RESUMO
BACKGROUND: Patients from ethnic and racial minority groups with primary hyperparathyroidism may have greater time delays to curative parathyroidectomy. Contributing factors are unclear. METHODS: This was a sequential mixed-methods study. The quantitative phase was a retrospective chart review of adults with primary hyperparathyroidism who underwent parathyroidectomy between 2015 and 2020, collecting demographic and clinical data. Social vulnerability of the patients' residential area, measured with the Social Vulnerability Index, and relevant clinical time intervals were calculated. A multivariable analysis of factors associated with greater time intervals was performed. The qualitative phase involved semistructured interviews with endocrinologists, analyzed inductively for themes. RESULTS: On chart review of 1,083 patients, the median age was determined to be 61 years and 856 (79%) were female. Six hundred twenty-eight (57.9%) were non-Hispanic White and 456 (42.1%) were Hispanic ethnicity or Asian, Pacific Islander, Black, Native American, Other or Unknown race. Patients of Hispanic ethnicity, or Asian or Pacific Islander, Black, Native American, Other or Unknown race were more likely than non-Hispanic White patients to live in the most socially vulnerable areas (19.3% vs 5.9%, P < .01) and had greater time intervals than non-Hispanic White patients between index hypercalcemia and first parathyroid hormone level, surgical referral, or parathyroidectomy (all P < .05). On multivariable analysis, age (coefficient 7.9, 95% CI 2.8-13.0) and living in the most socially vulnerable areas (coefficient 297.9, 95% CI 87-508.7) were associated with greater days between index hypercalcemia and parathyroidectomy. In the study's qualitative phase, identified themes for reasons for care delays included socioeconomic, nonsocioeconomic patient, and nonsocioeconomic nonpatient factors. CONCLUSION: Care delays are driven by a combination of socioeconomic and nonsocioeconomic factors.
Assuntos
Hiperparatireoidismo Primário , Paratireoidectomia , Tempo para o Tratamento , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Etnicidade/estatística & dados numéricos , Hiperparatireoidismo Primário/cirurgia , Paratireoidectomia/estatística & dados numéricos , Estudos Retrospectivos , Tempo para o Tratamento/estatística & dados numéricos , Grupos RaciaisAssuntos
Transtornos de Deglutição , Paratireoidectomia , Complicações Pós-Operatórias , Tireoidectomia , Humanos , Transtornos de Deglutição/epidemiologia , Transtornos de Deglutição/etiologia , Fatores de Risco , Idoso , Prevalência , Paratireoidectomia/efeitos adversos , Paratireoidectomia/estatística & dados numéricos , Tireoidectomia/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologiaRESUMO
BACKGROUND: Veterans with primary hyperparathyroidism are under diagnosed and undertreated. We report the results of a pilot study to address this problem. METHODS: We implemented a stakeholder-driven, multi-component intervention to increase rates of diagnosis and treatment for primary hyperparathyroidism at a single VA hospital. Intervention effects were evaluated using an interrupted time series analysis. RESULTS: The mean age of Veterans affected by the intervention was 67 years (SD 12.1) and 84 â% were men. Compared to the pre-intervention period, the intervention doubled the proportion of Veterans who were appropriately evaluated for hyperparathyroidism (absolute difference 25 â%, 95 â% CI 11 â%-38 â%, p â< â0.001) and increased referrals for treatment by 27 â% (95 â% CI 7 â%-47 â%, p â< â0.012). CONCLUSION: Our pilot study suggests it is feasible to address the underdiagnosis and undertreatment of primary hyperparathyroidism among Veterans.
Assuntos
Hiperparatireoidismo Primário , Humanos , Hiperparatireoidismo Primário/diagnóstico , Hiperparatireoidismo Primário/terapia , Hiperparatireoidismo Primário/complicações , Masculino , Feminino , Idoso , Projetos Piloto , Pessoa de Meia-Idade , Paratireoidectomia/estatística & dados numéricos , Hospitais de Veteranos/estatística & dados numéricos , Veteranos/estatística & dados numéricos , Estados Unidos/epidemiologia , Análise de Séries Temporais Interrompida , Encaminhamento e Consulta/estatística & dados numéricosAssuntos
Transtornos de Deglutição , Paratireoidectomia , Complicações Pós-Operatórias , Tireoidectomia , Humanos , Transtornos de Deglutição/epidemiologia , Transtornos de Deglutição/etiologia , Tireoidectomia/efeitos adversos , Fatores de Risco , Paratireoidectomia/efeitos adversos , Paratireoidectomia/estatística & dados numéricos , Prevalência , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , IdosoRESUMO
This study aimed to evaluate the prevalence and risk of malignant neoplasm in primary hyperparathyroidism (PHPT) patients. Potentially eligible studies were retrieved from PubMed and Embase databases from inception to November 2023 using search strategy consisting of terms for "Primary hyperparathyroidism" and "Malignant neoplasm". Eligible study must report prevalence of malignant neoplasm among patients with PHPT or compare the risk of malignant neoplasm between patients with PHPT and comparators. Point estimates with standard errors were extracted from each study and combined using the generic inverse variance method.A total of 11,926 articles were identified. After two rounds of systematic review, 50 studies were included. The meta-analysis revealed that pooled prevalence rates of overall cancer was 0.19 (95%CI: 0.13-0.25; I2 94%). The two most prevalent types of malignancy among patients with PHPT ware papillary thyroid cancer (pooled prevalence: 0.07; 95%CI: 0.06-0.08; I2 85%) and breast cancer (pooled prevalence: 0.05; 95%CI: 0.03-0.07; I2 87%). Subgroup analysis of studies focusing on patients undergoing parathyroidectomy reported a fourfold higher prevalence of papillary thyroid cancer than the remaining studies (0.08 versus 0.02). The meta-analysis of cohort studies found a significant association between PHPT and overall cancer with the pooled risk ratio of 1.28 (95%CI: 1.23-1.33; I2 66.9%).We found that the pooled prevalence of malignant neoplasm in PHPT was 19%, with papillary thyroid cancer and breast cancer being the most prevalent types. The meta-analysis of cohort studies showed that patient with PHPT carried an approximately 28% increased risk of malignancy.
