Health-related quality of life is impaired in primary hyperparathyroidism and significantly improves after surgery: a prospective study using the 15D instrument

Clinical characteristics and outcomes of patients operated for primary hyperparathyroidism at Tampere University Hospital in 2017-2018

BACKGROUND AND OBJECTIVE

Studies on the outcomes of parathyroid surgery are scarce. The aim was to report the outcomes and to study the association between pre- and peri-operative information with the outcomes of patients operated for primary hyperparathyroidism.

METHODS

This was a retrospective, descriptive study with unselected patients treated surgically for primary hyperparathyroidism from a catchment population of 704,500 in Finland. Data were acquired from the electronic hospital registers based on parathyroid surgery procedure codes between 1 January 2017 and 31 December 2018. Preoperative data, surgical data, preoperative and postoperative laboratory values, histopathological findings, and postoperative clinical data were recorded.

RESULTS

During the 2-year study period, 149 patients with primary hyperparathyroidism were treated surgically with a 97% remission rate. Surgical complications included postoperative bleeding in two patients (1%) and vocal cord paralysis in one patient (0.6%). No postoperative infections were reported. Three patients (2%) developed postoperative hypoparathyroidism necessitating the use of alfacalcidol more than 1 month after surgery. Ionized calcium measured 0-1 days after surgery was not statistically significantly associated with remission or postoperative hypoparathyroidism. Serum parathyroid hormone (PTH) assessed 0-1 days postoperatively was associated with persistent disease, but not with postoperative hypoparathyroidism. The histopathological diagnosis was adenoma or hyperplasia in 112 patients (75%), atypical adenoma in 28 patients (19%), and carcinoma in five patients (3%). Patients with parathyroid carcinoma had higher preoperative ionized calcium and PTH values than those with adenoma or hyperplasia.

CONCLUSIONS

Most patients who were operated due to primary hyperparathyroidism achieved normocalcemia after surgery, and the frequency of complications was low. Ionized calcium taken 0-1 days after surgery was not associated with remission of hyperparathyroidism or postoperative hypoparathyroidism. High postoperative serum PTH predicted persistent disease.

Improved sexual function after parathyroidectomy in women with primary hyperparathyroidism

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Quality of life in patients with primary hyperparathyroidism before and after parathyroidectomy: long term single center experience

BACKGROUND

Primary hyperparathyroidism (PHPT) is a common endocrine disorder caused by a parathyroid tumor or hyperplasia, which is often accompanied with quality of life (QoL) impairment. A parathyroidectomy (PTX) is the preferred standard treatment for PHPT patients. In this single center study we aimed to evaluate the impact of PHPT on patient's QoL and identify QoL changes at early and long-term follow-up after surgery.

METHODS

All the patients underwent routine PTX with the removal of the suspected hyperparathyroid gland(s). Patients filled out generic QoL questionnaire RAND SF-36, specific questionnaire PHPQoL and specific symptom assessment questionnaire PAS upon admission to the hospital before surgery, at 3 months, 12 months and 24 months after surgery.

RESULTS

A total of 92 patients with PHPT (median age was 56 years, 95.7% females) were included in the study. Before PTX patient's QoL by SF-36 scores was significantly lower as compared to healthy controls (p < 0.01). Almost 40% of patients had poor or very poor QoL. The most frequent symptoms by PAS before surgery were as follows: tiredness (97.8% of patients), weakness (94.6%), forgetfulness (94.6%), mood changes (90%), feeling "blue"/depression (88%), joint pains (83.3%), headaches (80.2%), constant irritability (77.2%), bone pains (75%), thirst (70.7%) and trouble getting out of a chair (67.4%). The half of the patients had moderate-to-severe (≥ 40 scores) tiredness, weakness, joint pains, forgetfulness, as well as mood changes. Post-operative QoL changes were analysed in the group of 72 patients. After surgery there was significant improvement in QoL by all scales of SF-36 questionnaire, excluding bodily pain, and the PHPQoL total score (GEE, p < 0.01) as compared with their values before surgery. Also severity of tiredness, mood changes, weakness and forgetfulness significantly decreased after surgery as compared to their baseline values (GEE, p < 0.05). Decreased mental component of QoL by PHPQoL (OR = 0.927, 95%CI = 0.874-0.984, p = 0.013) predicted improved QoL after surgery.

