). Parathyroidectomy was associated with mitigation of eGFR decline in patients with serum calcium >2.87 mmol/L.
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Affiliation(s)
- Catherine Y Zhu
- Section of Endocrine Surgery, Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA 90095, United States
| | - Hui X Zhou
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
- Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA, United States
| | - Chi-Hong Tseng
- Department of Medicine, UCLA David Geffen School of Medicine, Los Angeles, CA, United States
| | - Oliver J Fackelmayer
- Section of Endocrine Surgery, Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA 90095, United States
| | - Philip I Haigh
- Department of Surgery, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, United States
| | - Annette L Adams
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA, United States
| | - Michael W Yeh
- Section of Endocrine Surgery, Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA 90095, United States
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13
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Koumakis E, Gauthé M, Martinino A, Sindayigaya R, Delbot T, Wartski M, Clerc J, Roux C, Borderie D, Cochand-Priollet B, Cormier C, Gaujoux S. FCH-PET/CT in Primary Hyperparathyroidism With Discordant/Negative MIBI Scintigraphy and Ultrasonography. J Clin Endocrinol Metab 2023; 108:1958-1967. [PMID: 36750257 DOI: 10.1210/clinem/dgad073] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 01/31/2023] [Accepted: 02/02/2023] [Indexed: 02/09/2023]
Abstract
CONTEXT The contribution of [18F]F-fluorocholine (FCH)-positron emission tomography (PET)/computed tomography (CT) in normocalcemic primary hyperparathyroidism (nPHPT) remains unknown. OBJECTIVE To evaluate the sensitivity and specificity of FCH-PET/CT in a cohort of osteoporotic patients with nPHPT and discordant or negative [99mTc]Tc-sestamibi scintigraphy and ultrasonography who all underwent parathyroidectomy (PTX). DESIGN Longitudinal retrospective cohort study in patients referred for osteoporosis with mild biological primary hyperparathyroidism. SETTING Tertiary referral center with expertise in bone metabolism and surgical management of hyperparathyroidism. PATIENTS Among 109 patients with PHPT analyzed, 3 groups were individualized according to total serum calcium (tCa) and ionized calcium (iCa): 32 patients with hypercalcemia (HtCa group), 39 patients with normal tCa and elevated iCa (NtCa group), and 38 patients with both normal tCa and iCa (NiCa). All patients had biochemical follow-up confirming or not the success of PTX. MAIN OUTCOME MEASURES To evaluate the performance of FCH-PET/CT in terms of sensitivity and specificity, and to compare with first-line imaging procedures in the setting of nPHPT. RESULTS The sensitivity of FCH-PET/CT was 67% in the hypercalcemic group, 48% in the NtCa group (P = .05 vs HtCa), and 33% in the NiCa group (P = .004 vs HtCa). Specificity ranged from 97% to 99%. FCH-PET/CT was positive in 64.3% of patients with negative conventional imaging, with biochemical resolution after PTX in 77.8% of patients. Triple negative imaging was observed in 20 patients, with PHPT resolution in 85% of these patients. CONCLUSION This study highlights the contribution of FCH-PET/CT in a well-phenotyped cohort of normocalcemic patients with discordant or negative findings in [99mTc]Tc-sestamibi scintigraphy and ultrasonography. However, negative imaging in nPHPT does not rule out the possibility of surgical cure by an experienced surgeon.
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Affiliation(s)
- Eugenie Koumakis
- Department of Rheumatology, Cochin Hospital, APHP, Paris 75014, France
- Department of Rhumatology, Centre De Référence des Maladies Rares du Calcium et du Phosphate, Paris 75014, France
| | - Mathieu Gauthé
- Department of Nuclear Medicine, Scintep, Institut Daniel Hollard, 38000 Grenoble, France
| | - Alessandro Martinino
- Department of Hepatobiliary, and Endocrine Surgery, Cochin Hospital, AP-HP, Paris, France
| | - Rémy Sindayigaya
- Department of Hepatobiliary, and Endocrine Surgery, Cochin Hospital, AP-HP, Paris, France
| | - Thierry Delbot
- Department of Nuclear Medicine, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Myriam Wartski
- Department of Nuclear Medicine, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Jérôme Clerc
- Department of Nuclear Medicine, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Paris, France
- Department of Nuclear Medicine, Université de Paris, Paris, France
| | - Christian Roux
- Department of Rheumatology, Cochin Hospital, APHP, Paris 75014, France
- Department of Rhumatology, Centre De Référence des Maladies Rares du Calcium et du Phosphate, Paris 75014, France
| | - Didier Borderie
- Department of Automated Biological Diagnostic, Cochin Hospital, APHP, Paris, France
| | - Beatrix Cochand-Priollet
- Department of Pathology, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France
| | - Catherine Cormier
- Department of Rheumatology, Cochin Hospital, APHP, Paris 75014, France
- Department of Rhumatology, Centre De Référence des Maladies Rares du Calcium et du Phosphate, Paris 75014, France
| | - Sébastien Gaujoux
- Department of General, Visceral, and Endocrine Surgery, Pitié Salpêtrière Hospital, AP-HP, Paris, France
- Department of Hepato-Biliary and Pancreatic Surgery and Liver Transplantation, AP-HP Pitié-Salpêtrière Hospital, Paris
- Department of Hepato-Biliary And Pancreatic Surgery and Liver Transplantation, Sorbonne Université, Paris, France
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Corredor-Orlandelli D, Valenzuela-Vallejo L, Aguirre-Ruiz JF, Valenzuela Rincon A. Ectopic parathyroid adenoma causing hyperparathyroidism-induced psychosis: A case report. SAGE Open Med Case Rep 2023; 11:2050313X231180752. [PMID: 37434899 PMCID: PMC10331202 DOI: 10.1177/2050313x231180752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Accepted: 05/22/2023] [Indexed: 07/13/2023] Open
Abstract
Primary hyperparathyroidism is a disease with multisystemic and heterogeneous manifestations, characterized by underlying high parathormone concentrations. Despite neuropsychiatric involvement being one of the manifestations, psychosis is rare. This is the case of a 68-year-old female with a 10-day clinical course of anorexia, mutism, dysphagia, constipation, and weight loss. The patient had disorganized speech associated with paranoid delusions. Prior to this visit, the patient was recently diagnosed with a mixed anxiety-depressive disorder. For this reason, treatment with antidepressants in combination with atypical antipsychotics was administered without a satisfactory response. Neuroimaging, infectious panel, and toxicology screening showed no abnormal findings. Hypercalcemia secondary to a retropharyngeal ectopic parathyroid adenoma was the causative etiology of her primary hyperparathyroidism, and hypercalcemia treatment resolved the psychotic episode. We highlight the importance of recognizing psychosis as a possible initial presentation of hyperparathyroidism and hypercalcemia. Ruling out organic etiologies prior to diagnosing a primary cause of psychosis is crucial, as their treatment can reverse the psychotic symptoms.
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Affiliation(s)
- David Corredor-Orlandelli
- School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia
- Fundación Cardioinfantil—LaCardio, Bogotá, Colombia
| | - Laura Valenzuela-Vallejo
- School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia
- Fundación Cardioinfantil—LaCardio, Bogotá, Colombia
| | - Juan Felipe Aguirre-Ruiz
- Fundación Cardioinfantil—LaCardio, Bogotá, Colombia
- Internal Medicine Department, School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia
| | - Alex Valenzuela Rincon
- School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia
- Departments of Endocrinology and Internal Medicine, Fundación Cardioinfantil—LaCardio, Bogotá, Colombia
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15
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Cironi KA, Issa PP, Albuck AL, McCarthy C, Rezvani L, Hussein M, Luo X, Shama M, Toraih E, Kandil E. Comparison of Medical Management versus Parathyroidectomy in Patients with Mild Primary Hyperparathyroidism: A Meta-Analysis. Cancers (Basel) 2023; 15:3085. [PMID: 37370696 DOI: 10.3390/cancers15123085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 06/06/2023] [Accepted: 06/06/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Parathyroidectomy is the definitive cure for patients with primary hyperparathyroidism (pHPT) and has an annual prevalence of 0.2-1% in the United States. Some patients with mild disease are medically managed effectively using calcium-lowering medications and drugs against complications such as osteoporosis; however, many maintain a persistently high calcium level that negatively impacts their skeletal, renal, and psychogenic systems over the long term. This meta-analysis aims to compare the outcomes of medical management versus parathyroidectomy in patients with mild pHPT. STUDY DESIGN This meta-analysis was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using PubMed, Embase, and Web of Science by two teams of investigators. Analysis was run using R packages. RESULTS A total of 12 publications including seven randomized control, two prospective, and three retrospective trials with a total of 1346 patients were included for analysis. The average follow-up for all patients was 41 ± 23.8 months. Demographics, pre-treatment calcium, PTH, and bone mineral density (BMD) were similar between the medical (N = 632) and surgical (N = 714) cohorts. Post-treatment calcium and PTH levels were significantly higher in the medical cohort (10.46 vs. 9.39, p < 0.01), (106.14 vs. 43.25, p = 0.001), respectively. Interestingly, the post-treatment PTH in the medical cohort increased when compared to pre-treatment (83.84 to 106.14). Patients in the medical cohort had lower BMD in lumbar (0.48 g/cm2; OR = 0.42, 95% CI = 0.21, 0.83), femoral (0.48; OR = 0.42, 95% CI = 0.29, 0.61), and hip (0.61; OR = 0.33, 95% CI = 0.13, 0.85). Incidences of fracture, nephrolithiasis, cardiovascular death, or overall mortality were not significantly different between the cohorts. CONCLUSIONS The present study is the most comprehensive meta-analysis on mild pHPT to date. Our findings reflect that parathyroidectomy is the superior option in the treatment of mild pHPT patients as opposed to medical management.
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Affiliation(s)
| | - Peter P Issa
- School of Medicine, Louisiana State University, New Orleans, LA 70112, USA
| | - Aaron L Albuck
- School of Medicine, Tulane University, New Orleans, LA 70112, USA
| | | | - Leely Rezvani
- School of Medicine, Tulane University, New Orleans, LA 70112, USA
| | - Mohammad Hussein
- School of Medicine, Tulane University, New Orleans, LA 70112, USA
| | - Xinyi Luo
- School of Medicine, Tulane University, New Orleans, LA 70112, USA
| | - Mohamed Shama
- School of Medicine, Tulane University, New Orleans, LA 70112, USA
| | - Eman Toraih
- School of Medicine, Tulane University, New Orleans, LA 70112, USA
- Genetics Unit, Department of Histology and Cell Biology, Faculty of Medicine, Suez Canal University, Ismailia 41511, Egypt
| | - Emad Kandil
- School of Medicine, Tulane University, New Orleans, LA 70112, USA
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16
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Seib CD, Ganesan C, Furst A, Pao AC, Chertow GM, Leppert JT, Suh I, Montez-Rath ME, Harris AHS, Trickey AW, Kebebew E, Kurella Tamura M. Estimated Effect of Parathyroidectomy on Long-Term Kidney Function in Adults With Primary Hyperparathyroidism. Ann Intern Med 2023; 176:624-631. [PMID: 37037034 PMCID: PMC10866201 DOI: 10.7326/m22-2222] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/12/2023] Open
Abstract
BACKGROUND Multidisciplinary guidelines recommend parathyroidectomy to slow the progression of chronic kidney disease in patients with primary hyperparathyroidism (PHPT) and an estimated glomerular filtration rate (eGFR) less than 60 mL/min/1.73 m2. Limited data address the effect of parathyroidectomy on long-term kidney function. OBJECTIVE To compare the incidence of a sustained decline in eGFR of at least 50% among patients with PHPT treated with parathyroidectomy versus nonoperative management. DESIGN Target trial emulation was done using observational data from adults with PHPT, using an extended Cox model with time-varying inverse probability weighting. SETTING Veterans Health Administration. PATIENTS Patients with a new biochemical diagnosis of PHPT in 2000 to 2019. MEASUREMENTS Sustained decline of at least 50% from pretreatment eGFR. RESULTS Among 43 697 patients with PHPT (mean age, 66.8 years), 2928 (6.7%) had a decline of at least 50% in eGFR over a median follow-up of 4.9 years. The weighted cumulative incidence of eGFR decline was 5.1% at 5 years and 10.8% at 10 years in patients managed with parathyroidectomy, compared with 5.1% and 12.0%, respectively, in those managed nonoperatively. The adjusted hazard of eGFR decline did not differ between parathyroidectomy and nonoperative management (hazard ratio [HR], 0.98 [95% CI, 0.82 to 1.16]). Subgroup analyses found no heterogeneity of treatment effect based on pretreatment kidney function. Parathyroidectomy was associated with a reduced hazard of the primary outcome among patients younger than 60 years (HR, 0.75 [CI, 0.59 to 0.93]) that was not evident among those aged 60 years or older (HR, 1.08 [CI, 0.87 to 1.34]). LIMITATION Analyses were done in a predominantly male cohort using observational data. CONCLUSION Parathyroidectomy had no effect on long-term kidney function in older adults with PHPT. Potential benefits related to kidney function should not be the primary consideration for PHPT treatment decisions. PRIMARY FUNDING SOURCE National Institute on Aging.
