Clinical presentation and management of patients with primary hyperparathyroidism of the Swiss Primary Hyperparathyroidism Cohort: a focus on neuro-behavioral and cognitive symptoms

PURPOSE

To describe the clinical and biochemical profile of patients with primary hyperparathyroidism (PHPT) of the Swiss Hyperparathyroidism Cohort, with a focus on neurobehavioral and cognitive symptoms and on their changes in response to parathyroidectomy.

METHODS

From June 2007 to September 2012, 332 patients were enrolled in the Swiss PHPT Cohort Study, a nationwide prospective and non-interventional project collecting clinical, biochemical, and outcome data in newly diagnosed patients. Neuro-behavioral and cognitive status were evaluated annually using the Mini-Mental State Examination, the Hospital Anxiety and Depression Scale, and the Clock Drawing tests. Follow-up data were recorded every 6 months. Patients with parathyroidectomy had one follow-up visit 3-6 months' postoperatively.

RESULTS

Symptomatic PHPT was present in 43 % of patients. Among asymptomatic patients, 69 % (131/189) had at least one of the US National Institutes for Health criteria for surgery, leaving thus a small number of patients with cognitive dysfunction or neuropsychological symptoms, but without any other indication for surgery. At baseline, a large proportion showed elevated depression and anxiety scores and cognitive dysfunction, but with no association between biochemical manifestations of the disease and test scores. In the 153 (46 %) patients who underwent parathyroidectomy, we observed an improvement in the Mini-Mental State Examination (P = 0.01), anxiety (P = 0.05) and depression (P = 0.05) scores.

CONCLUSION

PHPT patients often present elevated depression and anxiety scores and cognitive dysfunction, but rarely as isolated manifestations. These alterations may be relieved upon treatment by parathyroidectomy.

Age-associated declines in muscle mass, strength, power, and physical performance: impact on fear of falling and quality of life

This 3-year longitudinal study among older adults showed that declining muscle mass, strength, power, and physical performance are independent contributing factors to increased fear of falling, while declines of muscle mass and physical performance contribute to deterioration of quality of life. Our findings reinforce the importance of preserving muscle health with advancing age.

INTRODUCTION

The age-associated loss of skeletal muscle quantity and function are critical determinants of independent physical functioning in later life. Longitudinal studies investigating how decrements in muscle components of sarcopenia impact fear of falling (FoF) and quality of life (QoL) in older adults are lacking.

METHODS

Twenty-six healthy older subjects (age, 74.1 ± 3.7; Short Physical Performance Battery (SPPB) score ≥10) and 22 mobility-limited older subjects (age, 77.2 ± 4.4; SPPB score ≤9) underwent evaluations of lower extremity muscle size and composition by computed tomography, strength and power, and physical performance at baseline and after 3-year follow-up. The Falls Efficacy Scale (FES) and Short Form-36 questionnaire (SF-36) were also administered at both timepoints to assess FoF and QoL, respectively.

RESULTS

At 3-year follow-up, muscle cross-sectional area (CSA) (p < 0.013) and power decreased (p < 0.001), while intermuscular fat infiltration increased (p < 0.001). These decrements were accompanied with a longer time to complete 400 m by 22 ± 46 s (p < 0.002). Using linear mixed-effects regression models, declines of muscle CSA, strength and power, and SPPB score were associated with increased FES score (p < 0.05 for each model). Reduced physical component summary score of SF-36 over follow-up was independently associated with decreased SPPB score (p < 0.020), muscle CSA (p < 0.046), and increased 400 m walk time (p < 0.003).

CONCLUSIONS

In older adults with and without mobility limitations, declining muscle mass, strength, power, and physical performance contribute independently to increase FoF, while declines of muscle mass and physical performance contribute to deterioration of QoL. These findings provide further rationale for developing interventions to improve aging muscle health.

Malnutrition in Very Old Hospitalized Patients: A New Etiologic Factor of Anemia?

BACKGROUND

Anemia and malnutrition are highly prevalent, frequently concomitant and associated with negative outcomes and mortality in the elderly.