CONCLUSIONS

Patients with PHPT demonstrated significantly impaired QoL in physical, psychological and social functioning as well experienced a wide profile of common PHPT symptoms. Successful PTX was accompanied with remarkable QoL improvement and decrease in subjective symptoms for at least 24 months after surgery.

Quality of Life in Primary Hyperparathyroidism

Quality of life is impaired in primary hyperparathyroidism (PHPT), regardless of the severity of the disease. Clinical studies have employed different instruments, including standardized and disease-specific questionnaires, and including patients with different phenotypes of PHPT. Neuropsychiatric symptoms and decline in cognitive status are common in PHPT. Patients may complain of these issues or they can be ascertained by questionnaires; they include depression, anxiety, impaired vitality, social and emotional functions, sleep disturbances, and altered mental function. Randomized controlled trials on the effects of surgical versus non-surgical treatments have collectively shown improvement in quality of life after parathyroidectomy, but results have been heterogeneous.

Classical and Nonclassical Manifestations of Primary Hyperparathyroidism

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).

Long-term Quality of Life After Parathyroidectomy for Primary Hyperparathyroidism: A Systematic Review

Importance

Definitive treatment of primary hyperparathyroidism (pHPT) with curative parathyroidectomy has been shown to improve nonspecific neurocognitive symptoms and may improve long-term quality of life (QOL). However, QOL is not currently routinely assessed preoperatively, and as a result, diminished QOL may be overlooked as an indication for surgery.

Objective

To examine results for measures of long-term QOL after parathyroidectomy in patients with pHPT.

Evidence Review

A systematic, English-language literature review was performed to assess the long-term association of parathyroidectomy, defined as a minimum of 1-year postoperative follow-up, with QOL in patients with pHPT. We conducted a search of PubMed and Scopus using Medical Subject Heading (MeSH) terms for hyperparathyroidism, parathyroid hormone, parathyroidectomy, hypercalcemia, and quality of life. All relevant literature published between June 1998 and February 15, 2021, was included. Study selection was guided by the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) strategy.

Findings

Thirty-one studies conducted in 14 countries with a minimum of 1 year of follow-up were included, comprising 3298 patients with pHPT (2975 underwent parathyroidectomy; 323 were observed), 5445 age- and sex-matched control participants, and 386 control patients with benign thyroid disease. To assess QOL, 21 studies (68%) used a general tool, the 36-item Short Form Survey (SF-36), and 8 (26%) used the disease-specific tool Parathyroidectomy Assessment of Symptoms (PAS). The remaining studies used a combination of 10 additional QOL tools. The median follow-up period was 1 year (range, 1-10 years). Of the 31 studies, 27 (87%) demonstrated significant score improvement in long-term QOL after parathyroidectomy, including 1 study that showed continued improvement in QOL 10 years after parathyroidectomy. The remaining 4 studies (13%) reported mixed results.

Conclusions and Relevance

This systematic review suggests that parathyroidectomy is associated with improved and sustained QOL in patients with pHPT. Patients with pHPT should be screened with a validated QOL tool such as the SF-36 or PAS at the time of diagnosis to guide discussion of these symptoms in the preoperative setting and the potential for long-term improvement after curative parathyroidectomy.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

[Quality of life in patients with primary hyperparathyroidism after surgery]

BACKGROUND

For a comprehensive assessment of the effect of surgery in patients with primary hyperparathyroidism (PHPT), as well as for monitoring the condition of patients after treatment, it sounds reasonable to evaluate quality of life (QoL) and symptoms in PHPT patients before and after surgery.

AIM

The aim of this study was to assess changes in the QoL and symptoms in patients with PHPT after surgery.