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Affiliation(s)
- Carolyn D Seib
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine; Division of General Surgery, Palo Alto Veterans Affairs Health Care System; and Geriatric Research, Education and Clinical Center, Veterans Affairs Palo Alto, Palo Alto, California (C.D.S.)
| | - Calyani Ganesan
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California (C.G., M.E.M.)
| | - Adam Furst
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine, Palo Alto, California (A.F., A.W.T.)
| | - Alan C Pao
- Division of Nephrology, Department of Medicine, and Department of Urology, Stanford University School of Medicine, Palo Alto, California (A.C.P., J.T.L.)
| | - Glenn M Chertow
- Division of Nephrology, Department of Medicine, and Department of Epidemiology and Population Health, Stanford University School of Medicine, Palo Alto, California (G.M.C.)
| | - John T Leppert
- Division of Nephrology, Department of Medicine, and Department of Urology, Stanford University School of Medicine, Palo Alto, California (A.C.P., J.T.L.)
| | - Insoo Suh
- Department of Surgery, New York University Grossman School of Medicine, New York, New York (I.S.)
| | - Maria E Montez-Rath
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, Palo Alto, California (C.G., M.E.M.)
| | - Alex H S Harris
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine, and Center for Innovation to Implementation, Veterans Affairs Palo Alto, Palo Alto, California (A.H.S.H.)
| | - Amber W Trickey
- Stanford-Surgery Policy Improvement Research and Education Center (S-SPIRE), Department of Surgery, Stanford University School of Medicine, Palo Alto, California (A.F., A.W.T.)
| | - Electron Kebebew
- Department of Surgery, Stanford University School of Medicine, Palo Alto, California (E.K.)
| | - Manjula Kurella Tamura
- Division of Nephrology, Department of Medicine, Stanford University School of Medicine, and Geriatric Research, Education and Clinical Center, Veterans Affairs Palo Alto, Palo Alto, California (M.K.T.)
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17
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Pappachan JM, Lahart IM, Viswanath AK, Borumandi F, Sodi R, Metzendorf MI, Bongaerts B. Parathyroidectomy for adults with primary hyperparathyroidism. Cochrane Database Syst Rev 2023; 3:CD013035. [PMID: 36883976 PMCID: PMC9995748 DOI: 10.1002/14651858.cd013035.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
BACKGROUND Primary hyperparathyroidism (PHPT), a disorder in which the parathyroid glands produce excessive amounts of parathyroid hormone, is most common in older adults and postmenopausal women. While most people with PHPT are asymptomatic at diagnosis, symptomatic disease can lead to hypercalcaemia, osteoporosis, renal stones, cardiovascular abnormalities and reduced quality of life. Surgical removal of abnormal parathyroid tissue (parathyroidectomy) is the only established treatment for adults with symptomatic PHPT to prevent exacerbation of symptoms and to be cured of PHPT. However, the benefits and risks of parathyroidectomy compared to simple observation or medical therapy for asymptomatic and mild PHPT are not well established. OBJECTIVES To evaluate the benefits and harms of parathyroidectomy in adults with PHPT compared to simple observation or medical therapy. SEARCH METHODS We searched CENTRAL, MEDLINE, LILACS, ClinicalTrials.gov and WHO ICTRP from their date of inception until 26 November 2021. We applied no language restrictions. SELECTION CRITERIA We included randomised controlled trials (RCTs) comparing parathyroidectomy with simple observation or medical therapy for the treatment of adults with PHPT. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were 1. cure of PHPT, 2. morbidity related to PHPT and 3. serious adverse events. Our secondary outcomes were 1. all-cause mortality, 2. health-related quality of life and 3. hospitalisation for hypercalcaemia, acute renal impairment or pancreatitis. We used GRADE to assess the certainty of the evidence for each outcome. MAIN RESULTS We identified eight eligible RCTs that included 447 adults with (mostly asymptomatic) PHPT; 223 participants were randomised to parathyroidectomy. Follow-up duration varied from six months to 24 months. Of the 223 participants (37 men) randomised to surgery, 164 were included in the analyses, of whom 163 were cured at six to 24 months (overall cure rate 99%). Parathyroidectomy compared to observation probably results in a large increase in cure rate at six to 24 months follow-up: 163/164 participants (99.4%) in the parathyroidectomy group and 0/169 participants in the observation or medical therapy group were cured of their PHPT (8 studies, 333 participants; moderate certainty). No studies explicitly reported intervention effects on morbidities related to PHPT, such as osteoporosis, osteopenia, kidney dysfunction, urolithiasis, cognitive dysfunction or cardiovascular disease, although some studies reported surrogate outcomes for osteoporosis and cardiovascular disease. A post-hoc analysis revealed that parathyroidectomy, compared to observation or medical therapy, may have little or no effect after one to two years on bone mineral density (BMD) at the lumbar spine (mean difference (MD) 0.03 g/cm2,95% CI -0.05 to 0.12; 5 studies, 287 participants; very low certainty). Similarly, compared to observation, parathyroidectomy may have little or no effect on femoral neck BMD after one to two years (MD -0.01 g/cm2, 95% CI -0.13 to 0.11; 3 studies, 216 participants; very low certainty). However, the evidence is very uncertain for both BMD outcomes. Furthermore, the evidence is very uncertain about the effect of parathyroidectomy on improving left ventricular ejection fraction (MD -2.38%, 95% CI -4.77 to 0.01; 3 studies, 121 participants; very low certainty). Four studies reported serious adverse events. Three of these reported zero events in both the intervention and control groups; consequently, we were unable to include data from these three studies in the pooled analysis. The evidence suggests that parathyroidectomy compared to observation may have little or no effect on serious adverse events (RR 3.35, 95% CI 0.14 to 78.60; 4 studies, 168 participants; low certainty). Only two studies reported all-cause mortality. One study could not be included in the pooled analysis as zero events were observed in both the intervention and control groups. Parathyroidectomy compared to observation may have little or no effect on all-cause mortality, but the evidence is very uncertain (RR 2.11, 95% CI 0.20 to 22.60; 2 studies, 133 participants; very low certainty). Three studies measured health-related quality of life using the 36-Item Short Form Health Survey (SF-36) and reported inconsistent differences in scores for different domains of the questionnaire between parathyroidectomy and observation. Six studies reported hospitalisations for the correction of hypercalcaemia. Two studies reported zero events in both the intervention and control groups and could not be included in the pooled analysis. Parathyroidectomy, compared to observation, may have little or no effect on hospitalisation for hypercalcaemia (RR 0.91, 95% CI 0.20 to 4.25; 6 studies, 287 participants; low certainty). There were no reported hospitalisations for renal impairment or pancreatitis. AUTHORS' CONCLUSIONS In accordance with the literature, our review findings suggest that parathyroidectomy, compared to simple observation or medical (etidronate) therapy, probably results in a large increase in cure rates of PHPT (with normalisation of serum calcium and parathyroid hormone levels to laboratory reference values). Parathyroidectomy, compared with observation, may have little or no effect on serious adverse events or hospitalisation for hypercalcaemia, and the evidence is very uncertain about the effect of parathyroidectomy on other short-term outcomes, such as BMD, all-cause mortality and quality of life. The high uncertainty of evidence limits the applicability of our findings to clinical practice; indeed, this systematic review provides no new insights with regard to treatment decisions for people with (asymptomatic) PHPT. In addition, the methodological limitations of the included studies, and the characteristics of the study populations (mainly comprising white women with asymptomatic PHPT), warrant caution when extrapolating the results to other populations with PHPT. Large-scale multi-national, multi-ethnic and long-term RCTs are needed to explore the potential short- and long-term benefits of parathyroidectomy compared to non-surgical treatment options with regard to osteoporosis or osteopenia, urolithiasis, hospitalisation for acute kidney injury, cardiovascular disease and quality of life.
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Affiliation(s)
- Joseph M Pappachan
- Department of Endocrinology & Metabolism, Lancashire Teaching Hospitals NHS Trust, Preston, UK
- Faculty of Science, Manchester Metropolitan University, Manchester, UK
- University of Manchester Medical School, Manchester, UK
| | - Ian M Lahart
- Faculty of Education, Health and Wellbeing, University of Wolverhampton, Walsall, UK
| | | | - Farzad Borumandi
- Department of Oral and Maxillofacial Surgery, University Hospitals Sussex NHS Foundation Trust, St. Richard's Hospital, Chichester and Worthing Hospital, Worthing, UK
| | - Ravinder Sodi
- Biochemistry, Pathology Department, Broomfield Hospital, Mid & South Essex NHS Foundation Trust, Chelmsford, UK
| | - Maria-Inti Metzendorf
- Institute of General Practice, Medical Faculty of the Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Brenda Bongaerts
- Institute of General Practice, Medical Faculty of the Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
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18
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Lundstam K, Pretorius M, Bollerslev J, Godang K, Fagerland MW, Mollerup C, Fougner SL, Pernow Y, Aas T, Hessman O, Rosén T, Nordenström J, Jansson S, Hellström M, Heck A. Positive Effect of Parathyroidectomy Compared to Observation on BMD in a Randomized Controlled Trial of Mild Primary Hyperparathyroidism. J Bone Miner Res 2023; 38:372-380. [PMID: 36593641 DOI: 10.1002/jbmr.4763] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 11/25/2022] [Accepted: 12/29/2022] [Indexed: 01/04/2023]
Abstract
Mild or asymptomatic disease is now the dominating presentation of primary hyperparathyroidism (PHPT). However, bone involvement with decreased bone mineral density (BMD) and an increased risk of fractures has been demonstrated. Indications for parathyroidectomy (PTX) in mild PHPT have been debated for years. There is a need of long-term randomized studies comparing PTX with observation without intervention (OBS). Here, we present bone health data from the Scandinavian Investigation of Primary Hyperparathyroidism (SIPH), a randomized controlled trial, comparing PTX to OBS. This study included 191 patients (96 OBS/95 PTX), and 129 patients (64 OBS/65 PTX) were followed for 10 years to the end of study (EOS). BMD was measured with dual-energy X-ray absorptiometry (DXA), peripheral fractures were noted, and spine radiographs were obtained for vertebral fracture assessment. There was a significant treatment effect of PTX on BMD compared with OBS for all analyzed compartments, most explicit for the lumbar spine (LS) and femoral neck (FN) (p < 0.001). The mean changes in T-score from baseline to 10 years were from 0.41 for radius 33% (Rad33) to 0.58 for LS greater in the PTX group than in the OBS group. There was a significant decrease in BMD for all compartments in the OBS group, most pronounced for FN, Rad33, and ultradistal radius (UDR) (p < 0.001). Even though there was a significant treatment effect of PTX compared with OBS, there was only a significant increase in BMD over time for LS (p < 0.001). We found no difference between groups in fracture frequency in the 10-year cohort, neither with modified intention-to-treat (mITT) analysis nor per protocol analysis. Because BMD is only a surrogate endpoint of bone health and PTX did not reduce fracture risk, observation could be considered a safe option for many patients with mild PHPT regarding bone health in a 10-year perspective. © 2023 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
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Affiliation(s)
- Karolina Lundstam
- Department of Radiology, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Radiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Mikkel Pretorius
- Section of Specialized Endocrinology, Oslo University Hospital, Oslo, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Jens Bollerslev
- Section of Specialized Endocrinology, Oslo University Hospital, Oslo, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Kristin Godang
- Section of Specialized Endocrinology, Oslo University Hospital, Oslo, Norway
| | - Morten W Fagerland
- Oslo Centre for Biostatistics and Epidemiology, Research Support Services, Oslo University Hospital, Oslo, Norway
| | - Charlotte Mollerup
- Clinic of Breast and Endocrine Surgery, Center HOC, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Stine L Fougner
- Department of Endocrinology, Clinic of Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
| | - Ylva Pernow
- Department of Molecular Medicine and Surgery, Department of Endocrinology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Turid Aas
- Department of Breast and Endocrine Surgery, Haukeland University Hospital, Bergen, Norway
| | - Ola Hessman
- Department of Surgery and Centre for Clinical Research of Uppsala University, Västmanland's Hospital, Västerås, Sweden
| | - Thord Rosén
- Department of Medicine, Section of Endocrinology, Diabetes, and Metabolism, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Jörgen Nordenström
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Svante Jansson
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Mikael Hellström
- Department of Radiology, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Radiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Ansgar Heck
- Section of Specialized Endocrinology, Oslo University Hospital, Oslo, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
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19
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Quality of life, mood and sleep quality in patients with primary hyperparathyroidism. Impact of socio-personal and clinical profile. ANNALES D'ENDOCRINOLOGIE 2023; 84:1-7. [PMID: 36202230 DOI: 10.1016/j.ando.2022.08.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 07/22/2022] [Accepted: 08/23/2022] [Indexed: 11/07/2022]
Abstract
INTRODUCTION Quality of life (QoL) in patients with primary hyperparathyroidism (PHPT) can be negatively affected by the disease, and it is important to identify risk factors. The objectives of the present study were to analyze QoL, mood and quality of sleep in patients with PHPT and to determine the impact of socio-personal and clinical variables. PATIENTS AND METHOD The study group included patients diagnosed with PHPT, and the control group was taken from general population, paired by age and gender. QoL was analyzed using the SF-36 and the PHPQoL questionnaires. The Beck-II and Pittsburg questionnaires were used to assess depression and sleep quality. Socio-personal and clinical variables were analyzed. Statistical analysis on SPSS software v.28 used the Student t-test, ANOVA, Pearson's rank correlation, Mann-Whitney test, Kruskal-Wallis test and Spearman's rank correlation. A multiple linear regression model of the QoL was constructed. RESULTS Sixty-five patients with PHPT were analyzed. A greater negative effect on QoL, mood and sleep quality were observed in patients with PHPT than in controls (P<0.05), with a good correlation between the various questionnaires. Several socio-personal variables had an effect on QoL and mood (P<0.05). QoL in patients with PHPT was affected by educational level, having offspring, and psychological symptoms (P<0.05). CONCLUSIONS Patients with PHPT had poorer QoL and greater neurocognitive disorder than the general population. Socio-personal profile should be taken into account in the clinical assessment of these patients, together with psychological symptoms.
