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__NOTOC____NOTOC__
__NOTOC__
{{Hyperparathyroidism}}


{{CMG}}; {{AE}} {{Anmol}}
{{CMG}}; {{AE}} {{Anmol}}


== Classification ==
==Tables==
{| class="wikitable"
{| class="wikitable"
! colspan="4" |Classification of hyperparathyridism
|+
!Diagnosis
!Lab findings
!
!
|-
|-
|Features
!
|'''Primary hyperparathyroidism'''
!
|'''Secondary hyperparathyroidism'''
!
|'''Tertiary hyperparathyroidism'''
!
|-
|-
|Pathology
|
|Hyperfunction of parathyroid cells due to hyperplasia, adenoma or carcinoma.
|Physiological stimulation of parathyroid in response to hypocalcaemia.
|Following long term physiological stimulation leading to hyperplasia.
|-
|Cause
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|
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|Associations
|May be associated with multiple endocrine neoplasia.
|Usually due to chronic renal failure or other causes of Vitamin D deficiency.
|Seen in chronic renal failure.
|-
|Serum calcium
|High
|Low/Normal
|High
|-
|Serum phosphate
|Low/Normal
|High
|High
|-
|Management
|Usually surgery if symptomatic. Cincacalcet can be considered in those not fit for surgery.
|Treatment of underlying cause.
|Usually cinacalcet or surgery in those that don't respond.
|}
=Epidemiology PE & DVT=
===Incidence===
*The incidence of VTE increases with age, ranging from less than 5 cases per 100,000 people in childhood to 500 cases per 100,000 people in the elderly.<ref name="pmid12814979">{{cite journal| author=White RH| title=The epidemiology of venous thromboembolism. | journal=Circulation | year= 2003 | volume= 107 | issue= 23 Suppl 1 | pages= I4-8 | pmid=12814979 | doi=10.1161/01.CIR.0000078468.11849.66 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12814979  }} </ref>
*Subjects who are more than 65 years of age are at three times higher risk for VTE compared to those who are 45-54 years old.<ref name="pmid15210384">{{cite journal| author=Cushman M, Tsai AW, White RH, Heckbert SR, Rosamond WD, Enright P et al.| title=Deep vein thrombosis and pulmonary embolism in two cohorts: the longitudinal investigation of thromboembolism etiology. | journal=Am J Med | year= 2004 | volume= 117 | issue= 1 | pages= 19-25 | pmid=15210384 | doi=10.1016/j.amjmed.2004.01.018 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15210384  }} </ref>
*In the United States, the annual incidence of VTE is estimated to be approximately 100 per 100,000 persons.<ref name="pmid12814979">{{cite journal |author=White RH |title=The epidemiology of venous thromboembolism |journal=Circulation |volume=107 |issue=23 Suppl 1 |pages=I4–8 |year=2003 |month=June |pmid=12814979 |doi=10.1161/01.CIR.0000078468.11849.66 |url=}}</ref>
===Age===
*The incidence of VTE increases with age, ranging from less than 5 cases per 100,000 people in childhood to 500 cases per 100,000 people in the elderly.<ref name="pmid12814979">{{cite journal| author=White RH| title=The epidemiology of venous thromboembolism. | journal=Circulation | year= 2003 | volume= 107 | issue= 23 Suppl 1 | pages= I4-8 | pmid=12814979 | doi=10.1161/01.CIR.0000078468.11849.66 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12814979  }} </ref>
*Subjects who are more than 65 years of age are at three times higher risk for VTE compared to those who are 45-54 years old.<ref name="pmid15210384">{{cite journal| author=Cushman M, Tsai AW, White RH, Heckbert SR, Rosamond WD, Enright P et al.| title=Deep vein thrombosis and pulmonary embolism in two cohorts: the longitudinal investigation of thromboembolism etiology. | journal=Am J Med | year= 2004 | volume= 117 | issue= 1 | pages= 19-25 | pmid=15210384 | doi=10.1016/j.amjmed.2004.01.018 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15210384  }} </ref>