MATERIALS AND METHODS

During prospective observational study, patients filled out QoL questionnaires and evaluated the presence and severity of their symptoms prior to parathyroidectomy (PTE) and 3, 12 months after surgery. Statistical analysis included the following methods: Student's t-test or Wilcoxon's non-parametric test, the generalized estimating equations (GEE), correlation analysis, χ2 and McNemar tests.

RESULTS

The study included 72 patients (mean age 52 years, 97.2% female) with symptomatic (68.1%) and asymptomatic (31.9%) PHPT. Before surgery patients with PHPT exhibited significantly decreased role functioning, physical and social well-being, and vitality. Half of PHPT patients experienced moderate-to-severe symptoms such as weakness, fatigue, loss of concentration, mood changes, as well as joint and bone pain; the association between symptoms experienced and the extent of QoL impairment before surgery was shown. Three months after PTE improvement in both physical and psychological components of QoL was shown. Positive QoL changes were demonstrated in patients with both symptomatic and asymptomatic PHPT and they preserved for 12 months after surgery. Also within 12 months after PTE significant decrease in PHPT-associated symptoms such as weakness, fatigue, loss of concentration and mood changes was found.

CONCLUSION

The results obtained demonstrate efficacy of PTE from the patient's perspective and confirm the value of QoL assessment in PHPT patients in management of this patients' population both for decision making and for evaluation of benefits of surgery and the degree of recovery of patients at long term follow-up.

Nontraditional Aspects of Sporadic Primary Hyperparathyroidism

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.

[Assessment of the quality of life of patients after parathyroidectomy from standard and small access]

ОБОСНОВАНИЕ. Первичный гиперпаратиреоз (ПГПТ) — это повышение секреторной активности околощитовидных желез (ОЩЖ) вследствие их опухолевого или гиперпластического изменения. Ввиду отсутствия эффективной альтернативы лечению ПГПТ хирургический способ по-прежнему остается единственным верным тактическим решением ведения больных с установленным диагнозом ПГПТ. В работе представлены отдаленные результаты и оценка качества жизни больных, перенесших хирургическое лечение из стандартного и малого доступов. Полученные результаты показали перспективность щадящего подхода к лечению ПГПТ, обусловленного аденомой ОЩЖ.ЦЕЛЬ. Изучение эффективности хирургического лечения ПГПТ на основании оценки качества жизни больных, перенесших паратиреоидэктомию из стандартного и малого доступов.МАТЕРИАЛЫ И МЕТОДЫ. Проведено ретроспективное исследование качества жизни пациентов с ПГПТ после хирургического лечения с использованием опросника SF-36 и линейной аналоговой шкалы (ЛАШ). Статистическая обработка данных выполнена на языке программирования R с использованием пакета FMSB. Количественные параметры были представлены в виде медианы (Меdian) и интерквартильного размаха (25-й (1st Qu) — нижний квартиль и 75-й (3rd Qu) — верхний квартиль). В качестве непараметрического статистического критерия использован U-критерий Манна–Уитни (Mann–Whitney U-test), на основании которого произведен расчет p-value. Расчетные данные результатов исследования представлены в графическом виде — в виде столбчатых диаграмм, spider plot и barplot.РЕЗУЛЬТАТЫ. В настоящем исследовании приняли участие 264 пациента. Пациенты были разделены на 2 группы: ГР1 — пациенты, оперированные из доступа по Кохеру с обязательной ревизией всех 4 ОЩЖ, ГР2 — пациенты, получившие оперативное лечение из малого доступа с удалением измененной ОЩЖ, без ревизии остальных ОЩЖ. При проведении анализа качества жизни пациентов до операции статистически значимых различий в группах по показателю PF (Physical Functioning) и VT (Vitality) выявлено не было. Проведение паратиреоидэктомии из малого доступа (пациенты ГР2) статистически значимо повышало качество жизни по домену GH (General Health) и VT (Vitality). Анализ ЛАШ до операции между группами не показал статистически значимых различий, в то время как после хирургического лечения показатели по ЛАШ отличаются в сторону улучшения в ГР2.ЗАКЛЮЧЕНИЕ. Результаты, полученные в ходе исследования, показали перспективность щадящего подхода к лечению ПГПТ, обусловленного аденомой ОЩЖ, что отражено в более высоких показателях качества жизни.