OBJECTIVES

To evaluate the association between these two entities, and test the hypothesis that protein-energy deficit could be etiology of anemia.

DESIGN

Prospective case-control study.

SETTING

Geriatric and Rehabilitation Hospital, Geneva University Hospitals, Switzerland.

PARTICIPANTS

392 patients (mean age 84.8 years old, 68.6% female).

MAIN OUTCOME MEASURES

Hematological (hemoglobin (Hb)), chemical (iron work up, cyanocobalamin, folates, renal function, C-Reactive Protein (CRP)) and nutrition (albumin, prealbumin) parameters, and mini nutritional assessment short form (MNA-SF).

RESULTS

The prevalence of anemia (defined as Hb<120 g/l) was 39.3%. Anemic patients were more frequently malnourished or at risk of malnutrition according to the MNA-SF (p=0.047), with lower serum albumin (p <0.001) and prealbumin (p <0.001) levels. Thirty-eight percent of these patients had multiple causes and 14.3% had no cause found for anemia. Among the latter 90.9% of patients with unexplained anemia had albumin levels lower than 35g/l. After exclusion of iron,vitamin B12 and folic acid deficits, anemic patients had lower albumin (p<0.001) and prealbumin (p 0.007) levels. Albumin level explained 84.5% of the variance in anemia. In multivariate analysis albumin levels remain associated with Hb only in anemic patients, explaining 6.4% of Hb variance (adj R2) and 14.7% (adj R2) after excluding inflammatory parameters (CRP>10).

CONCLUSIONS

Albumin levels are strongly associated with anemia in the elderly. Screening for undernutrition should be included in anemia assessment in those patients. Further prospective studies are warranted in order to explore the effect of protein and energy supplementation on hemoglobin level.

[Definition of sarcopenia and diagnostic evaluation in clinical practice]

Aging is associated with progressive increase in body fat and a corresponding decline in lean muscle mass. When the decrease in muscle mass reaches a critical threshold, this may affect muscle strength and consequently limit the ability to cope with the activities of daily living, reducing the independence of elders. It is widely accepted to define sarcopenia as the loss of skeletal muscle mass and strength that occurs with advancing age. It is more difficult to establish cut-off points which are clinically relevant. The purpose of this paper is to summarize the definitions of sarcopenia and the assessment tools that can be used in clinical practice.

[The risk of bisphosphonate-related osteonecrosis of the jaw]

Bisphosphonates are widely used in the treatment of osteonecrosis and oncology related bone complications. Their use is highly beneficial for the patient, but may be associated with adverse effects. Osteonecrosis of the jaw is an often cited complication of this treatment, but is in practice rarely seen. Its prevalence is low in cases of osteoporosis but a little higher in the oncological setting. Although its pathophysiology is not completely eluci-dated, certain risk factors have been identified such as tooth extraction which often precedes the affection. Management requires a multidisciplinary approach and a conservative treatment is usually preferred. Dealing with this rare condition requires identification of at risk patients so as to apply preventative measures.

Acute and long term mineral metabolism adaptation in living kidney donors: a prospective study

BACKGROUND

Living kidney donors (LKDs) experience an abrupt decline in glomerular filtration rate (GFR). Mineral metabolism adaptations in early CKD are still debated and not well studied in LKDs. We prospectively studied acute and long term mineral metabolism adaptation of LKDs.

METHODS

From May 2010 to December 2012, we included 27 adult LKDs. Their mineral parameters and renal function were repeatedly measured at days 0, 1, 2, 3, 180 and 360 after donation. We also measured in uninephrectomized rats' Klotho in the remnant kidney and FGF23 circulating levels.

RESULTS

In the first days after nephrectomy, LKDs experience transient dilution hypocalcemia and secondary hyperparathyroidism. Urinary phosphate reabsorption decreases in spite of an abrupt decline in circulating FGF23 and Klotho. In a more chronic stage, at days 180 and 360 after donation, LKDs have lower GFR and 1,25(OH)2D compared to pre-donation levels, with unchanged 25(OH)D. PTH levels increase, resulting in decreased plasma phosphate levels and renal tubular reabsorption of phosphate. In comparison to pre-donation, FGF23 levels are not significantly changed whereas circulating Klotho levels are lower than pre-donation but higher than immediately post-donation. In uninephrectomized rats, Klotho kidney expression increases after three weeks, whereas circulating FGF23 levels are unchanged.

