Fertility and pregnancy outcomes in primary hyperparathyroidism: Observations from a large insured population.

CONTEXT: Primary hyperparathyroidism (PHPT) has initially been implicated in adverse maternal and neonatal outcomes, while subsequent population studies have failed to show an association. OBJECTIVE: To compare maternal, pregnancy, and neonatal outcomes in patients with and without PHPT. DESIGN: Retrospective matched-cohort study (2005-2020). SETTING: An integrated healthcare delivery system in Southern California. PATIENTS: Women aged 18-44 years were included. Patients with biochemical diagnosis of PHPT were matched 1:3 with eucalcemic controls (non-PHPT). MAIN OUTCOME MEASURES: Achievement of pregnancy, pregnancy outcomes (including rates of abortion, maternal complications), and neonatal outcomes (including hypocalcemia, need for intensive care). RESULTS: The cohort comprised 386 women with PHPT and 1158 age-matched controls. Pregnancy rates between PHPT and control groups were similar (10.6% vs 12.8%). The adjusted rate ratio of pregnancy was 0.89 (95% CI: 0.64-1.24) (PHPT vs non-PHPT). Twenty-nine pregnancies occurred in women with co-existing PHPT and 191 pregnancies occurred in controls, resulting in 23 (79.3%) and 168 (88.0%) live births, respectively (p=0.023). Neonatal outcomes were similar. Live birth rates were similar (86.4%, 80%, 79.2%) for those undergoing parathyroidectomy prior (n=22), during (n=5), or after pregnancy/never (n=24). Among patients who underwent parathyroidectomy during pregnancy, no spontaneous abortions occurred in women entering pregnancy with peak calcium <11.5 mg/dL [2.9 mmol/L]. CONCLUSIONS: We observed no difference in pregnancy rates between women with or without PHPT. Performing parathyroidectomy before pregnancy or during the second trimester appears to be a safe and successful strategy, and adherence to this strategy may be most critical for patients with higher calcium levels (≥11.5 mg/dL [2.9 mmol/L]).

Long-term effects of primary hyperparathyroidism and parathyroidectomy on kidney function.

IMPORTANCE: Limited evidence supports kidney dysfunction as an indication for parathyroidectomy in asymptomatic primary hyperparathyroidism (PHPT). OBJECTIVE: To investigate the natural history of kidney function in PHPT and whether parathyroidectomy alters renal outcomes. DESIGN: Matched control study. SETTING: A vertically integrated health care system serving 4.6 million patients in Southern California. PARTICIPANTS: 6058 subjects with PHPT and 16 388 matched controls, studied from 2000 to 2016. EXPOSURES: Biochemically confirmed PHPT with varying serum calcium levels. MAIN OUTCOMES: Estimated glomerular filtration rate (eGFR) trajectories were compared over 10 years, with cases subdivided by severity of hypercalcemia: serum calcium 2.62-2.74 mmol/L (10.5-11 mg/dL), 2.75-2.87 (11.1-11.5), 2.88-2.99 (11.6-12), and >2.99 (>12). Interrupted time series analysis was conducted among propensity-score-matched PHPT patients with and without parathyroidectomy to compare eGFR trajectories postoperatively. RESULTS: Modest rates of eGFR decline were observed in PHPT patients with serum calcium 2.62-2.74 mmol/L (−1.0 mL/min/1.73 m2/year) and 2.75-2.87 mmol/L (−1.1 mL/min/1.73 m2/year), comprising 56% and 28% of cases, respectively. Compared with the control rate of −1.0 mL/min/1.73 m2/year, accelerated rates of eGFR decline were observed in patients with serum calcium 2.88-2.99 mmol/L (−1.5 mL/min/1.73 m2/year, P < .001) and >2.99 mmol/L (−2.1 mL/min/1.73 m2/year, P < .001), comprising 9% and 7% of cases, respectively. In the propensity score­matched population, patients with serum calcium >2.87 mmol/L exhibited mitigation of eGFR decline after parathyroidectomy (−2.0 [95% CI: −2.6 to −1.5] to −0.9 [95% CI: −1.5 to 0.4] mL/min/1.73 m2/year). CONCLUSIONS AND RELEVANCE: Compared with matched controls, accelerated eGFR decline was observed in the minority of PHPT patients with serum calcium >2.87 mmol/L (11.5 mg/dL). Parathyroidectomy was associated with mitigation of eGFR decline in patients with serum calcium >2.87 mmol/L.