Assuntos
Hiperparatireoidismo Primário , Humanos , Hiperparatireoidismo Primário/epidemiologia , Hiperparatireoidismo Primário/complicações , Fatores de Risco , Prevalência , Paratireoidectomia/estatística & dados numéricos , Neoplasias da Mama/epidemiologia , Câncer Papilífero da Tireoide/epidemiologia , Neoplasias da Glândula Tireoide/epidemiologiaRESUMO
BACKGROUND: Multicentre studies have previously reported on national outcomes of surgery for primary hyperparathyroidism, but not investigated whether management and outcome are uniform among countries. This study investigated whether there are differences among European countries in operative management and outcome of surgery for primary hyperparathyroidism. METHODS: Using data from Eurocrine®, a pan-European registry for endocrine surgeries, a retrospective observational cross-sectional multicentre study with 99 participating centres in 14 European countries was performed. Data on age, sex, calcium levels, operative strategy, conversion rate and rate of failed exploration were analysed for patients who underwent initial surgery for sporadic primary hyperparathyroidism. Primary outcome measures were intention to perform limited parathyroidectomy and the rate of hypercalcaemia at first follow-up. RESULTS: A total of 9548 patients were registered between 2015 and 2020. There were 7642 (80%, range 74.5-93.2%) females. There was intention to perform limited parathyroidectomy in 7320 of 9548 (76.7%) operations, ranging from 498 of 1007 (49.5%) to 40 of 41 (97.6%) among countries. Hypercalcaemia at first follow-up (median time to follow-up 15 days) was found in 416 of 9548 (4.4%) operations, ranging from 0 of 119 (0%) to 3 of 38 (7.9%) among countries. CONCLUSION: This study demonstrated large differences in the intention to perform limited parathyroidectomy for primary hyperparathyroidism among European countries, as well as differences in the rate of postoperative hypercalcaemia. Future studies are needed to evaluate the impact of these different healthcare practices on patient outcomes.
Assuntos
Hipercalcemia , Hiperparatireoidismo Primário , Paratireoidectomia , Humanos , Hiperparatireoidismo Primário/cirurgia , Feminino , Masculino , Paratireoidectomia/estatística & dados numéricos , Europa (Continente)/epidemiologia , Estudos Retrospectivos , Pessoa de Meia-Idade , Estudos Transversais , Hipercalcemia/etiologia , Idoso , Adulto , Resultado do Tratamento , Sistema de RegistrosRESUMO
BACKGROUND: Primary hyperparathyroidism is underdiagnosed and surgical treatment is underutilized and inequitably distributed. We present a review of the current literature on disparities in the treatment of hyperparathyroidism, with a focus on gaps in knowledge and paths forward. METHODS: We searched PubMed and Scopus for abstracts related to disparities in hyperparathyroidism. RESULTS: 16 articles (of 1541) met inclusion criteria. The most commonly examined disparity was race. Notably, Black, Hispanic, and Asian patients were less likely to undergo surgery after diagnosis, face delays in obtaining treatment, and less likely to see a high-volume surgeon. Similar disparities in care were noted among those without insurance, older patients, and patients with limited English proficiency. CONCLUSION: There are clear inequities in the treatment of hyperparathyroidism. Current research is in an early "identification" phase of disparities research; a new conceptual model based on established socioecological frameworks is provided to help move the field forward to "understanding" and "intervening" in surgical disparities.