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20
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Abstract
Primary hyperparathyroidism (PHPT) is classically characterized by hypercalcemia with elevated or inappropriately normal parathyroid hormone (PTH) levels. Elevated PTH levels in the presence of normal calcium levels are not infrequently found during the evaluation of metabolic bone disorders or kidney stone disease. This can be caused by secondary hyperparathyroidism (SHPT) or normocalcemic primary hyperparathyroidism (NPHPT). NPHPT is due to autonomous parathyroid function whereas SHPT is caused by a physiologic stimulation to PTH secretion. Many medical conditions and medications can contribute to SHPT, and differentiation between SHPT and NPHPT may be difficult. Cases are presented to illustrate examples. In this paper, we review the distinction between SHPT and NPHPT as well as end organ effects of NPHPT and outcomes of surgery in NPHPT. We suggest that the diagnosis of NPHPT be made only after careful exclusion of causes of SHPT and consideration of medications that can increase PTH secretion. Further, we advise a conservative approach to surgery in NPHPT.
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Affiliation(s)
- Joseph L Shaker
- Correspondence: Joseph L. Shaker, MD, W129N7155 Northfield Dr, Menomonee Falls, WI 53051, USA.
| | - Robert A Wermers
- Department of Medicine and Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, USA
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21
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Frey S, Wargny M, Blanchard C, Caillard C, Hadjadj S, Cariou B, Figueres L, Mirallié E. Effects of parathyroidectomy on kidney function in patients with primary hyperparathyroidism: Results of a prospective study. Surgery 2023; 173:146-153. [PMID: 36167701 DOI: 10.1016/j.surg.2022.05.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 05/16/2022] [Accepted: 05/20/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Altered glomerular filtration rate is a controversial indication for parathyroidectomy in patients with primary hyperparathyroidism. The objective of this study was to evaluate the estimated glomerular filtration rate change 12 months after parathyroidectomy for primary hyperparathyroidism according to preoperative kidney function. METHOD Patients who underwent parathyroidectomy for primary hyperparathyroidism between 2016 and 2021 (n = 381) were enrolled in a monocentric prospective cohort. Patients without 1-year follow-up or with missing data were excluded (n = 135, 35%). Patients were dichotomized according to their baseline estimated glomerular filtration rate: <60 mL/min (group 1) and ≥60 mL/min (group 2). Parameters were measured before and then at 6 and 12 months after parathyroidectomy. RESULTS Out of 246 included patients, 27 (11%) were assigned to group 1 and 219 (89%) to group 2. The mean baseline estimated glomerular filtration rate was 46.8 ± 11.5 and 87.3 ± 14.7 mL/min in groups 1 and 2, respectively. Group 1 patients were older (P = .0006) and had a higher median serum parathyroid hormone level (P = .021). At 6 months postoperative, 224 patients (91%) were normocalcemic. The estimated glomerular filtration rate raw change after parathyroidectomy was significantly higher in group 1 than in group 2 (4.2 ± 7.8 vs -2.2 ± 9.1 mL/min, P = .0004). In group 1, 13/27 patients (48%) improved their chronic kidney disease stage after parathyroidectomy, including 6/13 (46%) with postoperative estimated glomerular filtration rate ≥60 mL/min, whereas 2/27 (7%) worsened. The baseline estimated glomerular filtration rate <60 mL/min and elevated serum calcium level were associated with postoperative estimated glomerular filtration rate improvement in multivariable analysis (P = .0023 and .039, respectively). CONCLUSION Parathyroidectomy for primary hyperparathyroidism is more likely to improve kidney function in patients with preoperative estimated glomerular filtration rate <60 mL/min. These results strengthen the current guidelines for surgery.
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Affiliation(s)
- Samuel Frey
- Chirurgie Cancérologique, Digestive et Endocrinienne, Institut des Maladies de l'Appareil Digestif, CHU de Nantes, France; Université de Nantes, France; Nantes Université, CHU Nantes, CNRS, INSERM, l'institut du thorax, Nantes, France. https://twitter.com/samuelfrey13
| | - Matthieu Wargny
- Nantes Université, CHU Nantes, CNRS, INSERM, l'institut du thorax, Nantes, France; CHU de Nantes, INSERM, CIC 1413, Pôle Hospitalo-Universitaire 11: Santé Publique, Santé au Travail, Pharmacie, Stérilisation, Clinique des Données, France
| | - Claire Blanchard
- Chirurgie Cancérologique, Digestive et Endocrinienne, Institut des Maladies de l'Appareil Digestif, CHU de Nantes, France; Université de Nantes, France; Nantes Université, CHU Nantes, CNRS, INSERM, l'institut du thorax, Nantes, France
| | - Cécile Caillard
- Chirurgie Cancérologique, Digestive et Endocrinienne, Institut des Maladies de l'Appareil Digestif, CHU de Nantes, France
| | - Samy Hadjadj
- Nantes Université, CHU Nantes, CNRS, INSERM, l'institut du thorax, Nantes, France
| | - Bertrand Cariou
- Nantes Université, CHU Nantes, CNRS, INSERM, l'institut du thorax, Nantes, France
| | - Lucile Figueres
- Université de Nantes, France; Service de Néphrologie-Immunologie Clinique, CHU de Nantes, France
| | - Eric Mirallié
- Chirurgie Cancérologique, Digestive et Endocrinienne, Institut des Maladies de l'Appareil Digestif, CHU de Nantes, France; Université de Nantes, France.
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22
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Broekhuis JM, Chaves N, Chen HW, Drake FT, James BC. Disparities in Time to Surgeon Evaluation Among Patients with Primary Hyperparathyroidism. Surgery 2023; 173:103-110. [PMID: 36198492 DOI: 10.1016/j.surg.2022.06.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 05/18/2022] [Accepted: 06/14/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND A majority of patients with primary hyperparathyroidism are not referred for surgical evaluation. We hypothesized that disparities in the rate of surgeon evaluation by language, race and ethnicity, and insurance contribute to this deficit. METHODS We queried our institutional electronic health record registry for patients with first-incident hypercalcemia between 2010 and 2018 and subsequent biochemical diagnosis of primary hyperparathyroidism. We used the Kaplan-Meier method and Cox proportional hazards modeling to investigate estimated time to surgeon evaluation by language, race and ethnicity, and insurance status. RESULTS Of 1,333 patients with a diagnosis of primary hyperparathyroidism, 74% were female, 67% were White, 44% were privately insured, and 88% preferred English. Fewer than one third (n = 377; 28%) were evaluated by a surgeon. After adjusting for demographic and clinical factors, Asian (hazard ratio = 0.38; 95% confidence interval, 0.18-0.84; P = .016) and Black or African American patients (hazard ratio = 0.59; 95% confidence interval, 0.39-0.90; P = .014) had a lower rate of surgeon evaluation compared to White patients. Although patients with Medicaid had a lower rate of surgeon evaluation compared to privately insured patients (hazard ratio = 0.52; 95% confidence interval, 0.35-0.77; P = .001), there was no difference in rate for those with Medicare or who were uninsured. Patients with non-English and non-Spanish language had a lower rate of evaluation compared to those who preferred English (hazard ratio = 0.47; 95% confidence interval, 0.23-0.98; P = .043). CONCLUSION Rates of surgeon evaluation vary by race and ethnicity, insurance status, and preferred language. Evaluation of factors contributing to these disparities is needed to improve access to surgeon referral.
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Affiliation(s)
- Jordan M Broekhuis
- Harvard Medical School, Boston, MA; Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA. https://twitter.com/@j_broekhuis
| | - Natalia Chaves
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA. https://twitter.com/7736-1,67736.1-7,7
| | - Hao Wei Chen
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA. https://twitter.com/@HaoWei95
| | - F Thurston Drake
- Department of Surgery, Boston University School of Medicine, Boston Medical Center, MA. https://twitter.com/@F_ThurstonDrake
| | - Benjamin C James
- Harvard Medical School, Boston, MA; Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA. https://twitter.com/@benjamesMD
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23
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Collins RA, DiGennaro C, Beninato T, Gartland RM, Chaves N, Broekhuis JM, Reddy L, Lee J, Deimiller A, Alterio MM, Campbell MJ, Lee YJ, Khilnani TK, Stewart LA, O’Brien MA, Alvarado MVY, Zheng F, McAneny D, Liou R, McManus C, Dream SY, Wang TS, Yen TW, Alhefdhi A, Finnerty BM, Fahey TJ, Graves CE, Laird AM, Nehs MA, Drake FT, Lee JA, McHenry CR, James BC, Pasieka JL, Kuo JH, Lubitz CC. Limited disease progression in endocrine surgery patients with treatment delays due to COVID-19. Surgery 2023; 173:93-100. [PMID: 36210185 PMCID: PMC9420726 DOI: 10.1016/j.surg.2022.06.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 05/31/2022] [Accepted: 06/13/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND The COVID-19 pandemic profoundly impacted the delivery of care and timing of elective surgical procedures. Most endocrine-related operations were considered elective and safe to postpone, providing a unique opportunity to assess clinical outcomes under protracted treatment plans. METHODS American Association of Endocrine Surgeon members were surveyed for participation. A Research Electronic Data Capture survey was developed and distributed to 27 institutions to assess the impact of COVID-19-related delays. The information collected included patient demographics, primary diagnosis, resumption of care, and assessment of disease progression by the surgeon. RESULTS Twelve out of 27 institutions completed the survey (44.4%). Of 850 patients, 74.8% (636) were female; median age was 56 (interquartile range, 44-66) years. Forty percent (34) of patients had not been seen since their original surgical appointment was delayed; 86.2% (733) of patients had a delay in care with women more likely to have a delay (87.6% vs 82.2% of men, χ2 = 3.84, P = .05). Median duration of delay was 70 (interquartile range, 42-118) days. Among patients with a delay in care, primary disease site included thyroid (54.2%), parathyroid (37.2%), adrenal (6.5%), and pancreatic/gastrointestinal neuroendocrine tumors (1.3%). In addition, 4.0% (26) of patients experienced disease progression and 4.1% (24) had a change from the initial operative plan. The duration of delay was not associated with disease progression (P = .96) or a change in operative plan (P = .66). CONCLUSION Although some patients experienced disease progression during COVID-19 delays to endocrine disease-related care, most patients with follow-up did not. Our analysis indicated that temporary delay may be an acceptable course of action in extreme circumstances for most endocrine-related surgical disease.
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Affiliation(s)
- Reagan A. Collins
- Department of Surgery, Massachusetts General Hospital, Boston, MA,Texas Tech University Health Sciences Center School of Medicine, Lubbock, TX,Institute of Technology Assessment, Massachusetts General Hospital, Boston, MA
| | - Catherine DiGennaro
- Institute of Technology Assessment, Massachusetts General Hospital, Boston, MA
| | - Toni Beninato
- Department of Surgery, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | | | - Natalia Chaves
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Jordan M. Broekhuis
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA,Harvard Medical School, Boston, MA
| | - Lekha Reddy
- Department of Surgery, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Jenna Lee
- Department of Surgery, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | | | - Maeve M. Alterio
- Elson S. Floyd College of Medicine, Washington State University, Spokane, WA
| | | | - Yeon Joo Lee
- Department of Surgery, Weill Cornell Medicine/New York-Presbyterian Hospital, New York, NY
| | | | - Latoya A. Stewart
- Columbia University Vagelos College of Physicians and Surgeons, New York, NY
| | - Mollie A. O’Brien
- Department of Surgery, Boston Medical Center and Boston University School of Medicine, MA
| | | | - Feibi Zheng
- Department of Surgery, Baylor College of Medicine, Houston, TX
| | - David McAneny
- Department of Surgery, Boston Medical Center and Boston University School of Medicine, MA
| | - Rachel Liou
- Section of Endocrine Surgery, Columbia University, New York, NY
| | | | - Sophie Y. Dream
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Tracy S. Wang
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Tina W. Yen
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Amal Alhefdhi
- Department of General Surgery, Breast and Endocrine Section, King Faisal Specialist Hospital and Research Centre, Al Mathar Ash Shamali, Riyadh, Saudi Arabia
| | - Brendan M. Finnerty
- Department of Surgery, Weill Cornell Medicine/New York-Presbyterian Hospital, New York, NY
| | - Thomas J. Fahey
- Department of Surgery, Weill Cornell Medicine/New York-Presbyterian Hospital, New York, NY
| | | | - Amanda M. Laird
- Department of Surgery, Rutgers Cancer Institute of New Jersey, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Matthew A. Nehs
- Department of Surgery, Brigham and Women’s Hospital, Boston, MA
| | | | - James A. Lee
- Section of Endocrine Surgery, Columbia University, New York, NY
| | - Christopher R. McHenry
- Department of Surgery, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH
| | - Benjamin C. James
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA,Harvard Medical School, Boston, MA
| | - Janice L. Pasieka
- Department of Surgery, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Jennifer H. Kuo
- Section of Endocrine Surgery, Columbia University, New York, NY
| | - Carrie Cunningham Lubitz
- Department of Surgery, Massachusetts General Hospital, Boston, MA,Institute of Technology Assessment, Massachusetts General Hospital, Boston, MA,Harvard Medical School, Boston, MA,Reprint requests: Carrie Cunningham Lubitz, MD, MPH, 55 Fruit Street, Boston, MA 02114
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24
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Abstract
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.
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Affiliation(s)
- Cristiana Cipriani
- Department of Clinical, Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, Rome 00161, Italy.
| | - Luisella Cianferotti
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Florence, Viale GB Morgagni 50, Florence 50134, Italy
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25
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Bilezikian JP, Silverberg SJ, Bandeira F, Cetani F, Chandran M, Cusano NE, Ebeling PR, Formenti AM, Frost M, Gosnell J, Lewiecki EM, Singer FR, Gittoes N, Khan AA, Marcocci C, Rejnmark L, Ye Z, Guyatt G, Potts JT. Management of Primary Hyperparathyroidism. J Bone Miner Res 2022; 37:2391-2403. [PMID: 36054638 DOI: 10.1002/jbmr.4682] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 08/11/2022] [Accepted: 08/14/2022] [Indexed: 11/11/2022]
Abstract
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).