Parathyroidectomy for nephrolithiasis in primary hyperparathyroidism: Beneficial but not a panacea.

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.

Skeletal effects of combined medical and surgical management of primary hyperparathyroidism.

BACKGROUND: Parathyroidectomy (PTX) increases bone mineral density and decreases fracture risk in patients with primary hyperparathyroidism. This study examined the effect of adding bisphosphonates either before or after PTX on skeletal outcomes. METHODS: A retrospective cohort study of bisphosphonate-naïve patients (1995-2016) with osteoporosis and primary hyperparathyroidism (calcium >10.5 mg/dL; PTH >65) was performed. Time-varying Cox regression was used to estimate an adjusted risk of any fracture in 5 comparison groups: observation, bisphosphonates alone, PTX alone, bisphosphonates then PTX, and PTX then bisphosphonates. The secondary outcome was change in bone mineral density of the hip. RESULTS: The cohort comprised 1,737 patients, of whom 303 underwent PTX (17%), 433 received bisphosphonates only (25%), 125 had bisphosphonates then PTX (7%), and 69 had PTX then bisphosphonates (4%). PTX was associated with a decrease in fracture risk (HR 0.55, 95% CI 0.35-0.84), as was bisphosphonates then PTX (HR 0.46, 95% CI 0.25-0.83). In contrast, the fracture risks associated with PTX then bisphosphonates (HR 1.09, 95% CI 0.65-1.81) and bisphosphonates alone (HR 0.82, 95% CI 0.62-1.08) were similar to observation. Hip bone mineral density increased after both PTX (5.50%, 95% CI 3.39-7.61) and PTX then bisphosphonates (6.30%, 95% CI 2.53-10.07). CONCLUSION: Bisphosphonate initiation after PTX may interfere with the beneficial effects of PTX on fracture risk in osteoporotic patients with primary hyperparathyroidism.

Hypocalcemia after Total Thyroidectomy in Graves Disease.

CONTEXT: Total thyroidectomy has been shown to provide a cost-effective and efficient method of permanently treating Graves disease; however, hypocalcemia can be a common complication. OBJECTIVE: To evaluate the risk of hypocalcemia after total thyroidectomy in patients with vs without Graves disease. DESIGN: The 2016 American College of Surgeons National Surgical Quality Improvement Program participant use data files for procedure-targeted thyroidectomy and from 5871 patients were merged. This study included any patient who underwent total thyroidectomy. MAIN OUTCOME MEASURES: Whether symptomatic hypocalcemia developed anytime within 30 days after the thyroidectomy. A clinically severe hypocalcemic event was also evaluated as a secondary outcome measure. RESULTS: Of the 2143 patients who underwent total thyroidectomy, 222 patients experienced hypocalcemia after surgery, 124 of whom had symptomatic hypocalcemia postoperatively. Among patients with hypocalcemia, 16.3% had Graves disease, whereas only 9.4% of patients without Graves disease experienced significant hypocalcemia. Multivariable logistic regression analysis revealed that women (odds ratio = 1.79; 95% confidence interval = 1.16-2.76; p = 0.009) and patients who underwent parathyroid autotransplantation (odds ratio = 1.91; 95% confidence interval = 1.30-2.81; p = 0.001) were at greater risk of development of hypocalcemia. Older patients were less likely to experience hypocalcemia postoperatively (odds ratio = 0.586; 95% confidence interval = 0.44-0.79; p = 0.0001). CONCLUSION: Patients with Graves disease are about twice as likely to experience hypocalcemia or clinically severe hypocalcemia postoperatively than are patients without the disease.

BIOCHEMICAL DYNAMICS OF UNTREATED PRIMARY HYPERPARATHYROIDISM: AN OBSERVATIONAL STUDY.