Long-term health-related quality of life in persons diagnosed with an insulinoma in Finland 1980-2010

OBJECTIVE

Insulinomas are rare pancreatic neoplasms, which can usually be cured by surgery. As the diagnostic delay is often long and the prolonged hyperinsulinemia may have long-term effects on health and the quality of life, we studied the long-term health-related quality of life (HRQoL) in insulinoma patients.

DESIGN, PATIENTS AND MEASUREMENTS

The HRQoL of adults diagnosed with an insulinoma in Finland in 1980-2010 was studied with the 15D instrument, and the results were compared to those of an age- and gender-matched sample of the general population. The minimum clinically important difference in the total 15D score has been defined as ±0.015. The clinical characteristics, details of insulinoma diagnosis and treatment, and the current health status of the subjects were examined to specify the possible determinants of long-term HRQoL.

RESULTS

Thirty-eight insulinoma patients participated in the HRQoL survey (response rate 75%). All had undergone surgery with a curative aim, a median of 13 (min 7, max 34) years before the survey. The insulinoma patients had a clinically importantly and statistically significantly better mean 15D score compared with the controls (0.930 ± 0.072 vs 0.903 ± 0.039, P = .046) and were significantly better off regarding mobility, usual activities and eating. Among the insulinoma patients, younger age at the time of survey, higher level of education and smaller number of chronic diseases were associated with better overall HRQoL.

CONCLUSIONS

In the long term, the overall HRQoL of insulinoma patients is slightly better than that of the general population.

The effect of parathyroidectomy on quality of life in primary hyperparathyroidism: evaluation with using sf-36 and phpqol questionnaire

Quality of life (QoL) typically improves with a parathyroidectomy (PTx) in cases of primary hyperparathyroidism (PHPT), but the effect of surgery on QoL is not yet fully understood. This study evaluated the impact of PTx on health-related QoL (HRQoL). Patients who underwent PTx for PHPT between January 2016 and December 2019 were asked to complete the 36-Item Short Form Health Survey (SF-36) and the Primary Hyperparathyroidism Quality of Life (PHPQoL) questionnaire before surgery and 1 year later. A 5-point Likert scale was used: negative responses received a lower score and positive responses scored high. Forty-one of 50 patients completed the questionnaires before and 12 months after the surgery. The median patient age was 64 years (min-max: 32-83 years). In the study group, 33 were female, and 8 were male. The SF-36 results indicated that significant improvements had been observed in all 8 domains a year after surgery, particularly in the physical functioning and role, general health, energy, and mental health scales. The PHPQoL scores also improved significantly after PTx (p < 0.05). The improvement in the physical and mental health components was 50% and 76%, respectively. In conclusion, this study demonstrated that PTx for PHPT improved QoL.

[Validation and testing of the Russian version of PHPQoL questionnaire for quality of life assessment in patients with primary hyperparathyroidism (PHPT)]

BACKGROUND

 Quality of life (QoL) assessment before and after surgical treatment in patients with primary hyperparathyroidism (PHTP) may be useful for comprehensive evaluation of the treatment effect, as well as for monitoring of the patient' condition after surgery, including in real clinical practice.

AIM

 The aim of the study was to validate and test the Russian version of the PHPQoL questionnaire for assessment of the quality of life (QoL) in patients with primary hyperparathyroidism (PHPT) for further application in clinical practice and research in Russia.

MATERIALS AND METHODS

 The linguistic and cultural adaptation of the PHPQoL questionnaire was carried out in accordance with international guidelines. Psychometric properties of the tool, namely, its reliability, validity and sensitivity were tested in the focus group of patients with PHPTResults: In the whole, 65 patients with PHPT were involved into the study (mean age - 52.3 ± 10.5 years, 97% - -women): 67.7% patients were symptomatic, 35.4% patients had moderate or severe hypercalcemia. All the patients filled out the Russian version of PHPQoL before parathyroidectomy. One third of patients filled out the Russian version of PHPQoL twice - before surgery and 3 months after surgery. Satisfactory external and content validity of the Russian version of PHPQoL was demonstrated. Its stable structure confirmed satisfactory construct validity of the questionnaire. The ability of the tool to determine differences in severity of symptoms/problems due to PHPT before and after treatment was revealed. The positive effect of the surgery on QoL in PHPT patients was shown.