CONCLUSION

From six months after kidney donation, LKDs develop secondary hyperparathyroidism related to a decrease in 1,25(OH)2D, and decreased plasma phosphate levels. FGF23 levels do not rise in LKDs. Middle term mineral metabolism adaptations to decreased eGFR in donors include decrease in 1,25(OH)2D and increase in PTH and fractional excretion of phosphate resulting in lowered plasma phosphate levels, independently of FGF23. These adaptations differ from those described in CKD patients.

[Gait, balance and muscle assessment in older adults]

Deficits in gait, balance, and maximal and explosive force production in older adults are associated with an increased risk of falls and multiple adverse health outcomes (e.g., dependence, institutionalization and death). Assessment of gait, balance and muscle performances may have important implications for the screening and management of at-risk patients, and the development of targeted interventions. The present article provides a brief overview of available assessment methods, including validated clinical tests suitable for daily practice, and more complex instrumented assessments, recommended for clinical trials or longitudinal studies.

Alterations of bone microstructure and strength in end-stage renal failure

End-stage renal disease (ESRD) patients have a high risk of fractures. We evaluated bone microstructure and finite-element analysis-estimated strength and stiffness in patients with ESRD by high-resolution peripheral computed tomography. We observed an alteration of cortical and trabecular bone microstructure and of bone strength and stiffness in ESRD patients.

INTRODUCTION

Fragility fractures are common in ESRD patients on dialysis. Alterations of bone microstructure contribute to skeletal fragility, independently of areal bone mineral density.

METHODS

We compared microstructure and finite-element analysis estimates of strength and stiffness by high-resolution peripheral quantitative computed tomography (HR-pQCT) in 33 ESRD patients on dialysis (17 females and 16 males; mean age, 47.0 ± 12.6 years) and 33 age-matched healthy controls.

RESULTS

Dialyzed women had lower radius and tibia cortical density with higher radius cortical porosity and lower tibia cortical thickness, compared to controls. Radius trabecular number was lower with higher heterogeneity of the trabecular network. Male patients displayed only a lower radius cortical density. Radius and tibia cortical thickness correlated negatively with bone-specific alkaline phosphatase (BALP). Microstructure did not correlate with parathyroid hormone (PTH) levels. Cortical porosity correlated positively with "Kidney Disease: Improving Global Outcomes" working group PTH level categories (r = 0.36, p < 0.04). BMI correlated positively with trabecular number (r = 0.4, p < 0.02) and negatively with trabecular spacing (r = -0.37, p < 0.03) and trabecular network heterogeneity (r = -0.4, p < 0.02). Biomechanics positively correlated with BMI and negatively with BALP.

CONCLUSION

Cortical and trabecular bone microstructure and calculated bone strength are altered in ESRD patients, predominantly in women. Bone microstructure and biomechanical assessment by HR-pQCT may be of major clinical relevance in the evaluation of bone fragility in ESRD patients.

Effect of a multifactorial fall-and-fracture risk assessment and management program on gait and balance performances and disability in hospitalized older adults: a controlled study

This controlled intervention study in hospitalized oldest old adults showed that a multifactorial fall-and-fracture risk assessment and management program, applied in a dedicated geriatric hospital unit, was effective in improving fall-related physical and functional performances and the level of independence in activities of daily living in high-risk patients.

INTRODUCTION

Hospitalization affords a major opportunity for interdisciplinary cooperation to manage fall-and-fracture risk factors in older adults. This study aimed at assessing the effects on physical performances and the level of independence in activities of daily living (ADL) of a multifactorial fall-and-fracture risk assessment and management program applied in a geriatric hospital setting.

