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[null,"Baseline assessment tool for hyperparathyroidism (primary): diagnosis, assessment and initial management (NICE clinical guideline NG132)"]
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[null,"This baseline assessment tool can be used to evaluate whether practice is in line with the recommendations in Hyperparathyroidism (primary): diagnosis, assessment and initial management.  It can also help to plan activity to meet the recommendations."]
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[null,"The tool can be used by individual services or organisations. Alternatively, an assessment completed with the involvement of all relevant services or organisations would help to develop a picture of activity in the local area."]
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[null,"It should be used in conjunction with Hyperparathyroidism (primary): diagnosis, assessment and initial management (NICE clinical guideline NG132)."]
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[null,"In the first instance, consider whether the guideline is relevant and record the conclusion in the box below."]
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[null,"Is the guideline relevant?"]
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[null,"The data sheet contains the recommendations from the guideline. Information can be entered about current activity relevant to the recommendation, actions needed to meet the recommendation, deadlines and the names of the responsible leads.  Useful documents can be added as hyperlinks."]
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[null,"The table can be adapted to include any other local information that is thought to be useful."]
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[null,"If it would be helpful to group the recommendations, for example those that are key priorities for implementation or by deadline, use the filter function in the data menu. "]
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[null,"Tools and resources to help put the guidance into practice are available on the NICE website. "]
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[null,"National Institute for Health and Care Excellence\nLevel 1A, City Tower, Piccadilly Plaza, Manchester M1 4BT; www.nice.org.uk\n\nCopyright\n© NICE 2019. All rights reserved. Subject to Notice of rights.\n"]

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[null,"Baseline assessment tool for hyperparathyroidism (primary): diagnosis, assessment and initial management (NICE clinical guideline NG132)"]
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[null,null,null,null,null,"Number of relevant recommendations",{"$f":"COUNTIF(E8:E995,\"Yes\")","v":0}]
[null,null,null,null,null,"Number of recommendations met",{"$f":"COUNTIF(G8:G995,\"Yes\")","v":0}]
[null,null,null,null,null,"Percentage of recommendations met",{"$f":"IF(ISERROR(G4/G3),\"\",G4/G3)","v":""}]
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[null,"NICE recommendation","Guideline reference","Year of recommendation","Is the recommendation relevant?","Current activity/evidence","Recommendation met?","Actions needed to implement recommendation","Is there a risk associated with not implementing this recommendation?","Is there a cost or saving?","Deadline","Lead"]
[null,"1.1  Diagnostic testing in primary care"]
[null,"Measuring albumin-adjusted serum calcium "]
[null,"Measure albumin-adjusted serum calcium for people with any of the following features, which might indicate primary hyperparathyroidism: \n•\tsymptoms of hypercalcaemia, such as thirst, frequent or excessive urination, or constipation \n•\tosteoporosis or a previous fragility fracture (for recommendations on assessing the risk of fragility fracture in people with osteoporosis, see the NICE guideline on osteoporosis)\n•\ta renal stone (for recommendations on assessing and managing renal stones, see the NICE guideline on renal and ureteric stones)\n•\tan incidental finding of elevated albumin-adjusted serum calcium (2.6 mmol/litre or above).","1.1.1"]
[null,"Consider measuring albumin-adjusted serum calcium for people with chronic non-differentiated symptoms.","1.1.2"]
[null,"Do not measure ionised calcium when testing for primary hyperparathyroidism.","1.1.3"]
[null,"\tRepeat the albumin-adjusted serum calcium measurement at least once if the first measurement is either:\n•\t2.6 mmol/litre or above or\n•\t2.5 mmol/litre or above and features of primary hyperparathyroidism are present.\n\nBase the decision to carry out further repeat measurements on the level of albumin-adjusted serum calcium and the person's symptoms.","1.1.4"]
[null,"Measuring parathyroid hormone"]
[null,"Measure parathyroid hormone (PTH) for people whose albumin-adjusted serum calcium level is either:\n•\t2.6 mmol/litre or above on at least 2 separate occasions or \n•\t2.5 mmol/litre or above on at least 2 separate occasions and primary hyperparathyroidism is suspected.","1.1.5"]
