Association of psychosocial traits with coronary artery calcium development and progression: The Multi-Ethnic Study of Atherosclerosis.

BACKGROUND: Coronary artery calcium (CAC) is a well-established quantifiable risk factor for cardiovascular disease (CVD). We examined the association of anger, hostility, anxiety, and depression with the development and progression of CAC. METHODS: We studied the association of these psychosocial traits with CAC among participants in the Multi-Ethnic Study of Atherosclerosis (MESA). Anger was measured using the Spielberger Trait Anger questionnaire, hostility using a modified Cook-Medley Hostility questionnaire, anxiety using the Spielberger Trait Scale, and depression using the Center for Epidemiological Studies Depression Scale (CES-D). Among the subsample of participants with CAC = 0 at the beginning of the study period, Poisson regression models were used to determine the relative risk of developing CAC>0 over the study period. In the subsample that developed CAC>0, we used linear regression models to estimate the average increase in CAC associated with a unit increase in psychosocial trait. RESULTS: Median time of follow-up was 9.4 years (range 8.0-11.4 years). Cross-sectional analyses at baseline revealed no association of any of the psychosocial traits with the presence or magnitude of CAC (anger: RR 0.98, p < 0.01; hostility: RR 1.01, p = 0.25; anxiety: RR 0.99, p < 0.01; depression: RR 0.99, p < 0.01 [not statistically significant after adjustment for covariates]). No association was detected between the traits and development of CAC (anger: RR 0.99, p = 0.23; hostility: RR 1.01, p = 0.68, anxiety: RR 1.00, p = 0.49; depression: RR 1.00, p = 0.51). We also found no association between any of the traits and progression of CAC (anger: beta -3.21, p = 0.08; hostility: beta 2.28, p = 0.43; anxiety: 3.45, p = 0.02 [not statistically significant after adjustment for covariates]; depression: beta -1.46, p = 0.11). CONCLUSIONS: We found no association between anger, hostility, anxiety, or depression and CAC, suggesting these personality traits are not independent risk factors for CVD.

Trends in the frequency and quality of parathyroid surgery: analysis of 17,082 cases over 10 years.

OBJECTIVE: To examine trends in the frequency and quality of surgery for primary hyperparathyroidism (PHPT) in California during the period of 1999 to 2008. BACKGROUND: The quality of surgery for PHPT can be measured by the complication rate and the success rate of surgery. A fraction of patients with failed initial surgery undergo reoperation. METHODS: Data on patients undergoing parathyroidectomy (PTx) were obtained from the California Office of Statewide Health Planning and Development. Renal transplant recipients and dialysis patients were excluded. Hospitals were categorized by case volume: Very low: 1 to 4 operations annually; Low: 5 to 9; Medium, 10 to 19; High: 20 to 49; Very high: 50 or more. Complication rates and the percentage of cases requiring reoperation were analyzed. RESULTS: A total of 17,082 cases were studied. Annual case volume grew from 990 to 2746 (177% increase) over the study period, corresponding to a 147% increase in the per capita PTx rate. The proportion of cases performed by very high-volume hospitals increased from 6.4% to 20.5% (P < 0.001). The overall complication rate declined from 8.7% to 3.8% (P < 0.001). Complication rates were inversely related to hospital volume (very high volume, 3.9% vs very low volume, 5.2%, P < 0.05). Reoperation was performed in 363 patients (2.1%). The reoperation rate increased from 0.91% to 2.73% during the study period (P < 0.01). The reoperation rate was inversely and nonlinearly related to hospital volume, as described by the equation % reoperation = 100/(total hospital case volume). CONCLUSIONS: Surgery for PHPT has grown safer and more common over time. High-volume centers have lower rates of complication and reoperation.

Recurrent hyperparathyroidism and a novel nonsense mutation in a patient with hyperparathyriodism-jaw tumor syndrome.

OBJECTIVE: To present the case of a hyperparathyroidism-jaw tumor (HPT-JT) patient with a novel nonsense mutation of the CDC73 gene. METHODS: We present the case of a patient with a history of three prior maxillectomies and two prior parathyroidectomies who presented with recurrent primary hyperparathyroidism (PHPT). We also briefly review the literature pertaining to HPT-JT. RESULTS: Genetic analysis revealed a novel nonsense mutation (c.85G>T; pGlu29) in exon 1 of CDC73. The patient's son underwent genetic testing for a CDC73 mutation and was found to be negative. CONCLUSION: HPT-JT is a rare condition characterized by PHPT and benign tumors of the mandible and maxilla. Up to 15% of HPT-JT patients with PHPT have parathyroid carcinoma. HPT-JT is associated with an inactivating mutation of CDC73, a gene that codes for the tumor suppressor protein parafibromin. This report expands our understanding of the genetics underlying this rare disorder and emphasizes the importance of early detection in order to prevent hypercalcemic complications such as parathyroid carcinoma.

Endocrine surgery as a model for value-based health care delivery.

BACKGROUND: Experts advocate restructuring health care in the United States into a value-based system that maximizes positive health outcomes achieved per dollar spent. We describe how a value-based system implemented by the University of California, Los Angeles UCLA Section of Endocrine Surgery (SES) has optimized both quality and costs while increasing patient volume. METHODS: Two SES clinical pathways were studied, one allocating patients to the most appropriate surgical care setting based on clinical complexity, and another standardizing initial management of papillary thyroid carcinoma (PTC). The mean cost per endocrine case performed from 2005 to 2010 was determined at each of three care settings: A tertiary care inpatient facility, a community inpatient facility, and an ambulatory facility. Blood tumor marker levels (thyroglobulin, Tg) and reoperation rates were compared between PTC patients who underwent routine central neck dissection (CND) and those who did not. Surgical patient volume and regional market share were analyzed over time. RESULTS: The cost of care was substantially lower in both the community inpatient facility (14% cost savings) and the ambulatory facility (58% cost savings) in comparison with the tertiary care inpatient facility. Patients who underwent CND had lower Tg levels (6.6 vs 15.0 ng/mL; P = 0.024) and a reduced need for re-operation (1.5 vs 6.1%; P = 0.004) compared with those who did not undergo CND. UCLA maintained its position as the market leader in endocrine procedures while expanding its market share by 151% from 4.9% in 2003 to 7.4% in 2010. CONCLUSIONS: A value-driven health care delivery system can deliver improved clinical outcomes while reducing costs within a subspecialty surgical service. Broader application of these principles may contribute to resolving current dilemmas in the provision of care nationally.