Objective: The natural biochemical history of untreated primary hyperparathyroidism (PHPT) is poorly understood. The purpose of this study was to determine the extent of biochemical fluctuations in patients with PHPT. Methods: Retrospective cohort study from January 1, 1995, to December 31, 2014. Serum calcium and parathyroid hormone (PTH) levels in patients with classic (Ca >10.5 mg/dL, PTH >65 pg/mL) and nonclassic (Ca >10.5 mg/dL, PTH 40 to 65 pg/mL) PHPT were followed longitudinally at 1, 2, and 5 years. Biochemical profiles in follow-up were ranked in descending biochemical severity as classic PHPT, nonclassic PHPT, normal calcium with elevated PTH (Ca <10.5 mg/dL, PTH >65 pg/mL), possible PHPT (Ca >10.5 mg/dL, PTH 21 to 40 pg/mL), or absent PHPT (Ca >10.5 mg/dL, PTH <21 pg/mL or Ca <10.5 mg/dL, PTH <65 pg/mL). Results: Of 10,598 patients, 1,570 were treated with parathyroidectomy (n = 1,433) or medications (n = 137), and 4,367 were censored due to study closure, disenrollment, or death. In the remaining 4,661 untreated patients with 5 years of follow-up, 235 (5.0%) progressed to a state of increased biochemical severity, whereas 972 (20.8%) remained the same, and 3,454 (74.1%) regressed to milder biochemical states. In 2,522 untreated patients with classic PHPT, patients most frequently transitioned to the normal calcium with elevated PTH group (n = 1,257, 49.8%). In 2,139 untreated patients with nonclassic PHPT, patients most frequently transitioned to the absent PHPT group (n = 1,354, 63.3%). Conclusion: PHPT is a biochemically dynamic disease with significant numbers of patients exhibiting both increases and decreases in biochemical severity. Abbreviations: IQR = interquartile range; KPSC = Kaiser Permanente Southern California; PHPT = primary hyperparathyroidism; PTH = parathyroid hormone; PTx = parathyroidectomy.

End-organ effects of primary hyperparathyroidism: A population-based study.

BACKGROUND: Patients with primary hyperparathyroidism are at risk for skeletal and renal end-organ damage. METHODS: We studied patients with biochemically confirmed primary hyperparathyroidism from 1995-2014 and quantified the frequency of osteoporosis, nephrolithiasis, hypercalciuria, and decrease in renal function. RESULTS: The cohort comprised 9,485 patients. In total, 3,303 (35%) had preexisting end-organ effects (osteoporosis, 24%; nephrolithiasis, 10%; hypercalciuria, 5%). Of 6,182 remaining patients, 1,769 (29%) exhibited progression to 1 or more end-organ effects over a median 3.7 years. Among patients with classic primary hyperparathyroidism (calcium and parathyroid hormone increased), progression was unrelated to the degree of hypercalcemia (calcium >11.5 mg/dL, hazard ratio 1.03, 95% confidence interval 0.85-1.25; 11.1-11.5 mg/dL, HR 1.07, 95% confidence interval 0.93-1.23; 10.5-11.0 mg/dL = reference). Patients with nonclassic primary hyperparathyroidism (calcium increased, parathyroid hormone 40-65 pg/mL) had a lesser risk of progression (calcium >11.5 mg/dL, hazard ratio 0.68, 95% confidence interval 0.50-0.94; 11.1-11.5 mg/dL, hazard ratio 0.68, 95% confidence interval 0.56-0.82; 10.5-11.0 mg/dL, hazard ratio 0.66, 95% confidence interval 0.59-0.74). End-organ damage developed before or within 5 years of diagnosis for 62% of patients. CONCLUSION: End-organ manifestations of primary hyperparathyroidism develop before biochemical diagnosis or within 5 years in most patients. End-organ damage occurred more frequently in patients with classic primary hyperparathyroidism versus nonclassic primary hyperparathyroidism, regardless of severity of hypercalcemia.

Skeletal effects of failed parathyroidectomy.