===Gender===
*Studies about differences in the incidence of VTE by gender have mixed results.
**Some reported a higher incidence of DVT among young females<ref name="pmid9521222">{{cite journal| author=Silverstein MD, Heit JA, Mohr DN, Petterson TM, O'Fallon WM, Melton LJ| title=Trends in the incidence of deep vein thrombosis and pulmonary embolism: a 25-year population-based study. | journal=Arch Intern Med | year= 1998 | volume= 158 | issue= 6 | pages= 585-93 | pmid=9521222 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9521222  }} </ref>
**Some reported it higher among either older females<ref name="pmid8154949">{{cite journal| author=Kniffin WD, Baron JA, Barrett J, Birkmeyer JD, Anderson FA| title=The epidemiology of diagnosed pulmonary embolism and deep venous thrombosis in the elderly. | journal=Arch Intern Med | year= 1994 | volume= 154 | issue= 8 | pages= 861-6 | pmid=8154949 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=8154949  }} </ref>
**Some reported it higher in men.<ref name="pmid15210384">{{cite journal |author=Cushman M, Tsai AW, White RH, ''et al.'' |title=Deep vein thrombosis and pulmonary embolism in two cohorts: the longitudinal investigation of thromboembolism etiology |journal=Am. J. Med. |volume=117 |issue=1 |pages=19–25 |year=2004 |month=July |pmid=15210384 |doi=10.1016/j.amjmed.2004.01.018 |url=}}</ref><ref name="urlVenous Thromboembolism in Adult Hospitalizations — United States, 2007–2009">{{cite web |url=http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6122a1.htm?s_cid=mm6122a1_w |title=Venous Thromboembolism in Adult Hospitalizations — United States, 2007–2009 |format= |work= |accessdate=2012-10-06}}</ref>
*In addition, the risk for DVT was reported to consistently increase with age across both genders.<ref name="pmid15210384">{{cite journal |author=Cushman M, Tsai AW, White RH, ''et al.'' |title=Deep vein thrombosis and pulmonary embolism in two cohorts: the longitudinal investigation of thromboembolism etiology |journal=Am. J. Med. |volume=117 |issue=1 |pages=19–25 |year=2004 |month=July |pmid=15210384 |doi=10.1016/j.amjmed.2004.01.018 |url=}}</ref>
===Race===
* There is a significant difference in the incidence of DVT as it relates to race.  African Americans characteristically have the highest incidence of DVT while Caucasians rank as the second highest incidence of DVT.<ref name="pmid12814979">{{cite journal| author=White RH| title=The epidemiology of venous thromboembolism. | journal=Circulation | year= 2003 | volume= 107 | issue= 23 Suppl 1 | pages= I4-8 | pmid=12814979 | doi=10.1161/01.CIR.0000078468.11849.66 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12814979  }} </ref>
* When compared to African Americans and Caucasians, the incidence of DVT is noted to be two to four times lower in Hispanics and Asian-Pacific Islanders.<ref name="pmid12814979">{{cite journal| author=White RH| title=The epidemiology of venous thromboembolism. | journal=Circulation | year= 2003 | volume= 107 | issue= 23 Suppl 1 | pages= I4-8 | pmid=12814979 | doi=10.1161/01.CIR.0000078468.11849.66 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12814979  }} </ref>
* Lower thrombosis incidences in non-Caucasians may be related to a lower prevalence of disorders like [[Factor V Leiden]] or [[Thrombin#Prothrombin 20210a mutation|Prothrombin 20210A mutation]].<ref name="pmid9109469">{{cite journal| author=Ridker PM, Miletich JP, Hennekens CH, Buring JE| title=Ethnic distribution of factor V Leiden in 4047 men and women. Implications for venous thromboembolism screening. | journal=JAMA | year= 1997 | volume= 277 | issue= 16 | pages= 1305-7 | pmid=9109469 | doi= | pmc= | url= }} </ref><ref name="pmid9415695">{{cite journal| author=Gregg JP, Yamane AJ, Grody WW| title=Prevalence of the factor V-Leiden mutation in four distinct American ethnic populations. | journal=Am J Med Genet | year= 1997 | volume= 73 | issue= 3 | pages= 334-6 | pmid=9415695 | doi= | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9415695  }} </ref>