Assuntos
Disparidades em Assistência à Saúde , Hiperparatireoidismo Primário , Humanos , Hiperparatireoidismo Primário/cirurgia , Hiperparatireoidismo Primário/terapia , Hiperparatireoidismo Primário/diagnóstico , Disparidades em Assistência à Saúde/estatística & dados numéricos , Paratireoidectomia/estatística & dados numéricosRESUMO
BACKGROUND: There has been a notable shift towards the diagnosis of less severe and asymptomatic primary hyperparathyroidism (PHPT) in developed countries. However, there is a paucity of recent data from sub-Saharan Africa (SSA), and also, no reported data from SSA on the utility of intra-operative parathyroid hormone (IO-PTH) monitoring. In an earlier study from Inkosi Albert Luthuli Central Hospital (IALCH), Durban, South Africa (2003-2009), majority of patients (92.9%) had symptomatic disease. The aim of this study was to evaluate the clinical profile and management outcomes of patients presenting with PHPT at IALCH. METHODS: A retrospective chart review of patients with PHPT attending the Endocrinology clinic at IALCH between July 2009 and December 2021. Clinical presentation, laboratory results, radiologic findings, surgical notes and histology were recorded. RESULTS: Analysis included 110 patients (87% female) with PHPT. Median age at presentation was 57 (44; 67.5) years. Symptomatic disease was present in 62.7% (n:69); 20.9% (n:23) had a history of nephrolithiasis and 7.3% (n:8) presented with previous fragility fractures. Mean serum calcium was 2.87 ± 0.34 mmol/l; median serum-PTH was 23.3 (15.59; 45.38) pmol/l, alkaline phosphatase 117.5 (89; 145.5) U/l and 25-hydroxyvitamin-D 42.9 (33.26; 62.92) nmol/l. Sestamibi scan (n:106 patients) identified an adenoma in 83.02%. Parathyroidectomy was performed on 84 patients with a cure rate of 95.2%. Reasons for conservative management (n:26) included: no current surgical indication (n:7), refusal (n:5) or deferral of surgery (n:5), loss to follow-up (n:5) and assessed as high anaesthetic risk (n:4). IO-PTH measurements performed on 28 patients indicated surgical success in 100%, based on Miami criteria. Histology confirmed adenoma in 88.1%, hyperplasia in 7.1% and carcinoma in 4.8%. Post-operative hypocalcaemia developed in 30 patients (35.7%), of whom, 14 developed hungry bone syndrome (HBS). In multivariate analysis, significant risk factors associated with HBS included male sex (OR 7.01; 95% CI 1.28, 38.39; p 0.025) and elevated pre-operative PTH (OR 1.01; 95% CI 1.00, 1.02; p 0.008). CONCLUSIONS: The proportion of asymptomatic PHPT has increased at this centre over the past decade but symptomatic disease remains the dominant presentation. Parathyroidectomy is curative in the majority of patients. IO-PTH monitoring is valuable in ensuring successful surgery.
Assuntos
Hiperparatireoidismo Primário , Paratireoidectomia , Humanos , Hiperparatireoidismo Primário/cirurgia , Hiperparatireoidismo Primário/epidemiologia , Hiperparatireoidismo Primário/terapia , Hiperparatireoidismo Primário/diagnóstico , Feminino , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , África do Sul/epidemiologia , Adulto , Idoso , Paratireoidectomia/estatística & dados numéricos , Neoplasias das Paratireoides/cirurgia , Neoplasias das Paratireoides/epidemiologia , Neoplasias das Paratireoides/terapia , Neoplasias das Paratireoides/complicações , Neoplasias das Paratireoides/patologia , Hormônio Paratireóideo/sangue , Seguimentos , Gerenciamento Clínico , Resultado do Tratamento , Prognóstico , Cálcio/sangueRESUMO
BACKGROUND: The most important factors affecting the development of postoperative hypocalcaemia (PH) include intraoperative trauma to the parathyroid glands, incidental parathyroidectomy (IP), and the surgeon's experience. In this study, we aimed to determine the incidence of IP, evaluate its effect on postoperative calcium levels and investigate the effect of surgeon experience and volume on IP incidence and postoperative calcium levels. METHODS: This retrospective study included 645 patients who underwent thyroid surgery at the Department of General Surgery, Kütahya Health Sciences University between September 2016 and March 2020. All patients underwent surgery at a single clinic by general surgeons experienced in thyroid surgery and their residents (3-5 years). RESULTS: Normal parathyroid glands were reported in 58 (8.9%) of 645 patients. In 5 (8.6%) of 58 patients the parathyroid gland was detected in the intrathyroidal region. PH developed in ten patients (17.2%) with incidental removal of the parathyroid glands. A statistically significant difference was found between the number of incidentally removed parathyroid glands and the development of hypocalcaemia (p<0.05). Normal parathyroid glands were reported in the pathology of 37 (7.9%) patients operated on by general surgeons and 22 (12.6%) patients operated on by their residents. PH developed in 39 (8.2%) patients operated on by general surgeons and in 8 (4.5%) patients operated on by their residents. CONCLUSIONS: We found that the complication rate during the resident training process was the same as that of experienced general surgeons. A thyroidectomy can be safely performed by senior residents during residential training.