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Affiliation(s)
- John P Bilezikian
- Division of Endocrinology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Shonni J Silverberg
- Division of Endocrinology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Francisco Bandeira
- Division of Endocrinology, University of Pernambuco Medical School Recife, Recife, Brazil
| | | | - Manju Chandran
- Osteoporosis and Bone Metabolism Unit, Department of Endocrinology, Singapore General Hospital, Singapore, Singapore
| | - Natalie E Cusano
- Division of Endocrinology, Department of Medicine, Lenox Hill Hospital, New York, NY, USA
| | - Peter R Ebeling
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
| | - Anna Maria Formenti
- Institute of Endocrine and Metabolic Sciences, San Raffaele Vita-Salute University and IRCCS Hospital, Milan, Italy
| | - Morten Frost
- Bone and Calcium Unit & Molecular Endocrinology Unit, Department of Endocrinology, Odense University Hospital, Odense, Denmark
| | - Jessica Gosnell
- Department of Surgery, University of California, San Francisco, CA, USA
| | - E Michael Lewiecki
- New Mexico Clinical Research & Osteoporosis Center, Albuquerque, NM, USA
| | - Frederick R Singer
- Endocrine/Bone Disease Program, Saint John's Cancer Institute, Santa Monica, CA, USA
| | - Neil Gittoes
- Centre for Endocrinology, Diabetes and Metabolism, Queen Elizabeth Hospital and University of Birmingham, Birmingham, UK
| | - Aliya A Khan
- Division of Endocrinology and Metabolism, McMaster University, Hamilton, ON, Canada
| | - Claudio Marcocci
- Department of Clinical and Experimental Medicine, University of Pisa, Endocrine Unit 2, University Hospital of Pisa, Pisa, Italy
| | - Lars Rejnmark
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Zhikang Ye
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - John T Potts
- Endocrine Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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El-Hajj Fuleihan G, Chakhtoura M, Cipriani C, Eastell R, Karonova T, Liu JM, Minisola S, Mithal A, Moreira CA, Peacock M, Schini M, Silva B, Walker M, El Zein O, Marcocci C. Classical and Nonclassical Manifestations of Primary Hyperparathyroidism. J Bone Miner Res 2022; 37:2330-2350. [PMID: 36245249 DOI: 10.1002/jbmr.4679] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 08/11/2022] [Accepted: 08/12/2022] [Indexed: 11/09/2022]
Abstract
This narrative review summarizes data on classical and nonclassical manifestations of primary hyperparathyroidism (PHPT). It is based on a rigorous literature search, inclusive of a Medline search for systematic reviews from 1940 to December 2020, coupled with a targeted search for original publications, covering four databases, from January 2013-December 2020, and relevant articles from authors' libraries. We present the most recent information, identify knowledge gaps, and suggest a research agenda. The shift in the presentation of PHPT from a predominantly symptomatic to an asymptomatic disease, with its varied manifestations, has presented several challenges. Subclinical nephrolithiasis and vertebral fractures are common in patients with asymptomatic disease. The natural history of asymptomatic PHPT with no end organ damage at diagnosis is unclear. Some observational and cross-sectional studies continue to show associations between PHPT and cardiovascular and neuropsychological abnormalities, among the different disease phenotypes. Their causal relationship is uncertain. Limited new data are available on the natural history of skeletal, renal, cardiovascular, neuropsychological, and neuromuscular manifestations and quality of life. Normocalcemic PHPT (NPHPT) is often diagnosed without the fulfillment of rigorous criteria. Randomized clinical trials have not demonstrated a consistent long-term benefit of parathyroidectomy (PTX) versus observation on nonclassical manifestations. We propose further refining the definition of asymptomatic disease, into two phenotypes: one without and one with evidence of target organ involvement, upon the standard evaluation detailed in our recommendations. Each of these phenotypes can present with or without non-classical manifestations. We propose multiple albumin-adjusted serum calcium determinations (albumin-adjusted and ionized) and exclusion of all secondary causes of high parathyroid hormone (PTH) when establishing the diagnosis of NPHPT. Refining the definition of asymptomatic disease into the phenotypes proposed will afford insights into their natural history and response to interventions. This would also pave the way for the development of evidence-based guidance and recommendations. © 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).
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Affiliation(s)
- Ghada El-Hajj Fuleihan
- Calcium Metabolism and Osteoporosis Program, World Health Organization (WHO) Collaborating Center (CC) for Metabolic Bone Disorders, Division of Endocrinology, American University of Beirut, Beirut, Lebanon
| | - Marlene Chakhtoura
- Calcium Metabolism and Osteoporosis Program, World Health Organization (WHO) Collaborating Center (CC) for Metabolic Bone Disorders, Division of Endocrinology, American University of Beirut, Beirut, Lebanon
| | - Cristiana Cipriani
- Department of Clinical, Internal, Anaesthesiologic and Cardiovascular Sciences, 'Sapienza', Rome University, Rome, Italy
| | - Richard Eastell
- Academic Unit of Bone Metabolism, University of Sheffield, Sheffield, UK
| | - Tatiana Karonova
- Clinical Endocrinology Laboratory, Department of Endocrinology, Almazov National Medical Research Centre, St. Petersburg, Russia
| | - Jian-Min Liu
- Department of Endocrine and Metabolic Disease, Rui-jin Hospital, Shanghai Jiao-Tong University School of Medicine, Shanghai, China
| | - Salvatore Minisola
- Department of Clinical, Internal, Anaesthesiologic and Cardiovascular Sciences, 'Sapienza', Rome University, Rome, Italy
| | - Ambrish Mithal
- Institute of Endocrinology and Diabetes, Max Healthcare, New Delhi, India
| | - Carolina A Moreira
- Endocrine Division (SEMPR), Department of Internal Medicine, Federal University of Parana, Curitiba, Brazil
- Academic Research Center of Pro-Renal Institute, Curitiba, Brazil
| | - Munro Peacock
- Division of Endocrinology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Marian Schini
- Academic Unit of Bone Metabolism, University of Sheffield, Sheffield, UK
| | - Barbara Silva
- Endocrinology Unit, Department of Medicine, Centro Universitario de Belo Horizonte (UNI BH), Felicio Rocho Hospital, Belo Horizonte, Brazil
- Endocrinology Unit, Santa Casa Hospital, Belo Horizonte, Brazil
| | - Marcella Walker
- Division of Endocrinology, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Ola El Zein
- Saab Medical Library, American University of Beirut, Beirut, Lebanon
| | - Claudio Marcocci
- Department of Clinical and Experimental Medicine, Endocrine Unit 2, University Hospital of Pisa Chairman European Group on Graves' Orbitopathy Via Paradisa 2, University of Pisa Head, Pisa, Italy
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27
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Ye Z, Silverberg SJ, Sreekanta A, Tong K, Wang Y, Chang Y, Zhang M, Guyatt G, Tangamornsuksun W, Zhang Y, Manja V, Bakaa L, Couban RJ, Brandi ML, Clarke B, Khan AA, Mannstadt M, Bilezikian JP. The Efficacy and Safety of Medical and Surgical Therapy in Patients With Primary Hyperparathyroidism: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. J Bone Miner Res 2022; 37:2351-2372. [PMID: 36053960 DOI: 10.1002/jbmr.4685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 08/12/2022] [Accepted: 08/18/2022] [Indexed: 11/10/2022]
Abstract
Both medical and surgical therapy represent potential management options for patients with asymptomatic primary hyperparathyroidism (PHPT). Because uncertainty remains regarding both medical and surgical therapy, this systematic review addresses the efficacy and safety of medical therapy in asymptomatic patients or symptomatic patients who decline surgery and surgery in asymptomatic patients. We searched Medline, Embase, Cochrane Central Register of Controlled Trials, and PubMed from inception to December 2020, and included randomized controlled trials in patients with PHPT that compared nonsurgical management with medical therapy versus without medical therapy and surgery versus no surgery in patients with asymptomatic PHPT. For surgical complications we included observational studies. Paired reviewers addressed eligibility, assessed risk of bias, and abstracted data for patient-important outcomes. We conducted random-effects meta-analyses to pool relative risks and mean differences with 95% confidence intervals and used Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) to assess quality of evidence for each outcome. For medical therapy, 11 trials reported in 12 publications including 438 patients proved eligible: three addressed alendronate, one denosumab, three cinacalcet, two vitamin D, and two estrogen therapy. Alendronate, denosumab, vitamin D, and estrogen therapy all increased bone density. Cinacalcet probably reduced serum calcium and parathyroid hormone (PTH) levels. Cinacalcet and vitamin D may have a small or no increase in overall adverse events. Very-low-quality evidence raised the possibility of an increase in serious adverse events with alendronate and denosumab. The trials also provided low-quality evidence for increased bleeding and mastalgia with estrogen therapy. For surgery, six trials presented in 12 reports including 441 patients proved eligible. Surgery achieved biochemical cure in 96.1% (high quality). We found no convincing evidence supporting an impact of surgery on fracture, quality of life, occurrence of kidney stones, and renal function, but the evidence proved low or very low quality. Surgery was associated with an increase in bone mineral density. For patients with symptomatic and asymptomatic PHPT, who are not candidates for parathyroid surgery, cinacalcet probably reduced serum calcium and PTH levels; anti-resorptives increased bone density. For patients with asymptomatic PHPT, surgery usually achieves biochemical cure. These results can help to inform patients and clinicians regarding use of medical therapy and surgery in 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).
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Affiliation(s)
- Zhikang Ye
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Shonni J Silverberg
- Division of Endocrinology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Ashwini Sreekanta
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Kyle Tong
- Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Ying Wang
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Yaping Chang
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Mengmeng Zhang
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Wimonchat Tangamornsuksun
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.,Princess Srisavangavadhana College of Medicine, Chulabhorn Royal Academy, Bangkok, Thailand
| | - Yi Zhang
- Department of Pharmacy, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China.,Department of Pharmacy, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | | | - Layla Bakaa
- Honours Neuroscience Program, Faculty of Science, McMaster University, Hamilton, ON, Canada
| | - Rachel J Couban
- DeGroote Institute for Pain Research and Care (Couban), McMaster University, Hamilton, ON, Canada
| | - Maria Luisa Brandi
- Fondazione Italiana sulla Ricerca sulle Malattie dell'Osso (F.I.R.M.O. Foundation), Florence, Italy
| | - Bart Clarke
- Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Aliya A Khan
- Division of Endocrinology and Metabolism, McMaster University, Hamilton, ON, Canada
| | - Michael Mannstadt
- Endocrine Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - John P Bilezikian
- Division of Endocrinology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
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28
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Perrier N, Lang BH, Farias LCB, Poch LL, Sywak M, Almquist M, Vriens MR, Yeh MW, Shariq O, Duh QY, Yeh R, Vu T, LiVolsi V, Sitges-Serra A. Surgical Aspects of Primary Hyperparathyroidism. J Bone Miner Res 2022; 37:2373-2390. [PMID: 36054175 DOI: 10.1002/jbmr.4689] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 08/18/2022] [Accepted: 08/24/2022] [Indexed: 11/12/2022]
Abstract
Parathyroidectomy (PTX) is the treatment of choice for symptomatic primary hyperparathyroidism (PHPT). It is also the treatment of choice in asymptomatic PHPT with evidence for target organ involvement. This review updates surgical aspects of PHPT and proposes the following definitions based on international expert consensus: selective PTX (and reasons for conversion to an extended procedure), bilateral neck exploration for non-localized or multigland disease, subtotal PTX, total PTX with immediate or delayed autotransplantation, and transcervical thymectomy and extended en bloc PTX for parathyroid carcinoma. The systematic literature reviews discussed covered (i) the use of intraoperative PTH (ioPTH) for localized single-gland disease and (ii) the management of low BMD after PTX. Updates based on prospective observational studies are presented concerning PTX for multigland disease and hereditary PHPT syndromes, histopathology, intraoperative adjuncts, localization techniques, perioperative management, "reoperative" surgery and volume/outcome data. Postoperative complications are few and uncommon (<3%) in centers performing over 40 PTXs per year. This review is the first global consensus about surgery in PHPT and reflects the current practice in leading endocrine surgery units worldwide. © 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).
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Affiliation(s)
- Nancy Perrier
- Department of Surgical Oncology, Section of Surgical Endocrinology, University of Texas M D Anderson Cancer Center, Houston, TX, USA
| | - Brian H Lang
- Department of Surgery, Queen Mary Hospital, Pokfulam, Hong Kong
| | | | - Leyre Lorente Poch
- Endocrine Surgery Unit, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Mark Sywak
- Endocrine Surgery Unit, University of Sydney, Sydney, Australia
| | - Martin Almquist
- Department of Surgery, Skåne University Hospital, Lund University, Lund, Sweden
| | - Menno R Vriens
- Department of Surgical Oncology and Endocrine Surgery, University Medical Center, Utrecht, The Netherlands
| | - Michael W Yeh
- Department of Surgery, Section of Endocrine Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - Omair Shariq
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, University of Oxford, Headington, UK
| | - Quan-Yang Duh
- Department of Surgery, University of California, San Francisco, CA, USA
| | - Randy Yeh
- Memorial Sloan Kettering Cancer Center, Molecular Imaging and Therapy Service, New York, NY, USA
| | - Thinh Vu
- Neuroradiology Department, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Virginia LiVolsi
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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29
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Bilezikian JP, Khan AA, Silverberg SJ, Fuleihan GEH, Marcocci C, Minisola S, Perrier N, Sitges-Serra A, Thakker RV, Guyatt G, Mannstadt M, Potts JT, Clarke BL, Brandi ML, Balaya Z, Hofbauer L, Insogna K, Lacroix A, Liberman UA, Palermo A, Rizzoli R, Wermers R, Hannan FM, Pepe J, Cipriani C, Eastell R, Liu J, Mithal A, Moreira CA, Peacock M, Silva B, Walker M, Chakhtoura M, Schini M, Zein OE, Almquist M, Farias LCB, Duh Q, Lang BH, LiVolsi V, Swayk M, Vriens MR, Vu T, Yeh MW, Yeh R, Shariq O, Poch LL, Bandeira F, Cetani F, Chandran M, Cusano NE, Ebeling PR, Gosnell J, Lewiecki EM, Singer FR, Frost M, Formenti AM, Karonova T, Gittoes N, Rejnmark L. Evaluation and Management of Primary Hyperparathyroidism: Summary Statement and Guidelines from the Fifth International Workshop. J Bone Miner Res 2022; 37:2293-2314. [PMID: 36245251 DOI: 10.1002/jbmr.4677] [Citation(s) in RCA: 111] [Impact Index Per Article: 55.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 08/11/2022] [Accepted: 08/14/2022] [Indexed: 11/10/2022]
Abstract
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).