CONCLUSION

 The results obtained during the study confirm that the Russian version of PHPQoL is a reliable, valid and sensitive tool. Feasibility and applicability of its use in research and clinical practice in Russian endocrinology settings has been demonstrated.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Oral findings and treatment of patients with face transplants in Helsinki

OBJECTIVES

Oral health and balanced occlusion are important aspects of a well-functioning face transplant. This study describes the oral and dental status, dental management, and sialoendoscopy of the first 2 patients in Helsinki who underwent face transplantations.

STUDY DESIGN

Two patients received near-full face transplantations in 2016 and 2018, respectively. The transplanted tissues included a Le Fort type II maxilla, angle-to-angle mandible, all oral mucosa, ventral tongue tissue, and the muscles of the floor of the mouth. Comprehensive oral examinations and all required dental treatment, including follow-up examinations, were performed for both patients after the transplantations.

RESULTS

Both patients rehabilitated well, and their quality of life improved. Stable, functioning dentition and occlusion were achieved for both patients. Hyposalivation and dental caries were issues for both patients. Patient 1 also experienced infections in the jaws. Implants were placed in the transplanted jaws of patient 2 with successful osseointegration.

CONCLUSIONS

We report successful tooth-bearing face transplantations in 2 patients. Patient selection, particularly regarding oral health, is crucial in avoiding posttransplantation complications. Moreover, the oral and dental status of the donor should be examined by a dentist before transplantation, and regular follow-up dental examinations should be performed after transplantation.

Diagnostic and treatment delay in primary hyperparathyroidism. A pending issue

INTRODUCTION

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

OBJECTIVE

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

METHODS

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

RESULTS

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

DISCUSSION

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

Clinical characteristics and depression score response after parathyroidectomy in primary hyperparathyroidism

OBJECTIVE

Several studies indicate that patients with primary hyperparathyroidism (PHPT) undergoing parathyroid surgery have improvement in mood and neuropsychological functioning. The current analysis aims to examine the relationship between biochemical and clinical variables and the improvement in depression scores and in specific symptoms, after parathyroidectomy.

DESIGN

A prospective observational case-control study at a referral centre.

PATIENTS

Patients with PHPT undergoing parathyroidectomy (n = 88) or thyroid surgery (n = 85).

MEASUREMENTS

The Patient Health Questionnaire-9 (PHQ-9) was utilized to obtain depression scores at enrolment and 12 months after surgery. The changes in PHQ-9 were analysed and correlated with baseline clinical and biochemical parameters.

RESULTS

At enrolment, there was no difference between the groups in the number with a depression diagnosis (PHPT 34.1%, thyroid surgery, 35.5%, P = 0.86). However, baseline PHQ-9 scores were significantly higher in PHPT (median 7.5, range 0-27) than thyroid surgery patients (median 3.0, range 0-18, P < 0.0001). Following surgery, all PHQ-9 scores, total and symptom group (cognitive, somatic) improved and were no longer different between PHPT (total PHQ-9 median 2, range 0-16) and thyroid (median 1, range 0-14, P = 0.31) groups. Baseline parathyroid hormone level, but not calcium, had a weak relationship with change in PHQ-9 score after parathyroid surgery (P = 0.003). Baseline PHQ-9 score was correlated with change in PHQ-9 score at 12 months after parathyroid surgery (P < 0.001).

CONCLUSIONS

Depression scores improve in both somatic and cognitive domains after parathyroidectomy for PHPT and baseline severity of depression predicts the response.