Assuntos
Hipocalcemia , Paratireoidectomia , Tireoidectomia , Humanos , Tireoidectomia/efeitos adversos , Tireoidectomia/estatística & dados numéricos , Estudos Retrospectivos , Hipocalcemia/etiologia , Hipocalcemia/epidemiologia , Feminino , Paratireoidectomia/estatística & dados numéricos , Paratireoidectomia/efeitos adversos , Pessoa de Meia-Idade , Masculino , Adulto , Idoso , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Incidência , Achados Incidentais , Competência Clínica/estatística & dados numéricos , Glândulas Paratireoides/lesões , Glândulas Paratireoides/cirurgia , Cálcio/sangue , Adulto Jovem , Complicações Intraoperatórias/epidemiologia , Complicações Intraoperatórias/etiologiaRESUMO
BACKGROUND: In Jan 2018, we began routinely obtaining neck ultrasound (US) with 123I/99Tc-sestamibi (MIBI) for parathyroid gland localization and to identify thyroid pathology in the setting of primary hyperparathyroidism (1HPT). The aim of this study is to assess if routine neck US is a useful adjunct to 123I/99Tc-MIBI in 1HPT. METHODS: Patients undergoing surgery for 1HPT with both 123I/99Tc-MIBI and US at our institution after implementation of routine US were reviewed. Biopsy and surgical management of thyroid pathology was evaluated. 123I/99Tc-MIBI and US results were compared to intraoperative findings to determine sensitivity and positive predictive value (PPV) for parathyroid localization. RESULTS: From January 2018 to September 2019, there were 423 patients (mean, 61 years) that met inclusion criteria (80% women). Thyroid nodules were found on US in 57%, mean size 1.3 + 0.8 cm. Fine needle aspiration (FNA) was performed in 87 patients with nodules (36%). 35 patients (8.5%) required total or partial thyroidectomy for diagnoses/treatment. Papillary thyroid cancer (PTC) was found in 3.5% of the cohort with micro-PTC 53% and PTC 1-2 cm 40%. A successful parathyroid operation for 1HPT was achieved in 98.6% of patients. Positive predictive value for localization of abnormal parathyroid glands was 97% when US and 123I/99Tc-MIBI had concordant findings. DISCUSSION: Routine use of US in 1HPT commonly identifies nodules that are benign or low-risk PTC. Ultrasound is less sensitive for parathyroid localization but when used with 123I/99Tc-MIBI, concordant imaging has a high PPV.
Assuntos
Hiperparatireoidismo Primário/diagnóstico por imagem , Pescoço/diagnóstico por imagem , Neoplasias da Glândula Tireoide/diagnóstico por imagem , Nódulo da Glândula Tireoide/diagnóstico por imagem , Biópsia por Agulha Fina/estatística & dados numéricos , Feminino , Humanos , Hiperparatireoidismo Primário/complicações , Hiperparatireoidismo Primário/cirurgia , Masculino , Pessoa de Meia-Idade , Paratireoidectomia/estatística & dados numéricos , Valor Preditivo dos Testes , Compostos Radiofarmacêuticos , Tecnécio Tc 99m Sestamibi , Glândula Tireoide/diagnóstico por imagem , Glândula Tireoide/patologia , Glândula Tireoide/cirurgia , Neoplasias da Glândula Tireoide/complicações , Neoplasias da Glândula Tireoide/patologia , Neoplasias da Glândula Tireoide/cirurgia , Nódulo da Glândula Tireoide/complicações , Nódulo da Glândula Tireoide/patologia , Nódulo da Glândula Tireoide/cirurgia , Tireoidectomia/métodos , Tireoidectomia/estatística & dados numéricos , Ultrassonografia/métodosRESUMO
BACKGROUND: Preoperative parathyroid imaging guides surgeons during parathyroidectomy. This study evaluates the clinical impact of 18F-fluorocholine positron emission tomography for preoperative parathyroid localization on patients with primary hyperparathyroidism. METHODS: Patients with primary hyperparathyroidism and indications for parathyroidectomy had simultaneous 18F-fluorocholine positron emission tomography imaging/magnetic resonance imaging. In patients who underwent subsequent parathyroidectomy, cure was based on lab values at least 6 months after surgery. Location-based sensitivity and specificity of 18F-fluorocholine positron emission tomography imaging was assessed using 3 anatomic locations (left neck, right neck, and mediastinum), with surgery as the gold standard. RESULTS: In 101 patients, 18F-fluorocholine positron emission tomography localized at least 1 candidate lesion in 93% of patients overall and in 91% of patients with previously negative imaging, leading to a change in preoperative strategy in 60% of patients. Of 76 patients who underwent parathyroidectomy, 58 (77%) had laboratory data at least 6 months postoperatively, with 55/58 patients (95%) demonstrating cure. 18F-fluorocholine positron emission tomography successfully guided curative surgery in 48/58 (83%) patients, compared with 20/57 (35%) based on ultrasound and 13/55 (24%) based on sestamibi. In a location-based analysis, sensitivity of 18F-fluorocholine positron emission tomography (88.9%) outperformed both ultrasound (37.1%) and sestamibi (27.5%), as well as ultrasound and sestamibi combined (47.8%). CONCLUSION: Long-term results in the first cohort in the United States to use 18F-fluorocholine positron emission tomography for parathyroid localization confirm its utility in a challenging cohort, with better sensitivity than ultrasound or sestamibi.