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Affiliation(s)
- John P Bilezikian
- Division of Endocrinology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Aliya A Khan
- Division of Endocrinology and Metabolism, McMaster University, Hamilton, ON, Canada
| | - Shonni J Silverberg
- Division of Endocrinology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Ghada El-Hajj Fuleihan
- Calcium Metabolism and Osteoporosis Program, WHO CC for Metabolic Bone Disorders, Division of Endocrinology, American University of Beirut, Beirut, Lebanon
| | - Claudio Marcocci
- Department of Clinical and Experimental Medicine, University of Pisa, Endocrine Unit 2, University Hospital of Pisa, Pisa, Italy
| | - Salvatore Minisola
- Department of Clinical, Internal, Anaesthesiologic and Cardiovascular Sciences, 'Sapienza', Rome University, Rome, Italy
| | - Nancy Perrier
- Department of Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | | | - Rajesh V Thakker
- Academic Endocrine Unit, Radcliffe Department of Medicine, University of Oxford, Oxford Centre for Diabetes, Endocrinology and Metabolism (OCDEM), Churchill Hospital, Oxford, UK
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Michael Mannstadt
- Endocrine Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - John T Potts
- Endocrine Unit, Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Bart L Clarke
- Mayo Clinic Division of Endocrinology, Diabetes, Metabolism, and Nutrition, Mayo Clinic, Rochester, MN, USA
| | - Maria Luisa Brandi
- Fondazione Italiana sulla Ricerca sulle Malattie dell'Osso (F.I.R.M.O. Foundation), Florence, Italy
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Lu J, Zheng H, Lai V. Pilot Cross-Sectional Quality of Life Study of a Diverse Endocrine Surgery Patient Population. J Surg Res 2022; 278:257-266. [DOI: 10.1016/j.jss.2022.04.068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 03/19/2022] [Accepted: 04/23/2022] [Indexed: 10/18/2022]
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Chandran M, Yeh LTL, de Jong MC, Bilezikian JP, Parameswaran R. Cognitive deficits in primary hyperparathyroidism - what we know and what we do not know: A narrative review. Rev Endocr Metab Disord 2022; 23:1079-1087. [PMID: 35994179 DOI: 10.1007/s11154-022-09750-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/04/2022] [Indexed: 10/15/2022]
Abstract
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.
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Affiliation(s)
- Manju Chandran
- Osteoporosis and Bone Metabolism Unit, Department of Endocrinology, Singapore General Hospital, Singapore, Singapore.
- DUKE-NUS Medical School, Singapore, Singapore.
| | - Lydia Tan Li Yeh
- Division of Endocrine Surgery, National University Health System, Singapore, Singapore
| | - Mechteld C de Jong
- Division of Endocrine Surgery, National University Health System, Singapore, Singapore
| | - John P Bilezikian
- Division of Endocrinology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York City, NY, USA
| | - Rajeev Parameswaran
- Division of Endocrine Surgery, National University Health System, Singapore, Singapore
- Division of Endocrine Surgery, National University Hospital System, Singapore, Singapore
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32
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Livschitz J, Yen TWF, Evans DB, Wang TS, Dream S. Long-term Quality of Life After Parathyroidectomy for Primary Hyperparathyroidism: A Systematic Review. JAMA Surg 2022; 157:2796289. [PMID: 36103163 DOI: 10.1001/jamasurg.2022.4249] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2024]
Abstract
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.
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Affiliation(s)
| | - Tina W F Yen
- Department of Surgery, Medical College of Wisconsin, Milwaukee
| | - Douglas B Evans
- Department of Surgery, Medical College of Wisconsin, Milwaukee
| | - Tracy S Wang
- Department of Surgery, Medical College of Wisconsin, Milwaukee
| | - Sophie Dream
- Department of Surgery, Medical College of Wisconsin, Milwaukee
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33
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Seib CD, Ganesan C, Arnow KD, Pao AC, Leppert JT, Barreto NB, Kebebew E, Kurella Tamura M. Kidney Stone Events Following Parathyroidectomy vs Nonoperative Management for Primary Hyperparathyroidism. J Clin Endocrinol Metab 2022; 107:e2801-e2811. [PMID: 35363858 PMCID: PMC9202696 DOI: 10.1210/clinem/dgac193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Indexed: 11/19/2022]
Abstract
CONTEXT Primary hyperparathyroidism (PHPT) is associated with an increased risk of kidney stones. Few studies account for PHPT severity or stone risk when comparing stone events after parathyroidectomy vs nonoperative management. OBJECTIVE Compare the incidence of kidney stone events in PHPT patients treated with parathyroidectomy vs nonoperative management. DESIGN Longitudinal cohort study with propensity score inverse probability weighting and multivariable Cox proportional hazards regression. SETTING Veterans Health Administration integrated health care system. PATIENTS A total of 44 978 patients with > 2 years follow-up after PHPT diagnosis (2000-2018); 5244 patients (11.7%) were treated with parathyroidectomy. MAIN OUTCOMES MEASURE Clinically significant kidney stone event. RESULTS The cohort had a mean age of 66.0 years, was 87.8% male, and 66.4% White. Patients treated with parathyroidectomy had higher mean serum calcium (11.2 vs 10.8mg/dL) and were more likely to have a history of kidney stone events. Among patients with baseline history of kidney stones, the unadjusted incidence of ≥ 1 kidney stone event was 30.5% in patients managed with parathyroidectomy (mean follow-up, 5.6 years) compared with 18.0% in those managed nonoperatively (mean follow-up, 5.0 years). Patients treated with parathyroidectomy had a higher adjusted hazard of recurrent kidney stone events (hazard ratio [HR], 1.98; 95% CI, 1.56-2.51); however, this association declined over time (parathyroidectomy × time: HR, 0.80; 95% CI, 0.73-0.87). CONCLUSION In this predominantly male cohort with PHPT, patients treated with parathyroidectomy continued to be at higher risk of kidney stone events in the immediate years after treatment than patients managed nonoperatively, although the adjusted risk of stone events declined with time, suggesting a benefit to surgical treatment.
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Affiliation(s)
- Carolyn D Seib
- Correspondence: Carolyn Dacey Seib, MD, MAS, Stanford University, 300 Pasteur Dr, H3680, Stanford, CA 94305, USA.
| | - Calyani Ganesan
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA 94305, USA
| | - Katherine D Arnow
- Stanford–Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University School of Medicine, Palo Alto, CA 94304, USA
| | - Alan C Pao
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA 94305, USA
- Department of Urology, Stanford University School of Medicine, Palo Alto, CA 94305, USA
| | - John T Leppert
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA 94305, USA
- Department of Urology, Stanford University School of Medicine, Palo Alto, CA 94305, USA
| | - Nicolas B Barreto
- Stanford–Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University School of Medicine, Palo Alto, CA 94304, USA
| | - Electron Kebebew
- Department of Surgery, Stanford University School of Medicine, Palo Alto, CA 94305, USA
| | - Manjula Kurella Tamura
- Geriatric Research, Education and Clinical Center, Veterans Affairs Palo Alto, Palo Alto, CA 94304, USA
- Division of Nephrology, Stanford University School of Medicine, Palo Alto, CA 94305, USA
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Pretorius M, Lundstam K, Heck A, Fagerland MW, Godang K, Mollerup C, Fougner SL, Pernow Y, Aas T, Hessman O, Rosén T, Nordenström J, Jansson S, Hellström M, Bollerslev J. Mortality and Morbidity in Mild Primary Hyperparathyroidism: Results From a 10-Year Prospective Randomized Controlled Trial of Parathyroidectomy Versus Observation. Ann Intern Med 2022; 175:812-819. [PMID: 35436153 DOI: 10.7326/m21-4416] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Primary hyperparathyroidism (PHPT) is a common endocrine disorder associated with increased risk for fractures, cardiovascular disease, kidney disease, and cancer and increased mortality. In mild PHPT with modest hypercalcemia and without known morbidities, parathyroidectomy (PTX) is debated because no long-term randomized trials have been performed. OBJECTIVE To examine the effect of PTX on mild PHPT with regard to mortality (primary end point) and key morbidities (secondary end point). DESIGN Prospective randomized controlled trial. (ClinicalTrials.gov: NCT00522028). SETTING Eight Scandinavian referral centers. PATIENTS From 1998 to 2005, 191 patients with mild PHPT were included. INTERVENTION Ninety-five patients were randomly assigned to PTX, and 96 were assigned to observation without intervention (OBS). MEASUREMENTS Date and causes of death were obtained from the Swedish and Norwegian Cause of Death Registries 10 years after randomization and after an extended observation period lasting until 2018. Morbidity events were prospectively registered annually. RESULTS After 10 years, 15 patients had died (8 in the PTX group and 7 in the OBS group). Within the extended observation period, 44 deaths occurred, which were evenly distributed between groups (24 in the PTX group and 20 in the OBS group). A total of 101 morbidity events (cardiovascular events, cerebrovascular events, cancer, peripheral fractures, and renal stones) were also similarly distributed between groups (52 in the PTX group and 49 in the OBS group). During the study, a total of 16 vertebral fractures occurred in 14 patients (7 in each group). LIMITATION During the study period, 23 patients in the PTX group and 27 in the OBS group withdrew. CONCLUSION Parathyroidectomy does not appear to reduce morbidity or mortality in mild PHPT. Thus, no evidence of adverse effects of observation was seen for at least a decade with respect to mortality, fractures, cancer, cardiovascular and cerebrovascular events, or renal morbidities. PRIMARY FUNDING SOURCE Swedish government, Norwegian Research Council, and South-Eastern Norway Regional Health Authority.
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Affiliation(s)
- Mikkel Pretorius
- Section of Specialized Endocrinology, Oslo University Hospital, and Faculty of Medicine, University of Oslo, Oslo, Norway (M.P., A.H., J.B.)
| | - Karolina Lundstam
- Department of Radiology, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, and Department of Radiology, Sahlgrenska University Hospital, Gothenburg, Sweden (K.L., M.H.)
| | - Ansgar Heck
- Section of Specialized Endocrinology, Oslo University Hospital, and Faculty of Medicine, University of Oslo, Oslo, Norway (M.P., A.H., J.B.)
| | - Morten W Fagerland
- Oslo Centre for Biostatistics and Epidemiology, Research Support Services, Oslo University Hospital, Oslo, Norway (M.W.F.)
| | - Kristin Godang
- Section of Specialized Endocrinology, Oslo University Hospital, Oslo, Norway (K.G.)
| | - Charlotte Mollerup
- Clinic of Breast and Endocrine Surgery, Center HOC, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark (C.M.)
| | - Stine L Fougner
- Department of Endocrinology, Clinic of Medicine, St. Olavs Hospital, Trondheim University Hospital, Trondheim, Norway (S.L.F.)
| | - Ylva Pernow
- Department of Molecular Medicine and Surgery, Department of Endocrinology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden (Y.P.)
| | - Turid Aas
- Department of Breast and Endocrine Surgery, Haukeland University Hospital, Bergen, Norway (T.A.)
| | - Ola Hessman
- Department of Surgery and Centre for Clinical Research of Uppsala University, Västmanland Hospital, Västerås, Sweden (O.H.)
| | - Thord Rosén
- Department of Medicine, Section of Endocrinology, Diabetes, and Metabolism, Sahlgrenska University Hospital, Gothenburg, Sweden (T.R.)
| | - Jörgen Nordenström
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden (J.N.)
| | - Svante Jansson
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden (S.J.)
| | - Mikael Hellström
- Department of Radiology, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, and Department of Radiology, Sahlgrenska University Hospital, Gothenburg, Sweden (K.L., M.H.)
| | - Jens Bollerslev
- Section of Specialized Endocrinology, Oslo University Hospital, and Faculty of Medicine, University of Oslo, Oslo, Norway (M.P., A.H., J.B.)
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Brescia MDG, Rodrigues KC, d’Alessandro AF, Alves Filho W, van der Plas WY, Kruijff S, Arap SS, Toledo SPDA, Montenegro FLDM, Lourenço DM. Impact of parathyroidectomy on quality of life in multiple endocrine neoplasia type 1. Endocr Connect 2022; 11:EC-22-0021. [PMID: 35583183 PMCID: PMC9254320 DOI: 10.1530/ec-22-0021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 05/18/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Potential influences of parathyroidectomy (PTx) on the quality of life (QoL) in multiple endocrine neoplasia type 1-related primary hyperparathyroidism (HPT/MEN1) are unknown. METHOD Short Form 36 Health Survey Questionnaire was prospectively applied to 30 HPT/MEN1 patients submitted to PTx (20, subtotal; 10, total with autograft) before, 6 and 12 months after surgery. Parameters that were analyzed included QoL, age, HPT-related symptoms, general pain, comorbidities, biochemical/hormonal response, PTx type and parathyroid volume. RESULTS Asymptomatic patients were younger (30 vs 38 years; P = 0.04) and presented higher QoL scores than symptomatic ones: Physical Component Summary score (PCS) 92.5 vs 61.2, P = 0.0051; Mental Component Summary score (MCS) 82.0 vs 56.0, P = 0.04. In both groups, QoL remained stable 1 year after PTx, independently of the number of comorbidities. Preoperative general pain was negatively correlated with PCS (r = -0.60, P = 0.0004) and MCS (r = -0.57, P = 0.0009). Also, moderate/intense pain was progressively (6/12 months) more frequent in cases developing hypoparathyroidism. The PTx type and hypoparathyroidism did not affect the QoL at 12 months although remnant parathyroid tissue volume did have a positive correlation (P = 0.0490; r = 0.3625) to PCS 12 months after surgery. Patients with one to two comorbidities had as pre-PTx PCS (P = 0.0015) as 12 months and post-PTx PCS (P = 0.0031) and MCS (P = 0.0365) better than patients with three to four comorbidities. CONCLUSION A variable QoL profile was underscored in HPT/MEN1 reflecting multiple factors associated with this complex disorder as comorbidities, advanced age at PTx and presence of preoperative symptoms or of general pain perception. Our data encourage the early indication of PTx in HPT/MEN1 by providing known metabolic benefits to target organs and avoiding potential negative impact on QoL.