[null,"When measuring PTH, use a random sample and do a concurrent measurement of the albumin-adjusted serum calcium level.","1.1.6"]
[null,"Do not routinely repeat PTH measurement in primary care.","1.1.7"]
[null,"Seek advice from a specialist with expertise in primary hyperparathyroidism if the person’s PTH measurement is either:\n•\tabove the midpoint of the reference range and primary hyperparathyroidism is suspected or\n•\tbelow the midpoint of the reference range with a concurrent albumin-adjusted serum calcium level of 2.6 mmol/litre or above.","1.1.8"]
[null,"Do not offer further investigations for primary hyperparathyroidism if:\n•\tthe person’s PTH is within the reference range but below the midpoint of the reference range and \n•\ttheir concurrent albumin-adjusted serum calcium level is below 2.6 mmol/litre.","1.1.9"]
[null,"Look for alternative diagnoses, including malignancy, if the person’s PTH is below the lower limit of the reference range.","1.1.10"]
[null,"1.2   Testing and assessment in secondary care"]
[null,"Measuring vitamin D"]
[null,"For people with a probable diagnosis of primary hyperparathyroidism, measure vitamin D and offer vitamin D supplements if needed.","1.2.1"]
[null,"Excluding familial hypocalciuric hypercalcaemia"]
[null,"To differentiate primary hyperparathyroidism from familial hypocalciuric hypercalcaemia, measure urine calcium excretion using any one of the following tests:\n•\t24-hour urinary calcium excretion\n•\trandom renal calcium: creatinine excretion ratio\n•\trandom calcium: creatinine clearance ratio.","1.2.2"]
[null,"Assessment after diagnosis"]
[null,"For people with a confirmed diagnosis of primary hyperparathyroidism: \n•\tassess symptoms and comorbidities \n•\tmeasure eGFR (estimated glomerular filtration rate) or serum creatinine \n•\tdo a DXA (dual-energy X ray absorptiometry) scan of the lumbar spine, distal radius and hip\n•\tdo an ultrasound scan of the renal tract. ","1.2.3"]
[null,"1.3   Referral for surgery "]
[null,"Refer people with a confirmed diagnosis of primary hyperparathyroidism to a surgeon with expertise in parathyroid surgery if they have: \n•\tsymptoms of hypercalcaemia such as thirst, frequent or excessive urination, or constipation or\n•\tend-organ disease (renal stones, fragility fractures or osteoporosis) or\n•\tan albumin-adjusted serum calcium level of 2.85 mmol/litre or above.","1.3.1"]
[null,"Consider referral to a surgeon with expertise in parathyroid surgery for people with a confirmed diagnosis of primary hyperparathyroidism even if they do not have the features listed in recommendation 1.3.1.","1.3.2"]
[null,"1.4   Surgical management"]
[null,"Preoperative imaging"]
[null,"Offer preoperative imaging (usually ultrasound) to people having surgery for primary hyperparathyroidism if it will inform the surgical approach.","1.4.1"]
[null,"Consider a second preoperative imaging modality (usually a sestamibi scan) if it will further guide the surgical approach.","1.4.2"]
[null,"Do not offer more preoperative imaging if the first-modality (usually ultrasound) and second-modality scans (usually a sestamibi scan) do not identify an adenoma or are discordant.","1.4.3"]
[null,"Proceed with surgery, performed by a surgeon with expertise in 4‑gland exploration, even if preoperative imaging has not identified an adenoma.","1.4.4"]
[null,"If preoperative imaging shows an ectopic adenoma, refer the person to a centre with the relevant expertise.","1.4.5"]
[null,"Type of surgery"]
[null,"Offer a choice of either 4 gland exploration or focused parathyroidectomy to people whose preoperative imaging shows a single adenoma in the neck. Discuss the choice of surgery with the person, and explain:\n•\twhat happens during each type of surgery\n•\thow well each type of surgery works\n•\twhat types of anaesthesia are used\n•\thow long each type of surgery is likely to take\n•\thow large the resulting scars are likely to be\n•\tthe risks of each type of surgery.","1.4.6"]
[null,"Offer 4‑gland exploration to people who have had preoperative imaging that does not identify a single adenoma.","1.4.7"]
[null,"Consider 4‑gland exploration for people having surgery for primary hyperparathyroidism whose first-modality and second-modality scans are discordant.","1.4.8"]
[null,"Intraoperative parathyroid hormone monitoring"]
[null,"Do not use intraoperative parathyroid hormone monitoring in first-time parathyroid surgery.","1.4.9"]
[null,"Follow-up after surgery"]
[null,"Measure albumin-adjusted serum calcium and parathyroid hormone before discharge after surgery for primary hyperparathyroidism to provide baseline information for later follow‑up.","1.4.10"]
[null,"Measure albumin-adjusted serum calcium 3 to 6 months after surgery for primary hyperparathyroidism to confirm whether surgery has been successful.","1.4.11"]
[null,"If albumin-adjusted serum calcium is within the reference range 3 to 6 months after surgery for primary hyperparathyroidism, regard the surgery as successful. Monitor albumin-adjusted serum calcium once a year. See section 1.6 for recommendations on monitoring.","1.4.12"]