Assuntos
Colina/análogos & derivados , Hiperparatireoidismo Primário/diagnóstico , Glândulas Paratireoides/diagnóstico por imagem , Neoplasias das Paratireoides/diagnóstico , Tomografia por Emissão de Pósitrons/métodos , Idoso , Colina/administração & dosagem , Feminino , Radioisótopos de Flúor/administração & dosagem , Humanos , Hiperparatireoidismo Primário/etiologia , Hiperparatireoidismo Primário/patologia , Hiperparatireoidismo Primário/cirurgia , Imageamento por Ressonância Magnética/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Glândulas Paratireoides/patologia , Glândulas Paratireoides/cirurgia , Neoplasias das Paratireoides/complicações , Neoplasias das Paratireoides/patologia , Neoplasias das Paratireoides/cirurgia , Paratireoidectomia/estatística & dados numéricos , Tomografia por Emissão de Pósitrons/estatística & dados numéricos , Cuidados Pré-Operatórios/métodos , Cuidados Pré-Operatórios/estatística & dados numéricos , Tecnécio Tc 99m Sestamibi/administração & dosagem , Resultado do TratamentoRESUMO
CONTEXT: Preoperative localization studies are standard practice in patients undergoing parathyroidectomy for primary hyperparathyroidism (pHPT). The most common modalities are neck ultrasound (US) and sestamibi scanning. However, the nature of pHPT is changing, with imaging increasingly yielding negative results. Numerous studies suggest unlocalized disease is associated with poor outcomes, calling into question whether such patients are best treated conservatively. OBJECTIVE: This study aims to correlate parathyroidectomy outcomes with preoperative imaging in a single, high-volume institution. METHODS: Data from a prospectively maintained departmental database of operations performed from 2017 to 2019 were analyzed. All patients undergoing first-time surgery for sporadic pHPT were included. Data collected included patient demographics, preoperative imaging, surgical strategy, and postoperative outcomes. RESULTS: A total of 609 consecutive parathyroidectomies were included, with a median age of 59 years (range 20-87 years). The all-comer cure rate was 97.5%; this was 97.9% in dual localized patients (those with positive US and sestamibi), compared to 95.8% in the dual unlocalized group (those with negative US and sestamibi) (Pâ =â 0.33). Unilateral neck exploration was the chosen approach in 59.9% of patients with double-positive imaging and 5.7% of patients with double-negative imaging (otherwise, bilateral parathyroid visualization was performed). There was no significant difference in postoperative complications between patients undergoing unilateral or bilateral neck exploration. CONCLUSIONS: Patients with negative preoperative imaging who undergo parathyroidectomy are cured in almost 96% of cases, compared to 98% when the disease is localized. This difference does not reach statistical or clinical significance. These findings therefore support current recommendations that all patients with pHPT who are likely to benefit from operative intervention should be considered for parathyroidectomy, irrespective of preoperative imaging findings.
Assuntos
Hiperparatireoidismo Primário/diagnóstico , Glândulas Paratireoides/diagnóstico por imagem , Neoplasias das Paratireoides/diagnóstico , Paratireoidectomia/estatística & dados numéricos , Tomografia Computadorizada de Emissão de Fóton Único/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Tomada de Decisão Clínica , Feminino , Humanos , Hiperparatireoidismo Primário/etiologia , Hiperparatireoidismo Primário/cirurgia , Masculino , Pessoa de Meia-Idade , Glândulas Paratireoides/cirurgia , Neoplasias das Paratireoides/complicações , Neoplasias das Paratireoides/cirurgia , Paratireoidectomia/normas , Guias de Prática Clínica como Assunto , Período Pré-Operatório , Estudos Prospectivos , Compostos Radiofarmacêuticos/administração & dosagem , Tecnécio Tc 99m Sestamibi/administração & dosagem , Resultado do Tratamento , Ultrassonografia/estatística & dados numéricos , Adulto JovemRESUMO
BACKGROUND: In total, â¼15% of patients with sporadic primary hyperparathyroidism have multiglandular disease, which may be suspected preoperatively but can only be confirmed intra or postoperatively. The study aim is to determine how and when patients are diagnosed with multiglandular disease and to what extent different modalities contribute. METHODS: Consecutive cases of sporadic primary hyperparathyroidism (2013-2019) undergoing initial exploration were reviewed from a single-institution prospective database. Preoperative single-photon emission tomography/computed tomography and neck ultrasound were routinely performed to help direct either bilateral or unilateral exploration guided by intraoperative parathyroid hormone monitoring using the dual criteria. Multiglandular disease was defined as either resection of >1 enlarged parathyroid or hypercalcemia at ≥6 months after single gland resection. RESULTS: Of 1,890 patients with sporadic primary hyperparathyroidism, multiglandular disease was identified in 254 (13.4%); 244 (96.1%) were diagnosed intraoperatively and 10 (3.9%) postoperatively. In these multiglandular disease patients, single gland disease was suggested on single-photon emission tomography/computed tomography in 54.0%, ultrasound in 49.2%, and both were concordant for single gland disease in 29.4%. Intraoperative multiglandular disease diagnosis was prompted by an inadequate intraoperative parathyroid hormone monitoring drop in 38.5%, by surgeon interpretation of imaging in 38.1%, by observing ipsilateral gland enlargement in 11.0%, by finding an initial gland <200 mg in 10.3%, and 2.0% had unexpected multiglandular disease during thyroidectomy. Multiglandular disease was diagnosed by postoperative hypercalcemia in 10 of 254 patients (4.9%). CONCLUSION: To avoid failure at parathyroidectomy for primary hyperparathyroidism, expert surgeons use multiple approaches to diagnose and manage multiglandular disease. Preoperative localization studies alone are insufficient, missing multiglandular disease in at least 30% of cases. All examined adjuncts are informative, including intraoperative parathyroid hormone monitoring, imaging, and intraoperative visual cues.