BACKGROUND: Parathyroidectomy improves bone mineral density and decreases risk for fracture in patients with primary hyperparathyroidism. The aim of this study was to determine skeletal consequences of failed parathyroidectomy. METHODS: A retrospective, cohort study of patients with biochemically confirmed primary hyperparathyroidism within a vertically integrated health system was performed (1995-2014). Failed parathyroidectomy was defined by hypercalcemia within 6 months of initial parathyroidectomy. Time-varying Cox regression was used to estimate the risk for any fracture and hip fracture in 3 comparison groups: observation, successful parathyroidectomy, and failed parathyroidectomy. Bone mineral density changes also were compared. RESULTS: The cohort included 7,169 patients, of whom 5,802 (81%) were observed, 1,228 underwent successful parathyroidectomy (17%), and 137 underwent failed parathyroidectomy (2%). The adjusted risk for any fracture (hazard ratio, 1.28; 95% confidence interval, 0.85-1.92) and hip fracture (hazard ratio, 1.63; 95% CI, 0.77-3.45) associated with failed parathyroidectomy was similar to that associated with observation. Successful parathyroidectomy was associated with a decrease in any fracture (hazard ratio, 0.68; 95% confidence interval, 0.57-0.82) and hip fracture (hazard ratio, 0.43; 95% confidence interval, 0.27-0.68) compared with observation. Bone mineral density changes in the failed parathyroidectomy group paralleled those associated with observation. CONCLUSION: Failed parathyroidectomy is associated with a high risk for fracture similar to that seen with observation.

Population-Level Incidence and Predictors of Surgically Induced Diabetes and Exocrine Insufficiency after Partial Pancreatic Resection.

CONTEXT: Endocrine and exocrine insufficiency after partial pancreatectomy affect quality of life, cardiovascular health, and nutritional status. However, their incidence and predictors are unknown. OBJECTIVE: To identify the incidence and predictors of new-onset diabetes and exocrine insufficiency after partial pancreatectomy. DESIGN: We retrospectively reviewed 1165 cases of partial pancreatectomy, performed from 1998 to 2010, from a large population-based database. MAIN OUTCOME MEASURES: Incidence of new onset diabetes and exocrine insufficiency RESULTS: Of 1165 patients undergoing partial pancreatectomy, 41.8% had preexisting diabetes. In the remaining 678 patients, at a median 3.6 months, diabetes developed in 274 (40.4%) and pancreatic insufficiency developed in 235 (34.7%) patients. Independent predictors of new-onset diabetes were higher Charlson Comorbidity Index (CCI; hazard ratio [HR] = 1.62 for CCI of 1, p = 0.02; HR = 1.95 for CCI ≥ 2, p < 0.01) and pancreatitis (HR = 1.51, p = 0.03). There was no difference in diabetes after Whipple procedure vs distal pancreatic resections, or malignant vs benign pathologic findings. Independent predictors of exocrine insufficiency were female sex (HR = 1.32, p = 0.002) and higher CCI (HR = 1.85 for CCI of 1, p < 0.01; HR = 2.05 for CCI ≥ 2, p < 0.01). Distal resection and Asian race predicted decreased exocrine insufficiency (HR = 0.35, p < 0.01; HR = 0.54, p < 0.01, respectively). CONCLUSION: In a large population-based database, the rates of postpancreatectomy endocrine and exocrine insufficiency were 40% and 35%, respectively. These data are critical for informing patients' and physicians' expectations.

Influence of a negative sestamibi scan on the decision for parathyroid operation by the endocrinologist and surgeon.

BACKGROUND: It has been observed that negative sestamibi scans may impact practice patterns in patients with primary hyperparathyroidism. However, there are no published data on the issue. The objective was to elucidate the influence of negative sestamibi scans on referrals by endocrinologists for parathyroidectomy and surgeon decision-making. METHODS: All patients with primary hyperparathyroidism were identified within a region-wide health care system over a 2-year period. Data, including age, calcium, parathyroid hormone, renal function, bone density, and sestamibi scan results, were collected from the electronic medical record of all patients. The electronic referral system was used to track consultations with endocrinologists and surgeons. Multivariable logistic regression analysis was done to model factors involved in endocrinologist recommendations (referral or no referral to operation) and surgeon recommendations (parathyroidectomy or no parathyroidectomy). RESULTS: A total of 539 patients with primary hyperparathyroidism were identified, and 452 were seen by endocrinologists. Of these, 260 patients had sestamibi scans done (120 negative and 140 positive), and 201 (77%) patients were referred to surgeons. Compared with positive sestamibi scans, negative sestamibi scans were independently associated with no referral to surgeons, after adjusting for presence of classic symptoms, age, fitness for operation, calcium, parathyroid hormone, glomerular filtration rate, and bone density (odds ratio = 0.36; 95% confidence interval 0.18-0.73). Surgeons saw an additional 54 patients referred from nonendocrinologists or primary care physicians and sestamibi scans were completed. Surgeons recommended parathyroidectomy in 236 of the 255 patients. Negative sestamibi scans were independently associated with no recommendation for operation (odds ratio = 0.32; 95% confidence interval 0.11-0.91). Surgeons initially scheduled and completed parathyroidectomies in 211/255 patients. Cure rate after operation was 98%, and this was not influenced by the sestamibi scan result. CONCLUSION: Negative sestamibi scans influence decision making in the management of patients with primary hyperparathyroidism. Endocrinologists commonly order sestamibi scans, and if negative, they are less likely to refer patients to surgeons. Surgeons are also influenced by sestamibi scans, and if negative, they are less likely to recommend parathyroidectomy. Cure rate in sestamibi-negative patients is excellent after operation.