METHODS

A controlled intervention study was conducted among 122 geriatric inpatients (mean ± SD age, 84 ± 7 years) admitted with a fall-related diagnosis. Among them, 92 were admitted to a dedicated unit and enrolled into a multifactorial intervention program, including intensive targeted exercise. Thirty patients who received standard usual care in a general geriatric unit formed the control group. Primary outcomes included gait and balance performances and the level of independence in ADL measured 12 ± 6 days apart. Secondary outcomes included length of stay, incidence of in-hospital falls, hospital readmission, and mortality rates.

RESULTS

Compared to the usual care group, the intervention group had significant improvements in Timed Up and Go (adjusted mean difference [AMD] = -3.7s; 95 % CI = -6.8 to -0.7; P = 0.017), Tinetti (AMD = -1.4; 95 % CI = -2.1 to -0.8; P < 0.001), and Functional Independence Measure (AMD = 6.5; 95 %CI = 0.7-12.3; P = 0.027) test performances, as well as in several gait parameters (P < 0.05). Furthermore, this program favorably impacted adverse outcomes including hospital readmission (hazard ratio = 0.3; 95 % CI = 0.1-0.9; P = 0.02).

CONCLUSIONS

A multifactorial fall-and-fracture risk-based intervention program, applied in a dedicated geriatric hospital unit, was effective and more beneficial than usual care in improving physical parameters related to the risk of fall and disability among high-risk oldest old patients.

The FIM instrument to identify patients at risk of falling in geriatric wards: a 10-year retrospective study

OBJECTIVES

the main objective was to evaluate if the admission functional independence measure (FIM) score could be used to predict the risk of falls in geriatric inpatients.

DESIGN

a 10-year retrospective study was performed.

SETTING

the study was conducted in a 298-bed geriatric teaching hospital in Geneva, Switzerland.

SUBJECTS

all patients discharged from the hospital from 1 January 1997 to 31 December 2006 were selected.

MAIN OUTCOME MEASURES

measures used were FIM scores at admission using the FIM instrument and number of falls extracted from the institution's fall report forms.

RESULTS

during the study period, there were 23,966 hospital stays. A total of 8,254 falls occurred. Of these, 7,995 falls were linked to 4,651 stays. Falls were recorded in 19.4% of hospital stays, with a mean incidence of 7.84 falls per 1,000 patients-days. Although there was a statistically significant relationship between total FIM score, its subscales, and the risk of falling, the sensitivity, specificity, positive predictive value and negative predictive value obtained with receiver operating characteristic curves were insufficient to permit fall prediction. This might be due in part to a non-linear relationship between FIM score and fall risk.

CONCLUSION

in this study, the FIM instrument was found to be unable to predict risk of falls in general geriatric wards.

[Fall prevention: a challenge in the strategy of fracture prevention in the elderly]

Fracture risk depends on density and quality of bone but also on fall risk. Besides the resultant fractures, the human and socio-economic burden of falls pose many challenges to the issue of prevention for the elderly. A systematic approach to falls prevention should be considered as a part of routine care. The identification of intrinsic and extrinsic risk factors is an essential initial step to falls prevention. Intervention should be multidisciplinary and multifactorial, targeting modifiable risk factors, especially for high risk patients. We report the experience of a multidisciplinary program designed to prevent falls and fractures, conducted at the Geneva University Hospital.

Substitutionsbehandlung mit Vitamin D – für welche Patienten und welche Analoga?

Die chronische Niereninsuffizienz ist mit einer verminderten Produktion des aktiven Metaboliten des Vit D, 1 alpha, 25 Dihydroxy-Vitamin D assoziiert. Dies hat mehrere Konsequenzen, die nicht nur auf das Skelettsystem beschränkt sind. In der Tat besitzt Vit D verschiedene Wirkungen, die in diesem Review diskutiert werden. Die Substitution des Vit D wird sehr früh bei der Behandlung der chronischen Niereninsuffizienz in Betracht gezogen, dennoch herrscht noch Unsicherheit über die Art der Substitution. Die Rolle der Vit D-Analoga wird in diesem Review betont, wobei Calcitriol und Paricalcitol verglichen werden.