Assuntos
Hipercalcemia/cirurgia , Hiperparatireoidismo Primário/cirurgia , Glândulas Paratireoides/patologia , Paratireoidectomia/estatística & dados numéricos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Cálcio/sangue , Feminino , Seguimentos , Humanos , Hipercalcemia/sangue , Hipercalcemia/diagnóstico , Hiperparatireoidismo Primário/sangue , Hiperparatireoidismo Primário/diagnóstico , Hiperparatireoidismo Primário/patologia , Masculino , Pessoa de Meia-Idade , Diagnóstico Ausente , Glândulas Paratireoides/cirurgia , Hormônio Paratireóideo/sangue , Período Pós-Operatório , Estudos Prospectivos , Tomografia Computadorizada com Tomografia Computadorizada de Emissão de Fóton Único , Falha de Tratamento , Adulto JovemRESUMO
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.
Assuntos
Fatores Etários , Fragilidade/complicações , Hipertireoidismo/complicações , Qualidade de Vida/psicologia , Idoso , Estudos de Coortes , Feminino , Fragilidade/mortalidade , Humanos , Hipertireoidismo/mortalidade , Masculino , Pessoa de Meia-Idade , Paratireoidectomia/métodos , Paratireoidectomia/estatística & dados numéricos , Estudos Prospectivos , Inquéritos e QuestionáriosRESUMO
BACKGROUND: Among patients with primary hyperparathyroidism, parathyroidectomy offers a chance of cure and mitigation of disease-related complications. The impact of race/ethnicity on referral and utilization of parathyroidectomy has not been fully explored. METHODS: Population-based, retrospective cohort study using 100% Medicare claims from beneficiaries with primary hyperparathyroidism from 2006 to 2016. Associations of race/ethnicity with disease severity, surgeon evaluation, and subsequent parathyroidectomy were analyzed using adjusted multivariable logistic regression models. RESULTS: Among 210,206 beneficiaries with primary hyperparathyroidism, 63,136 (30.0%) underwent parathyroidectomy within 1 year of diagnosis. Black patients were more likely than other races/ethnicities to have stage 3 chronic kidney disease (10.8%) but had lower prevalence of osteoporosis and nephrolithiasis compared to White patients, Black and Hispanic patients were more likely to have been hospitalized for primary hyperparathyroidism-associated conditions (White 4.8%, Black 8.1%, Hispanic 5.8%; P < .001). Patients who were White and met operative criteria were more likely to undergo parathyroidectomy than Black, Hispanic, or Asian patients (White 30.5%, Black 23.0%, Hispanic 21.4%, Asian 18.7%; P < .001). Black and Hispanic patients had lower adjusted odds of being evaluated by a surgeon (odds ratios 0.71 [95% confidence interval 0.69-0.74], 0.68 [95% confidence interval 0.61-0.74], respectively) and undergoing parathyroidectomy if evaluated by a surgeon (odds ratios 0.72 [95% confidence interval 0.68-0.77], 0.82 [95% confidence interval 0.67-0.99]). Asian race was associated with lower adjusted odds of being evaluated by a surgeon (odds ratio 0.64 [95% confidence interval 0.57-0.71]), but no difference in odds of parathyroidectomy. CONCLUSION: Racial/ethnic disparities exist in the management of primary hyperparathyroidism among older adults. Determining the factors that account for this disparity require urgent attention to achieve parity in the management of primary hyperparathyroidism.
Assuntos
Disparidades em Assistência à Saúde/estatística & dados numéricos , Hiperparatireoidismo Primário/cirurgia , Paratireoidectomia/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Demandas Administrativas em Assistência à Saúde/estatística & dados numéricos , Negro ou Afro-Americano/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Feminino , Hispânico ou Latino/estatística & dados numéricos , Humanos , Hiperparatireoidismo Primário/economia , Masculino , Medicare/economia , Medicare/estatística & dados numéricos , Paratireoidectomia/economia , Estudos Retrospectivos , Estados Unidos , População Branca/estatística & dados numéricosRESUMO
BACKGROUND: Nephrolithiasis is a sequela of primary hyperparathyroidism and an indication for parathyroidectomy. The prevalence of primary hyperparathyroidism in patients with nephrolithiasis is 3% to 5%; however, recent studies suggest that many hypercalcemic patients with nephrolithiasis never undergo workup for primary hyperparathyroidism. Our goal is to evaluate primary hyperparathyroidism screening rates at a tertiary academic health institution and identify opportunities to increase referral rates in patients presenting with nephrolithiasis. METHODS: We retrospectively reviewed 15,725 patients across an academic health system who presented with nephrolithiasis between 2012 and 2020. Calcium levels measured within 6 months of presentation were identified, and those with hypercalcemia (≥10.3 mg/dL) were reviewed if parathyroid hormone levels were measured. Patients with primary hyperparathyroidism were evaluated to see if they were referred to a specialist for treatment. RESULTS: Of 15,725 patients presenting with nephrolithiasis, 12,420 (79%) had calcium levels measured; 630 patients (4.0%) were hypercalcemic, and 207 (33%) had parathyroid hormone levels measured. Patients were more likely to have parathyroid hormone levels sent if they were older, had higher calcium levels, or presented to an outpatient clinic (P = .028, P = .002, P < .001). We identified 89 patients (0.6%) with primary hyperparathyroidism, of which only 35 (39%) were referred for treatment. CONCLUSION: The proportion of patients presenting with nephrolithiasis ultimately diagnosed with primary hyperparathyroidism was significantly lower than others have reported. Additionally, a substantial number of patients with nephrolithiasis did not have calcium and/or parathyroid hormone levels measured. These missed opportunities for diagnosis are critical as early definitive management of primary hyperparathyroidism can prevent recurrent nephrolithiasis and other primary hyperparathyroidism-related end organ effects.