Preferential Use of Total Thyroidectomy without Prophylactic Central Lymph Node Dissection for Early-Stage Papillary Thyroid Cancer: Oncologic Outcomes in an Integrated Health Plan.

CONTEXT: The oncologic benefit of prophylactic central lymph node dissection (pCLND) in node-negative papillary thyroid cancer has been debated. OBJECTIVE: To determine the use of pCLND in an integrated health care system and to evaluate recurrence in the cohort. DESIGN: Retrospective cohort study of patients with clinically node-negative papillary thyroid cancer who underwent total thyroidectomy with or without pCLND in Kaiser Permanente Southern California Region hospitals between January 1996 and December 2008. Chart review of all patients was performed to collect demographic data, tumor features, stage, and recurrences. MAIN OUTCOME MEASURES: Proportion undergoing pCLND and recurrence rate of papillary thyroid cancer. RESULTS: There were 864 patients identified (mean age, 46.1 years). Almost all patients had total thyroidectomy alone, and 34 (3.9%) underwent pCLND. The TNM (tumor, node, metastasis) stages for the 2 groups were not significantly different (p = 0.18). Overall recurrence was 24 (2.8%). There were 23 (2.8%) recurrences in the no-pCLND group and 1 (2.9%) recurrence in the pCLND group (p = 0.95). The rate of recurrence in the central neck compartment in those without pCLND was 1.1% and 0% in the pCLND group (p = 0.54). The recurrence rate in the lateral neck compartment in the no-pCLND group was 2.2%, and this rate was 2.9% in the pCLND group (p = 0.76). The no-pCLND group had a recurrence-free survival rate of 96.4% at 10 years vs 96.8% in the pCLND patients (p = 0.80). CONCLUSION: Presently, routine pCLND is difficult to advocate in our medical system.

The Relationship of Parathyroidectomy and Bisphosphonates With Fracture Risk in Primary Hyperparathyroidism: An Observational Study.

BACKGROUND: The comparative effectiveness of surgical and medical treatments on fracture risk in primary hyperparathyroidism (PHPT) is unknown. OBJECTIVE: To measure the relationship of parathyroidectomy and bisphosphonates with skeletal outcomes in patients with PHPT. DESIGN: Retrospective cohort study. SETTING: An integrated health care delivery system. PARTICIPANTS: All enrollees with biochemically confirmed PHPT from 1995 to 2010. MEASUREMENTS: Bone mineral density (BMD) changes and fracture rate. RESULTS: In 2013 patients with serial bone density examinations, total hip BMD increased transiently in women with parathyroidectomy (4.2% at <2 years) and bisphosphonates (3.6% at <2 years) and declined progressively in both women and men without these treatments (-6.6% and -7.6%, respectively, at >8 years). In 6272 patients followed for fracture, the absolute risk for hip fracture at 10 years was 20.4 events per 1000 patients who had parathyroidectomy and 85.5 events per 1000 patients treated with bisphosphonates compared with 55.9 events per 1000 patients without these treatments. The risk for any fracture at 10 years was 156.8 events per 1000 patients who had parathyroidectomy and 302.5 events per 1000 patients treated with bisphosphonates compared with 206.1 events per 1000 patients without these treatments. In analyses stratified by baseline BMD status, parathyroidectomy was associated with reduced fracture risk in both osteopenic and osteoporotic patients, whereas bisphosphonates were associated with increased fracture risk in these patients. Parathyroidectomy was associated with fracture risk reduction in patients regardless of whether they satisfied criteria from consensus guidelines for surgery. LIMITATION: Retrospective study design and nonrandom treatment assignment. CONCLUSION: Parathyroidectomy was associated with reduced fracture risk, and bisphosphonate treatment was not superior to observation. PRIMARY FUNDING SOURCE: National Institute on Aging.