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Affiliation(s)
- Marília D’Elboux Guimarães Brescia
- Endocrine Genetics Unit (LIM-25), Endocrinology Division, University of São Paulo School of Medicine (FMUSP), Faculdade de Medicina da Universidade de São Paulo (FMUSP), Hospital das Clinicas (HCFMUSP), São Paulo, São Paulo, Brazil
- Parathyroid Unit – LIM-28, Laboratório de Cirurgia de Cabeça e Pescoço, Division of Head and Neck Surgery, Department of Surgery, Hospital das Clinicas (HCFMUSP), University of São Paulo School of Medicine (FMUSP), Faculdade de Medicina, Universidade de São Paulo, São Paulo, São Paulo, Brazil
- Correspondence should be addressed to M D G Brescia:
| | - Karine Candido Rodrigues
- Endocrine Genetics Unit (LIM-25), Endocrinology Division, University of São Paulo School of Medicine (FMUSP), Faculdade de Medicina da Universidade de São Paulo (FMUSP), Hospital das Clinicas (HCFMUSP), São Paulo, São Paulo, Brazil
- Endocrine Oncology Division, Institute of Cancer of the State of São Paulo (ICESP), University of São Paulo School of Medicine (FMUSP), Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, São Paulo, Brazil
| | - André Fernandes d’Alessandro
- Parathyroid Unit – LIM-28, Laboratório de Cirurgia de Cabeça e Pescoço, Division of Head and Neck Surgery, Department of Surgery, Hospital das Clinicas (HCFMUSP), University of São Paulo School of Medicine (FMUSP), Faculdade de Medicina, Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Wellington Alves Filho
- Department of Surgery, Walter Cantidio University Hospital, Federal University of Ceara School of Medicine (FAMED-UFC), Fortaleza, Brazil
| | - Willemijn Y van der Plas
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Schelto Kruijff
- Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Sergio Samir Arap
- Parathyroid Unit – LIM-28, Laboratório de Cirurgia de Cabeça e Pescoço, Division of Head and Neck Surgery, Department of Surgery, Hospital das Clinicas (HCFMUSP), University of São Paulo School of Medicine (FMUSP), Faculdade de Medicina, Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Sergio Pereira de Almeida Toledo
- Endocrine Genetics Unit (LIM-25), Endocrinology Division, University of São Paulo School of Medicine (FMUSP), Faculdade de Medicina da Universidade de São Paulo (FMUSP), Hospital das Clinicas (HCFMUSP), São Paulo, São Paulo, Brazil
| | - Fábio Luiz de Menezes Montenegro
- Parathyroid Unit – LIM-28, Laboratório de Cirurgia de Cabeça e Pescoço, Division of Head and Neck Surgery, Department of Surgery, Hospital das Clinicas (HCFMUSP), University of São Paulo School of Medicine (FMUSP), Faculdade de Medicina, Universidade de São Paulo, São Paulo, São Paulo, Brazil
| | - Delmar Muniz Lourenço
- Endocrine Genetics Unit (LIM-25), Endocrinology Division, University of São Paulo School of Medicine (FMUSP), Faculdade de Medicina da Universidade de São Paulo (FMUSP), Hospital das Clinicas (HCFMUSP), São Paulo, São Paulo, Brazil
- Endocrine Oncology Division, Institute of Cancer of the State of São Paulo (ICESP), University of São Paulo School of Medicine (FMUSP), Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, São Paulo, Brazil
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Koman A, Bränström R, Pernow Y, Bränström R, Nilsson IL, Granath F. Neuropsychiatric Comorbidity in Primary Hyperparathyroidism Before and After Parathyroidectomy: A Population Study. World J Surg 2022; 46:1420-1430. [PMID: 35246714 PMCID: PMC9054898 DOI: 10.1007/s00268-022-06485-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2022] [Indexed: 11/29/2022]
Abstract
Background Primary hyperparathyroidism (PHPT) is often accompanied by neuropsychiatric symptoms. This study aimed to map out psychiatric comorbidity as reflected by medical treatment for psychiatric symptoms. Methods A retrospective case–control analysis and a prospective cohort analysis of psychotropic drug utilization before and after PTX. A total of 8279 PHPT patients treated with parathyroidectomy in Sweden between July 1, 2008 and December 31, 2017 compared to a matched control cohort from the total population (n = 82,790). Information on filled prescriptions was collected from the Swedish Prescribed Drug Register (SDR). Socioeconomic data and diagnoses were added by linkage to national patient and population registers. Regression analyses were used to calculate relative drug utilization (OR) within 3 years prior to PTX and relative incidence of drug treatment (RR) within 3 years postoperatively. Results Utilization of antidepressant, anxiolytic and sleep medication was more comprehensive in PHPT patients compared with the controls prior to PTX. The most common were benzodiazepines [OR 1.40 (95% CI: 1.31–1.50)] and selective serotonin reuptake inhibitors [SSRI; OR 1.38 (95% CI: 1.30–1.47)]. Postoperatively, the excess prescription rate for anxiolytic benzodiazepines decreased within three years from a 30 to 19% excess and for benzodiazepines for sleep from 31 to 14%. No corresponding decrease in excess prescription rate was observed for SSRI. Conclusion PHPT is associated with increased utilization of antidepressive medications and benzodiazepines before PTX. This study implies that psychiatric symptoms should be considered in PHPT patients and continuous medication should be reevaluated after PTX. Supplementary Information The online version contains supplementary material available at 10.1007/s00268-022-06485-1.
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Affiliation(s)
- A Koman
- Department of Breast, Endocrine Tumors and Sarcoma, Karolinska University Hospital, Stockholm, Sweden. .,Department of Molecular Medicine and Surgery, Karolinska Institutet, 171 76, Stockholm, Sweden.
| | - R Bränström
- Department of Breast, Endocrine Tumors and Sarcoma, Karolinska University Hospital, Stockholm, Sweden.,Department of Molecular Medicine and Surgery, Karolinska Institutet, 171 76, Stockholm, Sweden
| | - Y Pernow
- Department of Molecular Medicine and Surgery, Karolinska Institutet, 171 76, Stockholm, Sweden.,Department of Endocrinology, Karolinska University Hospital, Stockholm, Sweden
| | - R Bränström
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - I-L Nilsson
- Department of Breast, Endocrine Tumors and Sarcoma, Karolinska University Hospital, Stockholm, Sweden.,Department of Molecular Medicine and Surgery, Karolinska Institutet, 171 76, Stockholm, Sweden
| | - Fredrik Granath
- Department of Medicine Solna, Division of Clinical Epidemiology, Karolinska Institutet, Stockholm, Sweden
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37
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Management of Primary Hyperparathyroidism. Indian J Surg Oncol 2022; 13:143-151. [PMID: 35462664 PMCID: PMC8986895 DOI: 10.1007/s13193-021-01319-3] [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: 01/23/2021] [Accepted: 04/07/2021] [Indexed: 12/26/2022] Open
Abstract
Primary hyperparathyroidism (PHPT) is the unregulated overproduction of parathyroid hormone (PTH) resulting in abnormal calcium homeostasis. The disease profile has evolved over the last century from symptomatic hyperparathyroidism to asymptomatic hyperparathyroidism. Primary hyperparathyroidism is a biochemical diagnosis. Parathyroidectomy is the only established cure for this disease. Every effort is made to localize the offending gland preoperaively with various imaging modalities. These localization studies along with intraoperative parathormone monitoring will direct the surgeon to either a focused parathyroidectomy or a four gland exploration. All symptomatic patients and asymptomatic patients who meet the criteria for surgery should undergo parathyroidectomy if no medical contraindications exist. Pharmacologic approaches are reserved for those patients unfit or unwilling to undergo surgery.
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38
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Sutton W, Canner JK, Shank JB, Fingeret AL, Karzai S, Segev DL, Prescott JD, Mathur A. The impact of patient age on practice patterns and outcomes for primary hyperparathyroidism. Am J Surg 2022; 224:400-407. [DOI: 10.1016/j.amjsurg.2022.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 02/04/2022] [Accepted: 03/01/2022] [Indexed: 11/26/2022]
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Liu Y, Zhang L, Hu N, Shao J, Yang D, Ruan C, Huang S, Wang L, Lu WW, Zhang X, Yang F. An optogenetic approach for regulating human parathyroid hormone secretion. Nat Commun 2022; 13:771. [PMID: 35140213 PMCID: PMC8828854 DOI: 10.1038/s41467-022-28472-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2019] [Accepted: 01/25/2022] [Indexed: 02/08/2023] Open
Abstract
Parathyroid hormone (PTH) plays crucial role in maintaining calcium and phosphorus homeostasis. In the progression of secondary hyperparathyroidism (SHPT), expression of calcium-sensing receptors (CaSR) in the parathyroid gland decreases, which leads to persistent hypersecretion of PTH. How to precisely manipulate PTH secretion in parathyroid tissue and underlying molecular mechanism is not clear. Here, we establish an optogenetic approach that bypasses CaSR to inhibit PTH secretion in human hyperplastic parathyroid cells. We found that optogenetic stimulation elevates intracellular calcium, inhibits both PTH synthesis and secretion in human parathyroid cells. Long-term pulsatile PTH secretion induced by light stimulation prevented hyperplastic parathyroid tissue-induced bone loss by influencing the bone remodeling in mice. The effects are mediated by light stimulation of opsin expressing parathyroid cells and other type of cells in parathyroid tissue. Our study provides a strategy to regulate release of PTH and associated bone loss of SHPT through an optogenetic approach. Parathyroid hormone (PTH) plays a role in maintaining calcium and phosphorus homeostasis, and in secondary hyperparathyroidism excess PTH secretion contributes to bone loss. Here the authors report an optogenetic approach to inhibit PTH secretion in human hyperplastic parathyroid cells, and prevented hyperplastic parathyroid tissue-induced bone loss in mice.
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Affiliation(s)
- Yunhui Liu
- The Brain Cognition and Brain Disease Institute (BCBDI), Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences (CAS), Shenzhen-Hong Kong Institute of Brain Science-Shenzhen Fundamental Research Institutions, Shenzhen, China.,University of Chinese Academy of Sciences, Beijing, China
| | - Lu Zhang
- The Brain Cognition and Brain Disease Institute (BCBDI), Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences (CAS), Shenzhen-Hong Kong Institute of Brain Science-Shenzhen Fundamental Research Institutions, Shenzhen, China.,Department of Orthopaedics and Traumatology, The University of Hong Kong, Hong Kong SAR, China
| | - Nan Hu
- Department of Nephrology and Shenzhen Key Laboratory of Kidney Diseases, Shenzhen People's Hospital, The Second Clinical Medical College of Jinan University, Shenzhen, China
| | - Jie Shao
- The Brain Cognition and Brain Disease Institute (BCBDI), Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences (CAS), Shenzhen-Hong Kong Institute of Brain Science-Shenzhen Fundamental Research Institutions, Shenzhen, China.,University of Chinese Academy of Sciences, Beijing, China
| | - Dazhi Yang
- Department of Orthopedics, Union Shenzhen Hospital, Huazhong University of Science and Technology, Shenzhen, China
| | - Changshun Ruan
- Research Center for Human Tissue and Organs Degeneration, Institute of Biomedicine and Biotechnology, Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences (CAS), Shenzhen, China
| | - Shishu Huang
- Department of Orthopaedic Surgery and Orthopaedic Research Center, West China Hospital of Sichuan University, Chengdu, China
| | - Liping Wang
- The Brain Cognition and Brain Disease Institute (BCBDI), Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences (CAS), Shenzhen-Hong Kong Institute of Brain Science-Shenzhen Fundamental Research Institutions, Shenzhen, China
| | - William W Lu
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Hong Kong SAR, China
| | - Xinzhou Zhang
- Department of Nephrology and Shenzhen Key Laboratory of Kidney Diseases, Shenzhen People's Hospital, The Second Clinical Medical College of Jinan University, Shenzhen, China.
| | - Fan Yang
- The Brain Cognition and Brain Disease Institute (BCBDI), Shenzhen Institute of Advanced Technology, Chinese Academy of Sciences (CAS), Shenzhen-Hong Kong Institute of Brain Science-Shenzhen Fundamental Research Institutions, Shenzhen, China. .,University of Chinese Academy of Sciences, Beijing, China.