Assuntos
Cálcio/sangue , Hipercalcemia/diagnóstico , Hiperparatireoidismo Primário/diagnóstico , Diagnóstico Ausente/prevenção & controle , Nefrolitíase/etiologia , Adulto , Idoso , Feminino , Humanos , Hipercalcemia/sangue , Hipercalcemia/etiologia , Hipercalcemia/cirurgia , Hiperparatireoidismo Primário/sangue , Hiperparatireoidismo Primário/complicações , Hiperparatireoidismo Primário/cirurgia , Masculino , Pessoa de Meia-Idade , Nefrolitíase/sangue , Nefrolitíase/diagnóstico , Hormônio Paratireóideo/sangue , Paratireoidectomia/estatística & dados numéricos , Encaminhamento e Consulta/estatística & dados numéricos , Estudos RetrospectivosRESUMO
BACKGROUND: Preventing cervical reoperations is important-especially after parathyroidectomy. We sought to examine early predictors of recurrence of primary hyperparathyroidism after surgical cure. METHODS: Adult patients with sporadic primary hyperparathyroidism treated with parathyroidectomy between September 1, 1997, and September 1, 2019, with confirmed eucalcemia at 6 months postoperatively were identified. Recurrence was defined as hypercalcemia (>10.2 mg/dL) with an elevated or nonsuppressed parathyroid hormone level on subsequent follow-up. RESULTS: Parathyroidectomy was performed in 522 patients (median age, 62.1 years, 77% female) with the majority undergoing planned minimally invasive parathyroidectomy (85.4%, n = 446). After a median follow-up of 30.9 months, 13 patients (2.5%) recurred (median time to recurrence 50.2 months, interquartile range 27.9-66.5), all of whom underwent planned minimally invasive parathyroidectomy (n = 13/446, 2.9%). Recurrence was more common in those with higher (but still normal) 6-month calcium (10.1 vs 9.3 mg/dL, P < .001) or parathyroid hormone values (64 vs 46 pg/mL, P < .01). Multivariate analysis revealed that age >66.5 years, calcium ≥9.8mg/dL and parathyroid hormone ≥80 pg/mL at 6 months were associated with increased risk of recurrence. In addition, the presence of at least 1 preoperative imaging study that conflicted with intraoperative findings among minimally invasive parathyroidectomy patients (n = 446) was associated with increased risk of recurrence (hazard ratio 4.93, 95% confidence interval 1.25-16.53, P = .016). CONCLUSION: Recurrence of sporadic primary hyperparathyroidism after initial surgical cure in the era of minimally invasive parathyroidectomy is 2.5%. Identification of those at risk for recurrence using 6-month serum calcium ≥9.8 mg/dL, parathyroid hormone ≥80 pg/mL, and/or potentially conflicting localization studies may inform surveillance strategies.
Assuntos
Hipercalcemia/cirurgia , Hiperparatireoidismo Primário/cirurgia , Procedimentos Cirúrgicos Minimamente Invasivos/estatística & dados numéricos , Paratireoidectomia/estatística & dados numéricos , Idoso , Cálcio/sangue , Feminino , Seguimentos , Humanos , Hipercalcemia/sangue , Hipercalcemia/diagnóstico , Hipercalcemia/epidemiologia , Hiperparatireoidismo Primário/sangue , Hiperparatireoidismo Primário/diagnóstico , Hiperparatireoidismo Primário/epidemiologia , Masculino , Pessoa de Meia-Idade , Hormônio Paratireóideo/sangue , Paratireoidectomia/métodos , Recidiva , Estudos Retrospectivos , Medição de Risco/métodos , Medição de Risco/estatística & dados numéricos , Resultado do TratamentoRESUMO
BACKGROUND: Clinical manifestations and treatment outcomes in children and adolescents with multiple endocrine neoplasia type 1 are not well characterized. METHODS: We conducted a retrospective cohort study of 80 patients with multiple endocrine neoplasia type 1 who commenced tumor surveillance at ≤18 years of age. RESULTS: Fifty-six patients (70%) developed an endocrine tumor by age ≤18 years (median age = 14 years, range = 6-18 years). Primary hyperparathyroidism occurred in >80% of patients, with >70% undergoing parathyroidectomy, in which less-than-subtotal (<3-gland) resection resulted in decreased disease-free outcomes versus subtotal (3-3.5-gland) or total (4-gland) parathyroidectomy (median 27 months versus not reached; P = .005). Pancreaticoduodenal neuroendocrine tumors developed in â¼35% of patients, of whom >70% had nonfunctioning tumors, >35% had insulinomas, and <5% had gastrinomas, with â¼15% having metastases and >55% undergoing surgery. Pituitary tumors developed in >30% of patients, and â¼35% were macroprolactinomas. Tumor occurrence in male patients and female patients was not significantly different. Genetic analyses revealed 38 germline MEN1 mutations, of which 3 were novel. CONCLUSION: Seventy percent of children aged ≤18 years with multiple endocrine neoplasia type 1 develop endocrine tumors, which include parathyroid tumors for which less-than-subtotal parathyroidectomy should be avoided; pancreaticoduodenal neuroendocrine tumors that may metastasize; and pituitary macroprolactinomas.