Hypothyroidism after hemithyroidectomy.

BACKGROUND: The risk of hypothyroidism after hemithyroidectomy is variable, and most estimates come from single institutional studies. The purpose of the present study was to determine the incidence of hypothyroidism at the population level, and to evaluate predictive factors for hypothyroidism after hemithyroidectomy. METHODS: This retrospective study identified euthyroid patients who underwent hemithyroidectomy between 2000 and 2010 for benign disease in Kaiser Permanente Southern California regional hospitals. The incidence of hypothyroidism [thyroid stimulating hormone (TSH) levels >4 µIU/ml] was analyzed. The independent effect of age-quartile, gender, race, thyroiditis, and preoperative TSH level on the development of hypothyroidism was evaluated. RESULTS: Of 1,240 euthyroid patients identified, 417 (34 %) developed hypothyroidism, and 314 (25 % of total group) needed levothyroxine. Hypothyroidism was more common in age-quartile 2 (32 %), age-quartile 3 (37 %), and age-quartile 4 (42 %) than in age-quartile 1 (25 %) [adjusted odds ratio (OR) = 1.87; 95 % confidence interval (CI) 1.27-2.76, p = 0.002; age-quartile 4 compared to age-quartile 1]. Hypothyroidism was more frequent with increasing preoperative TSH levels 36, 72, and 92 % in patients with TSH levels of 1.0-2, 2.01-3, and 3.01-4 µIU/ml, respectively, compared to 17 % in those with TSH levels <1 µIU/ml [adjusted OR = 45.1; 95 % CI 13.5-151, p < 0.0001; 3.01-4 µIU/ml compared to <1 µIU/ml]. Thyroiditis was also an independent predictor of hypothyroidism. CONCLUSIONS: About one third of euthyroid patients who undergo hemithyroidectomy develop hypothyroidism. The most significant predictor is the preoperative TSH level, with an approximate doubling of risk for each 1 unit of TSH increase over 1 µIU/ml. Our categorical scale is simple and allows for easy recall when counseling patients preoperatively.

Gallstone pancreatitis without cholecystectomy.

IMPORTANCE: Current guidelines recommend that patients with an initial episode of gallstone pancreatitis receive cholecystectomy. However, for various reasons, many patients do not. OBJECTIVE: To determine the risk of developing recurrent gallstone pancreatitis in patients who never receive a cholecystectomy. DESIGN: Retrospective cohort study using electronic medical records. SETTING: Inpatient and outpatient. PATIENTS: All patients in Kaiser Permanente Southern California with a primary diagnosis of acute gallstone pancreatitis hospitalized from January 1, 1995, through December 31, 2010, with no previous diagnosis of gallstone pancreatitis documented in the medical record. INTERVENTIONS: Endoscopic retrograde cholangiopancreatography (ERCP) with or without sphincterotomy and/or stent placement, or no intervention. MAIN OUTCOMES AND MEASURES: Recurrent acute pancreatitis. RESULTS: A total of 1119 patients were identified. The median age at diagnosis was 63 years. Among the patients, 802 received no intervention and 317 received ERCP. After a median follow-up of 2.3 years, the overall risk of recurrent pancreatitis was 14.6%; it was 8.2% and 17.1% in patients who had ERCP and no intervention, respectively (P < .001). The median time to recurrence was 11.3 and 10.1 months in the patients who had ERCP and no intervention, respectively. Kaplan-Meier estimates of recurrence for 1, 2, and 5 years in the ERCP group were 5.2%, 7.4%, and 11.1%, compared with 11.3%, 16.1%, and 22.7% in the no-intervention group (hazard ratio = 0.45; 95% CI, 0.30-0.69; P < .001). Charlson Comorbidity Index and intensive care unit stay were independently associated with recurrence, whereas age, sex, and admission Ranson score were not associated. CONCLUSIONS AND RELEVANCE: In patients who did not undergo cholecystectomy, the risk of recurrent pancreatitis is significant. Endoscopic retrograde cholangiopancreatography mitigates this risk and should be considered during initial hospitalization if cholecystectomy is not done.