Health-related quality of life improves 1 year after parathyroidectomy in primary hyperparathyroidism: A prospective cohort study

OBJECTIVE

Impaired quality of life (QoL) in primary hyperparathyroidism (PHPT) is commonly present. Patients may complain about nonspecific neurocognitive symptoms which can be difficult to quantify. Two different disease-specific questionnaires have been developed, that is, the parathyroid assessment of symptoms score (PAS) and the primary hyperparathyroidism quality of life (PHPQoL). Using these two questionnaires, we assessed relationship between QoL and biochemical indices in PHPT and effects of parathyroidectomy (PTX).

DESIGN

A prospective cohort study.

METHODS

Patients with PHPT diagnosed from 2015 to 2017 were asked to answer the questionnaires before and 12 months after PTX. Biochemistry was obtained on both occasions.

RESULTS

A total of 104 PHPT patients answered PAS and PHPQoL questionnaires at baseline, with a median age of 64 years (73% females). PHPQoL score correlated inversely with ionized calcium and PTH at baseline (P ˂ 0.04). Total PAS and PHPQoL score did not differ between those with and without osteoporosis, renal calcifications and impaired renal function. Based on levels of ionized calcium, PHPQoL differed significantly between patients with mild- and moderate-severe hypercalcemia (P = 0.01). Fifty-three patients answered PAS and PHPQoL 12 months after PTX showing an improved QoL at follow-up (P_all  ˂ 0.02). Stratifying patients into groups based on levels of ionized calcium showed a significantly improved PHPQoL score in patients with mild (˂1.45 mmol/L) as well as moderate-severe hypercalcemia (≥1.45 mmol/L) at follow-up (P_all  ˂ 0.03).

CONCLUSION

Quality of life improved 12 months after PTX in PHPT patients. Impaired QoL seems to be associated with the degree of hypercalcemia rather than organ manifestations attributable to PHPT.

Health-Related Quality of Life in Patients with Small Intestine Neuroendocrine Tumors

BACKGROUND

The prevalence of small intestine neuroendocrine tumors (SI-NETs) is increasing. Disease progression is often slow and treatment options and long-term survival rates have improved, but little is known about health-related quality of life (HRQoL) in these patients.

OBJECTIVE

To assess HRQoL and its predictors in SI-NET patients receiving contemporary treatments.

METHODS

We measured HRQoL with 15D and SF-36 questionnaires in 134 SI-NET patients and compared the 15D results to those of an age- and gender-standardized sample of the general population (n = 1,153). In the patients, we studied the impact of treatments, Ki-67, liver metastases, circulating tumor markers, comorbidities, and/or socioeconomic factors on HRQoL with linear regression analysis.

RESULTS

The mean disease duration of the patients was 81 (4-468) months, 91% had metastatic disease, and 79% received somatostatin analog treatment. Hepatic tumor load was 0% in 44.8%, < 10-25% in 44.0%, and > 25% in 11.2%, respectively. Mean fP-CgA and S-5HIAA concentrations were 15 (1.3-250) and 344 (24-7,470) nmol/L, respectively. Overall, HRQoL was significantly impaired in patients compared to controls (15D score 0.864 ± 0.105 vs. 0.905 ± 0.028, p < 0.001). SI-NET patients scored worse on 9 of 15 dimensions: sleep, excretion (i.e., bladder and bowel function), depression, distress, vitality, sexual activity (p < 0.001), breathing, usual activities, and discomfort and symptoms (p < 0.01-0.05). SF-36 scores were impaired and highly correlated with 15D scores (p < 0.001). HRQoL was impaired in patients with (n = 85) compared to patients without (n = 49) impaired excretion (0.828 vs. 0.933, p < 0.001). In the patient group, number of medications predicted impaired HRQoL.

CONCLUSIONS

Despite contemporary treatments, SI-NET patients have severely impaired HRQoL, including diarrhea, sleep, depression, vitality, and sexual activity.

Examining the health-related quality of life using EQ-5D-5L in patients with four kinds of chronic diseases from specialist outpatient clinics in Hong Kong SAR, China

BACKGROUND

Health-related quality of life (HRQoL) measures have been increasingly employed in the evaluation of health utility. The aim of this study was to evaluate the impact of four different kinds of chronic diseases on the HRQoL of patients from specialist outpatient clinics in Hong Kong (HK) using the 5-level EQ-5D (EQ-5D-5L) value set.

