Management Of PHPT Research Articles

Quality Indicators for the Diagnosis and Management of Primary Hyperparathyroidism

Primary hyperparathyroidism (pHPT) is a common endocrine disorder with many diagnostic and treatment challenges. Despite high-quality guidelines, care is variable, and there is low adherence to evidence-based treatment pathways. To develop quality indicators (QIs) to evaluate the diagnosis and treatment of pHPT that could measure, improve, and optimize quality of care and outcomes for patients with this disease. This quality improvement study used a guideline-based approach to develop QIs that were ranked by a Canadian 9-member expert panel of 3 endocrinologists, 3 otolaryngologists, and 3 endocrine surgeons. Data were analyzed between September 2020 and May 2021. Candidate indicators (CIs) were extracted from published primary hyperparathyroidism guidelines and summarized with supporting evidence. The 9-member expert panel rated each CI on the validity, reliability, and feasibility of measurement. Final QIs were selected from CIs using the modified RAND-University of California, Los Angeles appropriateness methodology. All panelists were then asked to rank the top 5 QIs for primary, endocrine, and surgical care. Forty QIs were identified and evaluated by the expert panel. After 2 rounds of evaluations and discussion, a total of 18 QIs were selected as appropriate measures of high-quality care. The top 5 QIs for primary, endocrine, and surgical care were selected following panelist rankings. This quality improvement study proposes 18 QIs for the diagnosis and management of pHPT. Furthermore, the top 5 QIs applicable to physicians commonly treating pHPT, including general physicians, internists, endocrinologists, otolaryngologists, and surgeons, are included. These QIs not only assess the quality of care to guide the process of improvement, but also can assess the implementation of evidence-based guideline recommendations. Using these indicators in clinical practice and health system registries can improve quality and cost-effectiveness of care for patients with pHPT.

Minimally invasive video-assisted parathyroidectomy (MIVAP) without intraoperative PTH determination.

Minimally invasive video-assisted parathyroidectomy (MIVAP) has become a standard approach to primary hyperparathyroidism (pHPT) since described. Although intraoperative parathyroid hormone assay (IOPTH) has been generalized as a complementary technique to MIVAP, its actual impact on the surgical success of this technique is not without controversy. The aim of this study was to describe our results in the management of pHPT with successful preoperative localization, by MIVAP technique, without IOPTH determination, confirming in a larger series our preliminary results. A retrospective descriptive study was conducted in pHPT patients treated by MIVAP with no IOPTH determination in a tertiary hospital between 2007 and 2019. A total of 167 patients were included in the study. Biochemical cure was achieved in 96.4%, and 94.1% did not present any surgical complication. The mean duration of surgery was 61min, and the mean length of hospital stay was 1.8days CONCLUSIONS: In case of positive preoperative localization studies, MIVAP is a safe and effective technique for the surgical treatment of pHPT due to a parathyroid adenoma, regardless of IOPTH determination, with a success rate > 95% and a low complication rate.

Updates in primary hyperparathyroidism.

This is a review of the latest papers on PHPT with the purpose of assessing the most recent evidence in the management of PHPT and to give updated recommendations for its evaluation, diagnosis, and treatment. I used my personal experience to collect papers that reinforce my ideas for the diagnosis and treatment of PHPT. Perhaps, in the near future, we will have more information about genetics, localization studies, surgical techniques, medical treatments, and statements that we have presented today will be obsolete.

Primary hyperparathyroidism during pregnancy.

Primary hyperparathyroidism (pHPT) during pregnancy is rare and associated with increased morbidity and mortality for both mother and fetus. This review aims to draw together recent thinking on pregnancy and pHPT. We have performed a Pubmed (Medline(®)) search with no time limit using "primary hyperparathyroidism", "pregnancy" or "management" as keywords. We reviewed 37 articles in English and French languages on pHPT characteristics, clinical presentations, pregnancy complications, birth outcomes and management of pHPT during pregnancy. The diagnosis of pHPT is characterized by an elevated serum calcium level associated with an inappropriate increase in the parathyroid hormone level. The clinical manifestations are directly related to the calcium level. Usual techniques to detect parathyroid adenoma or hyperplasia, as computerized tomography and 99mTc-sestamibi scintigraphy, are not recommended in pregnancy. Thus, ultrasonography of the neck is the current first-line investigation during pregnancy for localization of parathyroid diseases. pHPT during pregnancy with mildly elevated calcium levels may be managed with medical treatment: intravenous or oral rehydratation, with or without forced diuresis. Few drugs are available for pHTP during pregnancy; calcitonin and cinacalcet require further study; bisphosphonate should be restricted to life-threatening hypercalcemia. Surgery is the only curative treatment and is recommended when calcium levels are above 2.75 mmol/L. It should be performed in the second trimester and considered in the third trimester if there is inadequate response to medical therapy. Early diagnosis of pHPT in a pregnant woman, followed by appropriate management and treatment, has been shown to significantly reduce maternal and fetal complications.

Derangement of glucose metabolism in hyperparathyroidism.

The derangement of glucose metabolism is found frequently in all forms of hyperparathyroidism. Both in primary (PHPT) and secondary hyperparathyroidism (SHPT) PTH excess is thought to be involved in deteriorating insulin sensitivity and secretion though their different clinical and pathophysiological conditions. In PHPT these abnormalities are related to a high frequency of Type 2 diabetes mellitus and also impaired glucose tolerance according to recent clinical studies, without differences between symptomatic and asymptomatic clinical presentation. In chronic renal failure (CRF), the disorders of glucose metabolism due to SHPT do not bear an increased risk for diabetes whereas they seem to be involved in the progression of atherosclerotic vascular damage which connotes CRF. Moreover, clinical and experimental studies have shown that vitamin D deficiency associated with glucose metabolism abnormalities favors the development of the metabolic syndrome. The potential for metabolic and cardiovascular harm related to hyperparathyroidism, especially PHPT, is the most interesting issue for clinical endocrinologists. This short review of the clinical and pathophysiological data of literature on glucose homeostasis disorders in hyperparathyroidism focuses on its potential clinical and therapeutic impact, particularly in the management of PHPT.