Incidence and prevalence of primary hyperparathyroidism in a racially mixed population.

CONTEXT: The epidemiology of primary hyperparathyroidism (PHPT) has generally been studied in Caucasian populations. OBJECTIVE: The aim was to examine the incidence and prevalence of PHPT within a racially mixed population. DESIGN: A descriptive epidemiologic study was performed. PATIENTS/SETTING: The study population included 3.5 million enrollees within Kaiser Permanente Southern California. METHODS: All patients with at least one elevated serum calcium level (>10.5 mg/dL, 2.6 mmol/L) between 1995 and 2010 were included. Cases of PHPT were identified by electronic query of laboratory values using biochemical criteria, after exclusion of secondary or renal and tertiary hyperparathyroidism cases. The incidence and prevalence rates of PHPT were calculated according to sex, race, age group by decade, and year. RESULTS: Initial case finding identified 15,234 patients with chronic hypercalcemia, 13,327 (87%) of which had PHPT as defined by elevated or inappropriately normal parathyroid hormone levels. The incidence of PHPT fluctuated from 34 to 120 per 100,000 person-years (mean 66) among women, and from 13 to 36 (mean 25) among men. With advancing age, incidence increased and sex differences became pronounced (incidence 12-24 per 100,000 for both sexes younger than 50 y; 80 and 36 per 100,000 for women and men aged 50-59 y, respectively; and 196 and 95 for women and men aged 70-79 y, respectively). The incidence of PHPT was highest among blacks (92 women; 46 men, P < .0001), followed by whites (81 women; 29 men), with rates for Asians (52 women, 28 men), Hispanics (49 women, 17 men), and other races (25 women, 6 men) being lower than that for whites (P < .0001). The prevalence of PHPT tripled during the study period, increasing from 76 to 233 per 100,000 women and from 30 to 85 per 100 000 men. Racial differences in prevalence mirrored those found in incidence. CONCLUSIONS: PHPT is the predominant cause of hypercalcemia and is increasingly prevalent. Substantial differences are found in the incidence and prevalence of PHPT between races.

Obesity increases the odds of acquiring and incarcerating noninguinal abdominal wall hernias.

The current data available describing the relationship of obesity and abdominal wall hernias is sparse. The objective of this study was to investigate the current prevalence of noninguinal abdominal wall hernias and their correlation with body mass index (BMI) and other demographic risk factors. Patients with umbilical, incisional, ventral, epigastric, or Spigelian hernias with or without incarceration were identified using the regional database for 14 hospitals over a 3-year period. Patients were stratified based on their BMI. Univariate and multivariate analyses were performed to distinguish other significant risk factors associated with the hernias. Of 2,807,414 patients, 26,268 (0.9%) had one of the specified diagnoses. Average age of the patients was 52 years and 61 per cent were male. The majority of patients had nonincarcerated umbilical hernias (74%). Average BMI was 32 kg/m2. Compared with patients with a normal BMI, the odds of having a hernia increased with BMI: BMI of 25 to 29.9 kg/m2 odds ratio (OR) 1.63, BMI of 30 to 39.9 kg/m2 OR 2.62, BMI 40 to 49.9 kg/m2 OR 3.91, BMI 50 to 59.9 kg/m2 OR 4.85, and BMI greater than 60 kg/m2 OR 5.17 (P<0.0001). Age older than 50 years was associated with a higher risk for having a hernia (OR, 2.12; 95% [CI], 2.07 to 2.17), whereas female gender was associated with a lower risk (OR, 0.53; 95% CI, 0.52 to 0.55). Those with incarcerated hernias had a higher average BMI (32 kg/m2 vs 35 kg/m2; P<0.0001). Overall, BMI greater than 40 kg/m2 showed an increased chance of incarceration, and a BMI greater than 60 kg/m2 had the highest chance of incarceration, OR 12.7 (P<0.0001). Age older than 50 years and female gender were also associated with a higher risk of incarceration (OR, 1.28; 95% CI, 1.02 to 1.59 and OR, 1.80; CI, 1.45 to 2.24). Increasing BMI and increasing age are associated with a higher prevalence and an increased risk of incarceration of noninguinal abdominal wall hernias.