Longitudinal follow-up of body composition in hematopoietic stem cell transplant patients

Patients with hematological malignancies are well nourished prior to allogeneic hematopoietic stem cell transplantation (HSCT). HSCT and associated complications can affect body composition. The study evaluated cross-sectionally the prevalence and longitudinally the changes in lean body mass index (LBMI) in HSCT patients. Patients (n=82) were classified as normal or low LBMI. Logistic regression analyses were used to estimate odds ratios (OR) for low vs normal LBMI, between healthy volunteers and patients; for limited or extensive vs no chronic graft-versus-host-disease (GVHD); and for decreased (Karnofsky <80) vs normal functional status (>80). Patients were significantly more likely to have low LBMI at 6, 12 months, 2-3, 4-6 and >6 years than volunteers. In all, 38% of patients were below pre-HSCT LBMI at 4-6 years post-HSCT. Low LBMI was significantly associated with steroid treatment (OR 2.6, confidence intervals (CI) 1.3-5.2, P=0.008); limited (OR 5.5, CI 1.7-18.5, P=0.005) or extensive chronic GVHD (OR 20.3, CI 5.7-71.6, P<0.001); and decreased performance status (Karnofsky scores of < or =80) (OR 2.7, CI 1.3-5.9, P=0.01). Patients were more likely to have low LBMI than volunteers. Chronic GVHD and low performance status were associated with low LBMI; thus, complications and/or treatment increase the likelihood of low LBMI.

[Prevention of cortisone-induced osteoporosis]

Osteoporosis and fractures are the frequent consequences of glucocorticoid therapy. Cancellous bone is primarily affected with a decrease of bone formation and an increase of bone resorption. Prevention of corticosteroid-induced osteoporosis is based upon general measures such as calcium and vitamine D supplementation, adequate protein intake, regular physical exercise, and upon specific therapies like those used in primary osteoporosis. Bisphosphonates which are potent bone resorption inhibitors have been shown to reduce bone mineral density and to decrease vertebral fracture rate. Therefore, they appear to be a first choice in the prevention of corticosteroid-induced osteoporosis.

Survival and potential years of life lost after hip fracture in men and age-matched women

Hip fracture is associated with a higher mortality rate in men than in women. However, mean age of men and women with hip fracture differs markedly. Thus, some of the differences in the clinical pattern and outcome between genders could be related to different ages. To avoid the influence of age on gender-specific outcome, we analyzed prefracture conditions and hip fracture outcome in a cohort of men and of age-matched women. Risk factors for low bone mass were recorded in 106 men (mean age +/- SD, 80.3 +/- 9.3 years) and 264 age-matched women (mean age 81.4 +/- 8.0) with hip fracture. We compared mortality rate, survival, years of potential life lost and modification of housing conditions. These outcomes were prospectively assessed during an average 3.6 years follow-up (up to 7 years). Men with hip fracture differed from age-matched hip-fractured women by a higher alcohol and tobacco consumption, a greater frequency of living in couple, and by less prevalent fractures. Mortality rate after hip fracture was significantly higher in men (RR = 1.74, 95% CI 1.34-2.24). Since mortality is higher in the general male population, we compared reduction in life expectancy taking into account the gender-specific mortality rate. The excess mortality in each age-group of hip-fractured patients, which was measured during the whole follow-up period, and is an estimate of death attributable to fracture, did not differ between genders. Reduction in life expectancy due to hip fracture was similar in both genders (5.9 +/- 4.5 and 5.8 +/- 4.8 years, in men and women, respectively; NS), but the proportion of the years of life lost was higher in men (70 +/- 33%) than in women (59 +/- 42%, p < 0.01). It was concluded that for the same age, mortality rate after hip fracture was higher in men than in women. Although the reduction in life expectancy was similar in both genders, the proportion of the years of life lost was higher in men, suggesting a worse impact of hip fracture on survival in men, even after consideration of the higher mortality rate in the general male population.