PATIENTS AND METHODS

Patients who attended one of the 26 Hospital Authority's specialist outpatient clinics and met inclusion criteria were potentially sampled. The value of EQ-5D-5L (HK version) that asks the respondent to describe and rate his or her health status was used as the dependent variable. Four kinds of long-term health conditions and other demographic, socioeconomic, and health service use characteristics have been analyzed as independent variables. Chi-square test, robust one-way ANOVA, and the two-part model have been used to analyze the data.

RESULTS

A total of 7,496 (53.7%) patients reported to have at least one kind of chronic diseases. The mean score for hypertension (mean =0.882, standard error [SE] =0.207) is higher than the others, which followed by cancer, diabetes, and heart disease. Patients who were male, young, higher education attainment, and with chronic conditions got a higher EQ-5D score. In the two-part model, all the four long-standing health conditions were statistically significant in logistic model, but the magnitude of coefficients changed significantly in ordinary least squares model.

CONCLUSION

Chronic diseases have a significant negative impact on patients' HRQoL, but there might be a varying effect depending on what kind of chronic diseases patients had. Further research is also needed to plan appropriate strategies to improve patient-centered care.

Surgical treatment of concomitant thyroid and parathyroid disorders: analysis of 4882 cases

The thyroid gland disease incidence in hyperparathyroidism (HPT) is higher than the incidence of thyroid disease in general population. Likewise, HPT is more frequent in patients primary admitted due to thyroid disease, than in general population. The aim of this study was to determine the incidence and clinical characteristics of concomitant HPT and thyroid disease, based on a single center experience. From 2009 to 2014, a total of 4882 patients underwent thyroidectomy and/or parathyroidectomy at the Center for Endocrine Surgery, Belgrade. We reviewed the database to find out indications for surgery, clinical characteristics, operative and histopathological findings. Out of 4033 patients, who underwent thyroidectomy, in 114 cases (2.8 %) parathyroidectomy was simultaneously performed. Out of these 114 patients, 42 patients (37 %) had normocalcemic HPT. Among 849 patients primary operated due to HPT, thyroid gland disease that required surgery was found in 224 (26.4 %). In patients primary seen for HPT, thyroid cancer was found in 22 (9.8 %), Hashimoto's thyroiditis in 41 (18.3 %) and micropapillary carcinoma in 36 cases (16.1 %). Due to residual or recidivant HPT, 16 patients (15 who primary underwent parathyroidectomy and 1 primary seen for thyroid disease) needed a reoperation. There are a considerable number of patients with concomitant thyroid and parathyroid disease; this justifies the routine analyses of calcemia and PTH level in patients preparing for thyroidectomy, and sets up the ground for the thyroid investigations in HPT.

Primary hyperparathyroidism

Primary hyperparathyroidism (PHPT) is a common disorder in which parathyroid hormone (PTH) is excessively secreted from one or more of the four parathyroid glands. A single benign parathyroid adenoma is the cause in most people. However, multiglandular disease is not rare and is typically seen in familial PHPT syndromes. The genetics of PHPT is usually monoclonal when a single gland is involved and polyclonal when multiglandular disease is present. The genes that have been implicated in PHPT include proto-oncogenes and tumour-suppressor genes. Hypercalcaemia is the biochemical hallmark of PHPT. Usually, the concentration of PTH is frankly increased but can remain within the normal range, which is abnormal in the setting of hypercalcaemia. Normocalcaemic PHPT, a variant in which the serum calcium level is persistently normal but PTH levels are increased in the absence of an obvious inciting stimulus, is now recognized. The clinical presentation of PHPT varies from asymptomatic disease (seen in countries where biochemical screening is routine) to classic symptomatic disease in which renal and/or skeletal complications are observed. Management guidelines have recently been revised to help the clinician to decide on the merits of a parathyroidectomy or a non-surgical course. This Primer covers these areas with particular attention to the epidemiology, clinical presentations, genetics, evaluation and guidelines for the management of PHPT.