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40
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Purra S, Lone AA, Bhat MH, Misgar RA, Wani AI, Bashir MI, Masoodi SR, Purra W. Cardiac structural and functional abnormalities in primary hyperparathyroidism. J Endocrinol Invest 2022; 45:327-335. [PMID: 34324161 DOI: 10.1007/s40618-021-01645-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 07/17/2021] [Indexed: 12/22/2022]
Abstract
PURPOSE Studies on cardiac structural and functional abnormalities in primary hyperparathyroidism (PHPT) have yielded conflicting and inconsistent results. In this prospective case-control study, we sought to compare cardiac structure and function in symptomatic PHPT patients and controls. METHODS One hundred consecutive symptomatic PHPT patients and 113 matched controls underwent echocardiographic evaluation by the same operator. RESULTS Left ventricular mass index (LVMI) was significantly higher in patients as compared to controls, (median of 90.95 g/m2 vs 86.5 g/m2, p = 0.041). Patients had significantly lower early trans-mitral diastolic flow (E velocity) as compared to controls (57.13 ± 14.88 vs 64.76 ± 15.45 cm/s, p < 0.001). Patients also had significantly lower early to late mitral annular velocity (E/A) as compared to controls (0.98 ± 0.37 vs 1.10 ± 0.34, p 0.013). Patients had higher frequency of aortic valve calcification (29% vs 2.65%, p < 0.001), mitral annular calcification (23% vs. 4.42%, p < 0.001), myocardial and septal calcifications (25% vs none, p < 0.001) as compared to controls. Serum PTH, calcium and uric acid significantly correlated with calcifications. Serum calcium showed a negative correlation with E/A ratio. CONCLUSIONS Symptomatic patients with PHPT have substantial cardiac structural and functional abnormalities. These abnormalities include elevated LVMI, diastolic dysfunction, and aortic valve, mitral annular, septal and myocardial calcifications. We strongly suggest and conclude that the evaluation of PHPT patients should not only include traditional end organs like bones and kidneys but also the cardiovascular system in the form of echocardiography to detect subclinical cardiac dysfunction so that the cardiovascular health of such patients can be optimized.
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Affiliation(s)
- S Purra
- Department of Endocrinology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - A A Lone
- Department of Cardiology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - M H Bhat
- Department of Endocrinology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - R A Misgar
- Department of Endocrinology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India.
| | - A I Wani
- Department of Endocrinology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - M I Bashir
- Department of Endocrinology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - S R Masoodi
- Department of Endocrinology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India
| | - W Purra
- Department of Medicine, Government Medical College Srinagar, Srinagar, Jammu and Kashmir, India
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Matzen J, Bislev LS, Sikjær T, Rolighed L, Hitz MF, Eiken P, Hermann AP, Jensen JEB, Abrahamsen B, Rejnmark L. The effect of parathyroidectomy compared to non-surgical surveillance on kidney function in primary hyperparathyroidism: a nationwide historic cohort study. BMC Endocr Disord 2022; 22:14. [PMID: 34991581 PMCID: PMC8734053 DOI: 10.1186/s12902-021-00918-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 12/14/2021] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Patients with primary hyperparathyroidism (pHPT) and impaired kidney function (estimated glomerular filtration rate (eGFR) < 60 mL/min) are offered parathyroidectomy (PTX) to protect them from further complications. Surprisingly, two recent uncontrolled cohort studies have suggested a further decrease in kidney function following PTX. We aimed to examine the effects of PTX compared to non-surgical surveillance on kidney function in pHPT patients. METHODS Historic cohort study. From the Danish National Patient Registry (NPR) and major medical biochemistry laboratories in Denmark, we identified 3585 patients with biochemically confirmed pHPT among whom n = 1977 (55%) were treated with PTX (PTX-group) whereas n = 1608 (45%) were followed without surgery (non-PTX group). Baseline was defined as time of diagnosis and kidney function was re-assessed 9-15 months after PTX (PTX group) or 9-15 months after diagnosis (non-PTX group). RESULTS At follow-up, eGFR had decreased significantly in the PTX- compared to the non-PTX-group (median - 4% vs. - 1%, p < 0.01). Stratification by baseline eGFR showed that the decrease was significant for those with a baseline eGFR value of 80-89 and > 90 mL/min, but not for those with lower eGFR values. Findings did not differ between patients with mild compared to moderate/severe hypercalcemia. However, after mutual adjustments, we identified baseline levels of calcium, PTH, and eGFR as well as age and treatment (PTX vs. no-PTX) as independent predictors for changes in kidney function. CONCLUSION Compared to non-surgical surveillance, PTX is associated with a small but significant decrease in kidney function in pHPT patients with an initial normal kidney function.
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Affiliation(s)
- Josephine Matzen
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Lise Sofie Bislev
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Tanja Sikjær
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Lars Rolighed
- Department of Otorhinolaryngology, Aarhus University Hospital, Aarhus, Denmark
| | - Mette Friberg Hitz
- Department of Medical Endocrinology, Zealand University Hospital Køge, Køge, Denmark
- Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Pia Eiken
- Department of Endocrinology, Bispebjerg, Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Jens-Erik Beck Jensen
- Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Endocrinology, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Bo Abrahamsen
- Department of Clinical Research, University of Southern Denmark and Odense University Hospital, Odense C, Denmark
- Holbæk Hospital, Department of Medicine, Holbæk, Denmark
| | - Lars Rejnmark
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Aarhus, Denmark
- Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Scerrino G, Melfa G, Lo Brutto D, Mazzola S, Corigliano A, Vitale I, Tutino R, Rotolo G, Orlando G, Cocorullo G. Chronic asthenia in patients who have undergone endocrine neck surgery. Endocrine 2022; 75:159-168. [PMID: 34365588 DOI: 10.1007/s12020-021-02838-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 07/19/2021] [Indexed: 01/15/2023]
Abstract
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.
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Affiliation(s)
- Gregorio Scerrino
- Department of Surgical Oncological and Stomatological Disciplines, Unit of General and Emergency Surgery, University of Palermo, Via L. Giuffré, 5, 90127, Palermo, Italy
| | - Giuseppina Melfa
- Department of Surgical Oncological and Stomatological Disciplines, Unit of General and Emergency Surgery, University of Palermo, Via L. Giuffré, 5, 90127, Palermo, Italy.
| | - Daniela Lo Brutto
- Department of Surgical Oncological and Stomatological Disciplines, Unit of General and Emergency Surgery, University of Palermo, Via L. Giuffré, 5, 90127, Palermo, Italy
| | - Sergio Mazzola
- Unit of Clinical Epidemiology and Tumor Registry, Department of Laboratory Diagnostics, Policlinico "P. Giaccone", University of Palermo, Via L. Giuffré, 5, 90127, Palermo, Italy
| | - Alessandro Corigliano
- Department of Surgical Oncological and Stomatological Disciplines, Unit of General and Emergency Surgery, University of Palermo, Via L. Giuffré, 5, 90127, Palermo, Italy
| | - Irene Vitale
- Department of Surgical Oncological and Stomatological Disciplines, Unit of General and Emergency Surgery, University of Palermo, Via L. Giuffré, 5, 90127, Palermo, Italy
| | - Roberta Tutino
- Department of Surgical Oncological and Stomatological Disciplines, Unit of General and Emergency Surgery, University of Palermo, Via L. Giuffré, 5, 90127, Palermo, Italy
| | - Giulia Rotolo
- Department of Surgical Oncological and Stomatological Disciplines, Unit of General and Emergency Surgery, University of Palermo, Via L. Giuffré, 5, 90127, Palermo, Italy
| | - Giuseppina Orlando
- Department of Surgical Oncological and Stomatological Disciplines, Unit of General and Emergency Surgery, University of Palermo, Via L. Giuffré, 5, 90127, Palermo, Italy
| | - Gianfranco Cocorullo
- Department of Surgical Oncological and Stomatological Disciplines, Unit of General and Emergency Surgery, University of Palermo, Via L. Giuffré, 5, 90127, Palermo, Italy
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Seib CD, Meng T, Suh I, Harris AHS, Covinsky KE, Shoback DM, Trickey AW, Kebebew E, Tamura MK. Risk of Fracture Among Older Adults With Primary Hyperparathyroidism Receiving Parathyroidectomy vs Nonoperative Management. JAMA Intern Med 2022; 182:10-18. [PMID: 34842909 PMCID: PMC8630642 DOI: 10.1001/jamainternmed.2021.6437] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
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.
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Affiliation(s)
- Carolyn D Seib
- Stanford-Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University School of Medicine, Stanford, California.,Department of Surgery, Stanford University School of Medicine, Stanford, California.,Geriatric Research, Education and Clinical Center, Palo Alto Veterans Affairs Health Care System, Palo Alto, California
| | - Tong Meng
- Stanford-Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University School of Medicine, Stanford, California.,Department of Emergency Medicine, Stanford University School of Medicine, Stanford, California
| | - Insoo Suh
- Department of Surgery, New York University Grossman School of Medicine, New York, New York
| | - Alex H S Harris
- Stanford-Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University School of Medicine, Stanford, California.,Center for Innovation to Implementation, Palo Alto Veterans Affairs Health Care System, Palo Alto, California
| | | | - Dolores M Shoback
- Endocrine Research Unit, Department of Medicine, San Francisco Veterans Affairs Medical Center, University of California, San Francisco.,Department of Medicine, University of California, San Francisco
| | - Amber W Trickey
- Stanford-Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Electron Kebebew
- Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Manjula Kurella Tamura
- Geriatric Research, Education and Clinical Center, Palo Alto Veterans Affairs Health Care System, Palo Alto, California.,Division of Nephrology, Stanford University School of Medicine, Stanford, California
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Walker M, Silverberg SJ. Nontraditional Aspects of Sporadic Primary Hyperparathyroidism. Endocrinol Metab Clin North Am 2021; 50:629-647. [PMID: 34774238 DOI: 10.1016/j.ecl.2021.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Nontraditional aspects of primary hyperparathyroidism refer to the condition's rheumatic, gastrointestinal, cardiovascular, and neuropsychological effects. Although gastrointestinal and rheumatic symptomatology were features of classical primary hyperparathyroidism, they do not seem to be a part of the modern presentation of primary hyperparathyroidism. In contrast, neuropsychological symptoms such as altered mood and cognition, as well as cardiovascular disease, have been associated with the form of primary hyperparathyroidism seen today, but the relationship is not clearly causal. Evidence does not support reversibility after parathyroidectomy and therefore none of the nontraditional manifestations are considered sole indications for recommending surgery at this time.
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Affiliation(s)
- Marcella Walker
- Division of Endocrinology, Department of Medicine, Columbia University Irving Medical Center, New York, NY 10032, USA
| | - Shonni J Silverberg
- Division of Endocrinology, Department of Medicine, Columbia University, Columbia University Irving Medical Center, New York, NY 10032, USA.
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45
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Silva BC, Bilezikian JP. Skeletal abnormalities in Hypoparathyroidism and in Primary Hyperparathyroidism. Rev Endocr Metab Disord 2021; 22:789-802. [PMID: 33200346 DOI: 10.1007/s11154-020-09614-0] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/11/2020] [Indexed: 12/22/2022]
Abstract
Both hypoparathyroidism (HypoPT), as well as its pathological counterpart, primary hyperparathyroidism (PHPT), can lead to skeletal abnormalities. Chronic deficiency of PTH in patients with HypoPT is associated with a profound reduction in bone remodeling, with consequent increases in bone density, and abnormalities in microarchitecture and bone strength. It is still not clear whether there is an increase in fracture risk in HypoPT. While standard therapy with calcium supplements and active vitamin D does not restore bone homeostasis, treatment of HypoPT with PTH appears to correct some of those abnormalities. In PHPT, the continuous exposure to high levels of PTH causes an increase in bone remodeling, in which bone resorption prevails. In the symptomatic form of PHPT, patients can present with fragility fractures, and/or the classical radiological features of osteitis fibrosa cystica. However, even in mild PHPT, catabolic skeletal actions of PTH are evident through reduced BMD, deterioration of bone microarchitecture and increased risk of fragility fractures. Successful parathyroidectomy improves skeletal abnormalities. Medical treatment, such as bisphosphonates and denosumab, can also increase bone density in patients with PHPT who do not undergo surgery. This article reviews skeletal involvement in HypoPT and in PHPT, as assessed by bone remodeling, DXA, trabecular bone score, and quantitative computed tomography, as well as data on bone strength and fracture risk. The effects of PTH replacement on the skeleton in subjects with HypoPT, and the outcome of parathyroidectomy in patients with PHPT, are also reviewed here.
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Affiliation(s)
- Barbara C Silva
- Department of Medicine, Centro Universitario de Belo Horizonte - UNI BH, Belo Horizonte, Brazil
- Endocrinology Unit, Felicio Rocho Hospital, Belo Horizonte, Brazil
- Endocrinology Unit, Santa Casa Hospital, Belo Horizonte, Brazil
| | - John P Bilezikian
- Metabolic Bone Diseases Unit, Division of Endocrinology, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, 630 W. 168th Street, PH 8E: 105G, New York, NY, 10032, USA.
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46
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Park SY, Scotting O, Yen TWF, Evans DB, Wang TS, Dream S. Underdiagnosis of primary hyperparathyroidism in patients with osteoarthritis undergoing arthroplasty. Surgery 2021; 171:731-735. [PMID: 34844753 DOI: 10.1016/j.surg.2021.09.035] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 08/31/2021] [Accepted: 09/29/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Primary hyperparathyroidism (HPT) is commonly underdiagnosed and undertreated. Joint pain is a nonspecific symptom associated with osteoarthritis or primary HPT. We hypothesize that patients treated for osteoarthritis are underdiagnosed with primary HPT. METHODS Adult patients diagnosed with hip/knee osteoarthritis at the Medical College of Wisconsin from January 2000 to October 2020 were queried. Patients with a calcium level drawn within 1 year of diagnosis of osteoarthritis were included. Patients who had undergone prior parathyroidectomy were excluded. Patients were stratified by serum calcium level, HPT diagnosis, and PTH level. Arthroplasty rates were compared between groups. RESULTS Of 54,788 patients, 9,967 patients (18.2%) had a high serum calcium level, of whom 1,089 (10.9%) had a diagnosis of HPT. Only 76 (7.0%) patients with HPT underwent parathyroidectomy, 208 (19.1%) underwent knee/hip arthroplasty, and 14 (1.3%) underwent both. Arthroplasty was performed in 1,793 patients without evaluation and/or definitive treatment for HPT. There were higher rates of arthroplasty performed in patients with a high serum calcium level compared with those without (21.2% vs 17.4%, P < .001). CONCLUSION Patients with high serum calcium levels were more likely to undergo arthroplasty than those with normocalcemia. Hypercalcemia in the setting of hip or knee osteoarthritis should prompt a full evaluation for primary HPT.