Hypoparathyroidism associated with aneurysm of the left subclavian artery (Kommerell's diverticulum) in an adult patient with a chromosome 22q11.2 deletion

Hypoparathyroidism may either be acquired or of congenital origin. From the latter group, which represents a minority of cases, agenesis or hypoplasia of the parathyroid glands resulting in symptomatic hypocalcemia in the newborn or infant frequently is caused by a microdeletion of chromosome 22q11.2. We describe a man in whom hypoparathyroidism was first diagnosed at the age of 59 years. The endocrine disorder was found to be associated with this chromosome imbalance and also with an aneurysm of the left subclavian artery (Kommerell's diverticulum) compressing the esophagus and trachea. Given the potential implication for genetic counseling, a 22q11.2 deletion should be considered in the differential diagnosis of adult patients with hypoparathyroidism of unknown origin and should be searched for by appropriate molecular cytogenetic technique.

Bone mineral density in lung-transplant recipients before and after graft: prevention of lumbar spine post-transplantation-accelerated bone loss by pamidronate

BACKGROUND

Lung-transplant recipients are at risk of osteoporosis. They may have low bone mass even before posttransplantation immunosuppressive therapy. We studied bone mineral density (BMD) before and after lung transplantation and compared the efficacy of antiresorptive therapies to calcium and vitamin D supplementation.

METHODS

Areal BMD was assessed in 42 patients awaiting lung transplantation and measured again after surgery at 6 (n = 29), and at 12 months (n = 20). Nineteen patients received antiresorptive therapy (30 mg pamidronate IV every 3 months (n = 14), or hormonal replacement therapy (n = 5)), and 10 patients received only calcium and vitamin D supplements.

RESULTS

Mean age- and gender-adjusted lumbar spine (LS) and femoral neck (FN) BMD was significantly decreased prior to transplantation (- 0.6 +/- 0.2, p< 0.01, and - 1.5 +/- 0.2 standard deviation, p < 0.001, respectively). At that time, 29% were osteoporotic (T-score < - 2.5 below the peak bone mass), while 55% were below - 1.0 T-score. Antiresorptive therapy decreased the rate of LS bone loss during the first 6 months and led to a significant increase of BMD at 1 year, with LS changes of + 0.2 +/- 0.1 vs - 0.4 +/- 0.1 Z-score in the calcium-vitamin D group (p< 0.002), and + 0.2 +/- 0.1 vs - 0.04 +/- 0.1 for FN (NS). One out of 20 patients experienced clinically evident fractures during antiresorptive therapy, and 3 out of 12 in the calcium-vitamin D group.

CONCLUSION

A significant proportion of patients awaiting lung transplantation was osteoporotic or osteopenic. Antiresorptive therapy (pamidronate or hormone-replacement therapy (HRT)) prevented accelerated LS bone loss after graft.

Effect of multiple intravenous pamidronate courses in Paget's disease of bone

BACKGROUND

Pamidronate is a bisphosphonate whose short-term biological efficacy in Paget's disease of bone was convincingly established many years ago. A less well studied area is the efficacy of pamidronate in slowing disease progression and in preventing and treating complications.

MATERIAL AND METHODS

We conducted an uncontrolled retrospective study of 79 Paget's disease patients given multiple intravenous pamidronate courses over a mean period of 45 +/- 19 months. The pamidronate dose per course was 180 mg, usually given over three days. The disease was severe and in some cases had proved refractory to other medications. Reasons for pamidronate therapy were pain or other subjective symptoms; established bone, joint, or nervous system complications; or prevention or these complications in patients with involvement of high-risk sites.

RESULTS

Bone and joint pain improved under therapy, and in 78% of cases the outcome in terms of complication treatment and/or prevention was favorable. An important finding was waning of the clinical and biological effects of pamidronate as the number of courses increased. Fourteen percent of patients developed resistance to pamidronate, which seemed more closely related to disease extension than to focal lesion activity.

CONCLUSION

These data suggest that a prompt return to normal of laboratory markers, most notably total alkaline phosphatase, should be sought, if needed by using higher doses than in our study.