Assuntos
Neoplasias Duodenais/epidemiologia , Hiperparatireoidismo Primário/epidemiologia , Neoplasia Endócrina Múltipla Tipo 1/complicações , Neoplasias Pancreáticas/epidemiologia , Neoplasias das Paratireoides/epidemiologia , Adolescente , Criança , Neoplasias Duodenais/genética , Neoplasias Duodenais/cirurgia , Feminino , Humanos , Hiperparatireoidismo Primário/genética , Hiperparatireoidismo Primário/cirurgia , Masculino , Neoplasia Endócrina Múltipla Tipo 1/genética , Neoplasia Endócrina Múltipla Tipo 1/cirurgia , Neoplasias Pancreáticas/genética , Neoplasias Pancreáticas/cirurgia , Neoplasias das Paratireoides/genética , Neoplasias das Paratireoides/cirurgia , Paratireoidectomia/estatística & dados numéricos , Estudos RetrospectivosRESUMO
BACKGROUND: Nephrolithiasis is a classic indication for parathyroidectomy in primary hyperparathyroidism patients; however, the effects of parathyroidectomy on nephrolithiasis recurrence are not well studied. The aim was to determine effect of parathyroidectomy on time to first nephrolithiasis recurrence and recurrence rate per patient-years. METHODS: A retrospective cohort study of patients diagnosed with primary hyperparathyroidism and at least one episode of nephrolithiasis was performed. The patients were divided into observation, presurgery, and postsurgery groups. Endpoints were time to first recurrence of nephrolithiasis and average recurrence rate per patient-years. RESULTS: The cohort was comprised of 1,252 patients. In addition, 334 (27%) patients underwent parathyroidectomy and 918 (73%) were observed. The surgical and nonsurgical groups differed significantly in age, sex, Charlson, calcium, and primary hyperparathyroidism level. Overall recurrence rate was 31.3%. The 5-, 10-, and 15-year recurrence-free survival rates were 74.4%, 56.3%, 49.5%, respectively (presurgery), 82.4%, 70.9%, 62.8%, respectively (postsurgery; P < .0001), and 86.3%, 77.7%, and 70.6%, respectively (observation). The presurgery group had an increased risk of first recurrence compared with the observation group (hazard ratio 1.89; 95% confidence interval, 1.44-2.47). The average recurrence rates among all surgical patients who recurred were 1 event per 4.3 patient-years presurgery versus 1 event per 6.7 patient-years postsurgery (P = .0001). CONCLUSION: Recurrent nephrolithiasis is a significant problem in patients with primary hyperparathyroidism. Parathyroidectomy prolongs the time to first recurrence and decreases the number of re-recurrences over time but does not eliminate recurrences. Observation may also be a reasonable approach in selected patients.
Assuntos
Hiperparatireoidismo Primário/cirurgia , Nefrolitíase/cirurgia , Paratireoidectomia/estatística & dados numéricos , Prevenção Secundária/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Cálcio/sangue , Intervalo Livre de Doença , Feminino , Seguimentos , Humanos , Hiperparatireoidismo Primário/sangue , Hiperparatireoidismo Primário/complicações , Hiperparatireoidismo Primário/mortalidade , Estimativa de Kaplan-Meier , Masculino , Pessoa de Meia-Idade , Nefrolitíase/sangue , Nefrolitíase/etiologia , Nefrolitíase/mortalidade , Hormônio Paratireóideo/sangue , Recidiva , Estudos Retrospectivos , Prevenção Secundária/estatística & dados numéricos , Fatores de Tempo , Adulto JovemRESUMO
BACKGROUND: The incidence of adverse perioperative cardiac complications after parathyroidectomy has not been well described. This study aimed to evaluate the incidence of perioperative chest pain and cardiac complications after parathyroidectomy and to evaluate risk factors that may identify patients who are more likely to benefit from a cardiac workup. METHODS: We performed a retrospective study of all patients undergoing parathyroidectomy for primary hyperparathyroidism by a single endocrine surgeon at a tertiary endocrine centre between 2011 and 2018. Patient demographics, clinicopathologic variables, operative and postoperative details (reported chest pain, performance of a cardiac workup and new postoperative cardiac diagnosis) were reviewed. Patients with chest pain were compared to those without chest pain using the Fisher exact test and Student t test. RESULTS: Fourteen of 295 patients (4.7%) reported chest pain in the immediate postoperative period. Most patients were investigated with a 12-lead electrocardiogram and troponin (n = 12/14), yet none were diagnosed with a cardiac event. When comparing patients with and without chest pain, there was no significant difference in age, gender, body mass index, presence of cardiovascular risk factors, American Society of Anesthesiologists score or length of surgery. CONCLUSION: Postoperative chest pain after parathyroidectomy is not an uncommon event and leads to a cardiac workup in most cases; however, the risk of significant postoperative cardiac events is minimal. In the "choosing wisely" era, one should evaluate each patient's pretest probability of such events and avoid extensive workup in low-risk patients to avoid unnecessary costs to the health care system.