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Affiliation(s)
- Sarah Y Park
- Medical College of Wisconsin, Department of Surgery, Milwaukee, WI
| | - Oliver Scotting
- Medical College of Wisconsin, Department of Orthopedic Surgery, Milwaukee, WI. https://twitter.com/OScotting
| | - Tina W F Yen
- Medical College of Wisconsin, Department of Surgery, Milwaukee, WI
| | - Douglas B Evans
- Medical College of Wisconsin, Department of Surgery, Milwaukee, WI
| | - Tracy S Wang
- Medical College of Wisconsin, Department of Surgery, Milwaukee, WI. https://twitter.com/tracyswangNYMKE
| | - Sophie Dream
- Medical College of Wisconsin, Department of Surgery, Milwaukee, WI.
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47
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Hope TA, Graves CE, Calais J, Ehman EC, Johnson GB, Thompson D, Aslam M, Duh QY, Gosnell JE, Shen WT, Roman SA, Sosa JA, Kluijfhout WP, Seib CD, Villaneuva-Meyer JE, Pampaloni MH, Suh I. Accuracy of 18F-Fluorocholine PET for the Detection of Parathyroid Adenomas: Prospective Single-Center Study. J Nucl Med 2021; 62:1511-1516. [PMID: 33674400 PMCID: PMC8612343 DOI: 10.2967/jnumed.120.256735] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 02/03/2021] [Indexed: 11/16/2022] Open
Abstract
The purpose of this prospective study was to determine the correct localization rate (CLR) of 18F-fluorocholine PET for the detection of parathyroid adenomas in comparison to 99mTc-sestamibi imaging. Methods: This was a single-arm prospective trial. Ninety-eight patients with biochemical evidence of primary hyperparathyroidism were imaged before parathyroidectomy using 18F-fluorocholine PET/MRI. 99mTc-sestamibi imaging performed separately from the study was evaluated for comparison. The primary endpoint of the study was the CLR on a patient level. Each imaging study was interpreted by 3 masked readers on a per-region basis. Lesions were validated by histopathologic analysis of surgical specimens. Results: Of the 98 patients who underwent 18F-fluorocholine PET, 77 subsequently underwent parathyroidectomy and 60 of those had 99mTc-sestamibi imaging. For 18F-fluorocholine PET in patients who underwent parathyroidectomy, the CLR based on the masked reader consensus was 75% (95% CI, 0.63-0.82). In patients who underwent surgery and had an available 99mTc-sestamibi study, the CLR increased from 17% (95% CI, 0.10-0.27) for 99mTc-sestamibi imaging to 70% (95% CI, 0.59-0.79) for 18F-fluorocholine PET. Conclusion: In this prospective study using masked readers, the CLR for 18F-fluorocholine PET was 75%. In patients with a paired 99mTc-sestamibi study, the use of 18F-fluorocholine PET increased the CLR from 17% to 70%. 18F-fluorocholine PET is a superior imaging modality for the localization of parathyroid adenomas.
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Affiliation(s)
- Thomas A Hope
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California
- Department of Radiology, San Francisco VA Medical Center, San Francisco, California
| | - Claire E Graves
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Jeremie Calais
- Ahmanson Translational Theranostics Division, Department of Molecular and Medical Pharmacology, UCLA, Los Angeles, California
| | - Eric C Ehman
- Department of Radiology, Mayo Clinic, Rochester, Minnesota
| | - Geoffrey B Johnson
- Department of Radiology, Mayo Clinic, Rochester, Minnesota
- The Department of Immunology, Mayo Clinic, Rochester, Minnesota
| | - Daniel Thompson
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California
| | - Maya Aslam
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California
| | - Quan-Yang Duh
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Jessica E Gosnell
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Wen T Shen
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Sanziana A Roman
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Julie A Sosa
- Department of Surgery, University of California San Francisco, San Francisco, California
| | - Wouter P Kluijfhout
- Department of Surgical Oncology and Endocrine Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Carolyn D Seib
- Department of Surgery, Stanford University, Stanford, California; and
| | - Javier E Villaneuva-Meyer
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California
| | - Miguel H Pampaloni
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California
| | - Insoo Suh
- Department of Surgery, University of California San Francisco, San Francisco, California;
- Department of Surgery, New York University Langone Health, New York, New York
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48
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Khan R, Martin J, Das G. The Impact of Observation Versus Parathyroidectomy on Bone Mineral Density and Fracture Risk Determined by FRAX Tool in Patients With Primary Hyperparathyroidism. J Clin Densitom 2021; 24:571-580. [PMID: 33390308 DOI: 10.1016/j.jocd.2020.12.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 12/09/2020] [Accepted: 12/10/2020] [Indexed: 11/27/2022]
Abstract
To study impact of observation (OBV) vs parathyroidectomy (PTX) on biochemistry, bone mineral density (BMD) and fracture risk calculated by Fracture Risk Assessment (FRAX) tool in primary hyperparathyroidism (PHPT). Retrospective study of 60 patients (OBV - 26; PTX - 34 patients). Mean adjusted calcium improved in both groups [OBV - 2.76 ± 0.07 vs 2.51 ± 0.20 mmol/L; p < 0.00001, PTX - 2.87 ± 0.21 vs 2.36 ± 0.12 mmol/L; p < 0.00001]. Mean parathyroid hormone level declined in both but more in PTX group [OBV - 11.4 ± 5.2 vs. 9.7 ± 5.6 pmol/L; p = 0.04, PTX - 14.3 ± 8.2 vs 4.6 ± 2.2 pmol/L; p < 0.00001]. In OBV group, BMD and T scores declined at all sites. Mean percentage change of BMD was -5.8 % at femoral neck (FN), -4.9 % at total hip (TH), -6.2 % at lumbar spine (LS) and -10.0 % at lower 1/3rd radius (LR). PTX led to stabilization of BMD at FN (3.0 %), TH (-0.6 %) and LS (2.2 %) but significant improvement at LR (13.9 %; p = 0.0005). In OBV group, 10 year risk of hip fracture (HF) (7.5 ± 9.0 % vs. 8.6 ± 9.0; p = 0.01) and major osteoporotic fracture (OF) (16.6 ± 10.9 % vs 18.3 ± 10.8 %; p = 0.002) worsened with time whereas in PTX group, risk of both type of fractures remained stable (HF; p = 0.48 and OF; p = 0.43). Comparison between groups showed greater improvement in median % change of fracture risk for both HF and OF in PTX group. OBV in PHPT lead to greater decline in BMD at all skeletal sites and imparted significant risk of HF and major OF. PTX offered stabilization of BMD at most sites but improvement at LR with unchanged fracture risk. FRAX tool should be used more frequently and universally.
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Affiliation(s)
- Rahim Khan
- Specialist Trainee in Endocrinology, Royal Glamorgan Hospital, Cwm Taf Morgannwg University Health Board, Llantrisant, United Kingdom
| | - James Martin
- Consultant in Rheumatology, Royal Glamorgan Hospital, Cwm Taf Morgannwg University Health Board, Llantrisant, United Kingdom
| | - Gautam Das
- Consultant in Endocrinology, Prince Charles Hospital, Cwm Taf Morgannwg University Health Board, Merthyr Tydfil, United Kingdom.
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Мокрышева НГ, Еремкина АК, Мирная СС, Крупинова ЮА, Воронкова ИА, Ким ИВ, Бельцевич ДГ, Кузнецов НС, Пигарова ЕА, Рожинская ЛЯ, Дегтярев МВ, Егшатян ЛВ, Румянцев ПО, Андреева ЕН, Анциферов МБ, Маркина НВ, Крюкова ИВ, Каронова ТЛ, Лукьянов СВ, Слепцов ИВ, Чагай НБ, Мельниченко ГА, Дедов ИИ. [The clinical practice guidelines for primary hyperparathyroidism, short version]. PROBLEMY ENDOKRINOLOGII 2021; 67:94-124. [PMID: 34533017 PMCID: PMC9753843 DOI: 10.14341/probl12801] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 08/19/2021] [Indexed: 12/14/2022]
Abstract
Primary hyperparathyroidism (PHPT) is an endocrine disorder of parathyroid glands characterized by excessive secretion of parathyroid hormone (PTH) with an upper normal or elevated blood calcium level. Classical PHPT refers to a symptomatic, multi-system disorder, wich can lead to a significant decrease in the quality of life, disability of patients, and even an increased risk of premature death. Hypercalcemia and the catabolic effect of PTH on various cells are considered as the main pathogenetic mechanisms of the PHPT associated complications. In the last two decades, there has been an increase in the incidence of PHPT, mainly due to the mild forms of the disease, primarily due to the routine calcium screening in North America, Western Europe and, Asia. High prevalence of the disease, as well as the variety of clinical manifestations, cause the attention of different specialists - physicians, rheumatologists, urologists, nephrologists, cardiologists and other doctors. This review cover the main issues of Russian guidelines for the management of PHPT, approved in 2020, including laboratory and instrumental methods, differential diagnosis, surgical and conservative approach, short-term and long-term follow-up. This guidelines also include the recommendations for special groups of patients with hereditary forms of PHPT, parathyroid carcinoma, PHPT during pregnancy.
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Affiliation(s)
- Н. Г. Мокрышева
- Национальный медицинский исследовательский центр эндокринологии
| | - А. К. Еремкина
- Национальный медицинский исследовательский центр эндокринологии
| | | | - Ю. А. Крупинова
- Национальный медицинский исследовательский центр эндокринологии
| | - И. А. Воронкова
- Национальный медицинский исследовательский центр эндокринологии
| | - И. В. Ким
- Национальный медицинский исследовательский центр эндокринологии
| | - Д. Г. Бельцевич
- Национальный медицинский исследовательский центр эндокринологии
| | - Н. С. Кузнецов
- Национальный медицинский исследовательский центр эндокринологии
| | - Е. А. Пигарова
- Национальный медицинский исследовательский центр эндокринологии
| | - Л. Я. Рожинская
- Национальный медицинский исследовательский центр эндокринологии
| | - М. В. Дегтярев
- Национальный медицинский исследовательский центр эндокринологии
| | - Л. В. Егшатян
- Национальный медицинский исследовательский центр эндокринологии
| | | | - Е. Н. Андреева
- Национальный медицинский исследовательский центр эндокринологии
| | - М. Б. Анциферов
- Эндокринологический диспансер Департамента здравоохранения города Москвы
| | - Н. В. Маркина
- Эндокринологический диспансер Департамента здравоохранения города Москвы
| | - И. В. Крюкова
- Московский областной научно-исследовательский клинический институт им. М.Ф. Владимирского
| | - Т. Л. Каронова
- Национальный медицинский исследовательский центр им. В.А. Алмазова
| | | | | | - Н. Б. Чагай
- Ставропольский государственный медицинский университет
| | | | - И. И. Дедов
- Национальный медицинский исследовательский центр эндокринологии
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50
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Lecourt A, Creff G, Coudert P, De Crouy Chanel O, Guggenbuhl P, Jegoux F. Surgical management of MILD hyperparathyroidism. Eur Arch Otorhinolaryngol 2021; 278:3901-3910. [PMID: 34328555 DOI: 10.1007/s00405-021-06953-9] [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: 04/02/2021] [Accepted: 06/21/2021] [Indexed: 11/24/2022]
Abstract
INTRODUCTION There is no consensus for management of Mild primary hyperparathyroidism (MILD-pHP). Specific management has been suggested by some authors. We have compared the surgical management of the patients with MILD-pHP to those with Classic primary hyperparathyroidism (C-pHP) treated by surgery according to The Fourth International Workshop on pHP. MATERIALS AND METHODS Data of 173 patients who underwent a parathyroidectomy were reviewed and retrospectively analysed. Management of 32 patients with MILD-pHPT (18.5%) patients were compared to that of 141 (81.5%) patients with C-pHPT. RESULTS MILD-pHP group was more often discovered after non-fractured osteoporosis (21.9% vs 7.1%, p = 0.02) and surgery for chondrocalcinosis was more often carried out (6.3% vs 0%, p = 0.03) in the MILD-pHP group. A Mini-Invasive Parathyroidectomy (MIP) was carried out in 81.3% of cases, and 87.5% of patients had a single adenoma. The rate of multiglandular pathology was not different. Same day discharge was significantly higher in MILD-pHP group (37.5% vs 17.7%, p = 0.01). Success was obtained in 87.5% in the MILD-pHP group, there was no significant difference with the C-pHP group (92.9%, p = 0.48). There was no significant difference in the imaging performances. Imaging discordance was observed in 18.8% of cases in MILD-pHP and 33.6% in C-pHP (p = 0.38) without correlation with surgical failure. CONCLUSION This study suggests that, by selecting patients on the basis of concordant imaging and international recommendations, there is no difference in outcome between MILD-pHP and C-pHP treated surgically.
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Affiliation(s)
- Adèle Lecourt
- ENT Department, Rennes University Medical Center, 35000, Rennes, France. .,Service d'ORL et de Chirurgie Cervico-Faciale, CHU de Rennes, 2 Rue Henri Le Guilloux, 35000, Rennes Cedex, France.
| | - Gwenaëlle Creff
- ENT Department, Rennes University Medical Center, 35000, Rennes, France
| | - Paul Coudert
- ENT Department, Rennes University Medical Center, 35000, Rennes, France
| | | | - Pascal Guggenbuhl
- Rheumatologic Department, Rennes University Medical Center, Rennes 1 University, INSERM, Institut NUMECAN (Nutrition Metabolisms and Cancer), 35000, Rennes, France
| | - Franck Jegoux
- ENT Department, Rennes University Medical Center, 35000, Rennes, France
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