===Recurrence of VTE===
* One-third (about 33%) of people with VTE will have a recurrence within 10 years.<ref name="pmid20331949">{{cite journal| author=Beckman MG, Hooper WC, Critchley SE, Ortel TL| title=Venous thromboembolism: a public health concern. | journal=Am J Prev Med | year= 2010 | volume= 38 | issue= 4 Suppl | pages= S495-501 | pmid=20331949 | doi=10.1016/j.amepre.2009.12.017 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20331949  }} </ref><ref name="CDC3">[http://www.cdc.gov/ncbddd/dvt/data.html CDC- Deep Vein Thrombosis (DVT) / Pulmonary Embolism (PE) — Blood Clot Forming in a Vein]</ref>
* The risk of recurrence of [[VTE]] in patients diagnosed with first-time [[VTE]] is estimated to be around 7-8 percent per year during an average follow up period of 2.2 years of subsequent observation of 265 patients.<ref name="pmid15210384">{{cite journal |author=Cushman M, Tsai AW, White RH, ''et al.''|title=Deep vein thrombosis and pulmonary embolism in two cohorts: the longitudinal investigation of thromboembolism etiology |journal=Am. J. Med.|volume=117 |issue=1 |pages=19–25 |year=2004 |month=July |pmid=15210384 |doi=10.1016/j.amjmed.2004.01.018 |url=}}</ref>
* Among patients with a first episode of VTE, the risk of recurrence of VTE is particularly elevated in the first 6 to 12 months following the first episode of VTE.  The risk of recurrent VTE remains up to 10 years, with a estimated cumulative incidence of first overall VTE recurrence of 30 %.  Predictors for recurrence of [[VTE]] include [[malignancy]], neurological diseases, and [[paresis]].<ref name="pmid10737275">{{cite journal| author=Heit JA, Mohr DN, Silverstein MD, Petterson TM, O'Fallon WM, Melton LJ| title=Predictors of recurrence after deep vein thrombosis and pulmonary embolism: a population-based cohort study. | journal=Arch Intern Med | year= 2000 | volume= 160 | issue= 6 | pages= 761-8 | pmid=10737275 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10737275  }} </ref>
* In recent years, the increase in [[thrombosis]] incidence may be related to improved diagnostic modalities and increased awareness by clinicians.<ref name="pmid12814979">{{cite journal |author=White RH |title=The epidemiology of venous thromboembolism |journal=Circulation |volume=107 |issue=23 Suppl 1 |pages=I4–8 |year=2003|month=June |pmid=12814979 |doi=10.1161/01.CIR.0000078468.11849.66 |url=}}</ref>
===Complications of VTE===
* Estimates suggest that 60,000-100,000 Americans die of VTE, 10 to 30% of which will die within one month of diagnosis.<ref name="pmid20331949">{{cite journal| author=Beckman MG, Hooper WC, Critchley SE, Ortel TL| title=Venous thromboembolism: a public health concern. | journal=Am J Prev Med | year= 2010 | volume= 38 | issue= 4 Suppl | pages= S495-501 | pmid=20331949 | doi=10.1016/j.amepre.2009.12.017 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20331949  }} </ref><ref name="CDC3">[http://www.cdc.gov/ncbddd/dvt/data.html CDC- Deep Vein Thrombosis (DVT) / Pulmonary Embolism (PE) — Blood Clot Forming in a Vein]</ref>