Surgery for primary hyperparathyroidism: are the consensus guidelines being followed?

OBJECTIVE: To determine parathyroidectomy (PTx) rates in patients who satisfy the consensus guidelines for surgical treatment of primary hyperparathyroidism (PHPT). BACKGROUND: Surgery for PHPT is recommended for all symptomatic patients and select asymptomatic patients meeting established consensus criteria. Adherence to the consensus guidelines has not been examined systematically, because of inadequate information regarding patients managed nonoperatively. METHODS: All nonuremic patients with PHPT during the period 1995-2008 were identified using the Kaiser Permanente-Southern California laboratory database, encompassing 3.5 million individuals annually. Multivariate logistic regression was used to examine predictors of PTx. RESULTS: We found 3388 patients with PHPT, of whom 265 (8%) were symptomatic (nephrolithiasis). Nephrolithiasis was predictive of PTx (OR 2.94 vs asymptomatic), with 51% of symptomatic patients undergoing surgery. Among asymptomatic patients, the proportion meeting consensus criteria was 39% during the early period (1995-2002) and 51% during the late period (2003-2008). The PTx rate for these patients exceeded that for asymptomatic patients not meeting consensus criteria but remained low (early 44% vs 19%, P < 0.0001; late 39% vs 16%, P < 0.0001). The following individual criteria were predictive of PTx: calcium >11.5 mg/dL (OR 2.27), hypercalciuria (OR 3.28, P < 0.0001), and age < 50 years (OR 1.54, P < 0.0001). However, the absolute PTx rates associated with satisfaction of these criteria were in the 50% range. Bone density scores did not influence likelihood of PTx and renal impairment predicted against PTx (OR 0.35, P < 0.0001). CONCLUSIONS: The consensus guidelines regarding PHPT have not been followed in our study population. PTx appears to be underutilized in both asymptomatic and symptomatic patients.

Defunctioning loop ileostomy for pelvic anastomoses: predictors of morbidity and nonclosure.

OBJECTIVE: The aim of this study was to determine the morbidity of a defunctioning loop ileostomy and the subsequent closure rate, and to identify the predictors of complications and nonclosure of stoma. DESIGN: This study is a retrospective review of a single-institution experience. PATIENTS: All patients who underwent a planned temporary defunctioning loop ileostomy performed synchronously with a pelvic anastomosis during a 6-year period were included. MAIN OUTCOME MEASURES: The primary outcome measures were the ileostomy complication rate for the entire spectrum of care, readmission and reoperation rates to treat ileostomy complications, and subsequent closure rate. Patient and treatment factors were evaluated for their independent effect on complications and closure rate with the use of multivariable logistic regression. RESULTS: One hundred twenty-three patients were identified (median age, 51 years). Of these patients, 64.2% developed ≥1 minor or major ileostomy complications (13.8% during index hospitalization, 52.8% as outpatient, and 23.4% after closure). Readmitted for dehydration following ileostomy formation were 11.4% of patients. The ileostomy was closed in 76.4% of patients with 8.6% requiring a midline laparotomy. The overall ileostomy-related reoperation rate was 10.4% (2.4% during index hospitalization, 1.6% at readmission, and 6.4% following ileostomy closure). Obesity (BMI ≥30 kg/m) was associated with a higher overall ileostomy complication rate (OR 8.56, 95% CI 1.64-44.74) and outpatient complication rate (OR 7.69, 95% CI 2.48-23.81). Age >65 years (OR 53.34, 95% CI 4.21-676.14) and hypertension (OR 8.36, 95% CI 1.09-64.43) increased the risks of high ileostomy output and dehydration. Obesity (OR 4.61, 95% CI 1.14-18.54) and smoking (4.47, 95% CI 1.43-13.98) decreased the likelihood of ileostomy closure. LIMITATION: This study was limited by its retrospective nature. CONCLUSIONS: The morbidity of a defunctioning loop ileostomy remains significant. Obesity is an independent predictor of ileostomy complications. Older age and hypertension increase the risks of high-output stoma and dehydration. Almost one quarter of patients never have the ileostomy closed. Obesity and smoking are associated with less likelihood of a subsequent ileostomy closure.