* Among people who have had a DVT, one-half will have long-term complications ([[post-thrombotic syndrome]]) such as swelling, pain, discoloration, and scaling in the affected limb.<ref name="pmid20331949">{{cite journal| author=Beckman MG, Hooper WC, Critchley SE, Ortel TL| title=Venous thromboembolism: a public health concern. | journal=Am J Prev Med | year= 2010 | volume= 38 | issue= 4 Suppl | pages= S495-501 | pmid=20331949 | doi=10.1016/j.amepre.2009.12.017 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20331949  }} </ref><ref name="CDC3">[http://www.cdc.gov/ncbddd/dvt/data.html CDC- Deep Vein Thrombosis (DVT) / Pulmonary Embolism (PE) — Blood Clot Forming in a Vein]</ref>
{| class="wikitable"
|
|
*Hospitalized medical patients:
**Increased risk of thrombosis
***Anticoagulant thromboprophylaxis with low-molecular-weight heparin [LMWH], low-dose unfractionated heparin (LDUH) bid, LDUH tid, or fondaparinux
**Low risk of thrombosis
***Use of pharmacological prophylaxis or mechanical prophylaxis is not recommended
**Bleeding or at high risk of bleeding
***Anticoagulant thromboprophylaxis is not recommended
**Increased risk of thrombosis who are bleeding or at high risk for major bleeding
***Optimal use of mechanical thromboprophylaxis with graduated compression stockings (GCS) or intermittent pneumatic compression (IPC)
**:'''Note:''' When bleeding risk decreases, and if risk persist, pharmacologic thromboprophylaxis be substituted for mechanical thromboprophylaxis.
**Who receive an initial course of thromboprophylaxis
***Extending the duration of thromboprophylaxis beyond the period of patient immobilization or acute hospital stay is not recommended.
|-
|
|
* Routine ultrasound screening for DVT is  not recommended
* Using LMWH or LDUH thromboprophylaxis over no prophylaxis is recommended
* Patients with bleeding, or are at high risk for major bleeding
** Mechanical thromboprophylaxis with GCS  or IPC until the bleeding risk decreases, rather than no mechanical thromboprophylaxis
** '''Note:''' When bleeding risk decreases, and if VTE risk persist, pharmacologic thromboprophylaxis be substituted for mechanical thromboprophylaxis.
|-
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* Outpatients with cancer
|
** No additional risk factors for VTE
*** Routine prophylaxis with LMWH or LDUH and the prophylactic use of vitamin K antagonists is not recommended
** Indwelling central venous catheters
** Routine prophylaxis with LMWH or LDUH and the prophylactic use of vitamin K antagonists is not recommended
* Outpatients with solid tumors
** Additional risk factors for VTE and at low risk of bleeding
*** Prophylactic-dose LMWH or LDUH over no prophylaxis is recommended
** '''Note:''' Additional risk factors for venous thrombosis in cancer outpatients include previous venous thrombosis, immobilization, hormonal therapy, angiogenesis inhibitors, thalidomide, and lenalidomide.
|-
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* Routine use of thromboprophylaxis
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* At increased risk of VTE
** Frequent ambulation, calf muscle exercise, or sitting in an aisle seat if feasible
** Use of properly fitted, below-knee GCS providing 15 to 30 mm Hg of pressure at the ankle during travel
** Note: Increased  risk implies including previous VTE, recent surgery or trauma, active malignancy, pregnancy, estrogen use, advanced age, limited mobility, severe obesity, or known thrombophilic disorder.
* Not at increased risk of VTE
** Use of GCS is not recommended
* Use of aspirin or anticoagulants to prevent VTE
|-
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* The long-term daily use of mechanical or pharmacologic thromboprophylaxis to prevent VTE
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|}

Latest revision as of 17:32, 14 January 2019


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Anmol Pitliya, M.B.B.S. M.D.[2]

Tables

Diagnosis Lab findings

References

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