[null,"Unsuccessful surgery"]
[null,"For people who have had unsuccessful surgery for primary hyperparathyroidism:\n•\tconduct a multidisciplinary team review at a specialist centre that includes:\n-\tinitial findings from surgery\n-\tprevious imaging and histology \n-\tthe clinical and biochemical indications for repeat surgery\n•\toffer monitoring as set out in section 1.6.","1.4.13"]
[null,"If repeat surgery is performed for primary hyperparathyroidism, it should be done at a centre with expertise in reoperative parathyroid surgery.","1.4.14"]
[null,"1.5   Non-surgical management"]
[null,"Calcimimetics"]
[null,"Consider cinacalcet  for people with primary hyperparathyroidism if surgery has been unsuccessful, is unsuitable or has been declined, and if their albumin-adjusted serum calcium level is either: \n•\t2.85 mmol/litre or above with symptoms of hypercalcaemia or\n•\t3.0 mmol/litre or above with or without symptoms of hypercalcaemia.","1.5.1"]
[null,"For people whose initial albumin-adjusted serum calcium level is 2.85 mmol/litre or above with symptoms of hypercalcaemia, base decisions on whether to continue treatment with cinacalcet on how well it reduces symptoms.","1.5.2"]
[null,"For people whose initial albumin-adjusted serum calcium level is 3.0 mmol/litre or above, base decisions on whether to continue treatment with cinacalcet on how well it reduces either symptoms or albumin-adjusted serum calcium level.","1.5.3"]
[null,"Bisphosphonates"]
[null,"Consider a bisphosphonate to reduce fracture risk for people with primary hyperparathyroidism and increased fracture risk.","1.5.4"]
[null,"Do not offer bisphosphonates for chronic hypercalcaemia of primary hyperparathyroidism.","1.5.5"]
[null,"1.6   Monitoring"]
[null,"Offer monitoring to all people diagnosed with primary hyperparathyroidism, as set out in table 1.","1.6.1"]
[null,"1.7   Pregnancy "]
[null,"Care before pregnancy"]
[null,"Offer parathyroid surgery to women who have primary hyperparathyroidism and are considering pregnancy.","1.7.1"]
[null,"Care during pregnancy"]
[null,"Discuss the management of primary hyperparathyroidism for pregnant women with a multidisciplinary team (MDT) in a specialist centre, and refer the woman for specialist care if needed. The MDT should include: \n•\tan obstetrician\n•\ta physician with expertise in primary hyperparathyroidism\n•\ta surgeon\n•\ta midwife\n•\tan anaesthetist.","1.7.2"]
[null,"Do not offer cinacalcet to pregnant women with primary hyperparathyroidism.","1.7.3"]
[null,"Do not offer a bisphosphonate to pregnant women with primary hyperparathyroidism.","1.7.4"]
[null,"Be aware that women with primary hyperparathyroidism are at increased risk of hypertensive disease in pregnancy. For recommendations on diagnosing and managing hypertension in pregnant women, see the NICE guideline on hypertension in pregnancy.","1.7.5"]
[null,"Consult a specialist centre MDT for advice on monitoring for pregnant women with primary hyperparathyroidism.","1.7.6"]
[null,"1.8   Information and support"]
[null,"Follow the recommendations on enabling people to actively participate in their care in the NICE guideline on patient experience in adult NHS services.","1.8.1"]
[null,"Give people with primary hyperparathyroidism information about the condition, including:\n•\twhat primary hyperparathyroidism is\n•\twhat the parathyroid glands do\n•\tcauses of primary hyperparathyroidism\n•\tsymptoms \n•\tdiagnosis, including diagnosis if calcium or parathyroid hormone levels are normal\n•\tprognosis \n•\tpossible effects on daily life \n•\tpossible long-term effects.","1.8.2"]
[null,"\tGive people information about treatments for primary hyperparathyroidism that includes:\n•\tthe surgical and non-surgical treatments that are available \n•\thow well the treatments are likely to work\n•\tthe advantages and disadvantages of each treatment, including possible complications and side effects \n•\twhy these particular treatments are being offered \n•\twhy other treatments are not advised.","1.8.3"]
[null,"Give advice on how to reduce the symptoms of primary hyperparathyroidism and prepare for surgery or other treatment, including:\n•\texercise\n•\tdiet\n•\thydration\n•\tpain relief\n•\twhat to expect after treatment, recovery time and return to daily activities, including return to work.","1.8.4"]
[null,"Discuss ongoing care and monitoring for primary hyperparathyroidism, explaining the type and frequency of monitoring that will be offered and the purpose of each. See section 1.6 for recommendations on monitoring.","1.8.5"]

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[null,"Table 1 Monitoring for people with primary hyperparathyroidism"]
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[null,"People who have had successful parathyroid surgery","People who have not had parathyroid surgery, or whose surgery has not been successful"]
[null,"Measure albumin-adjusted serum calcium once a year.","Measure albumin-adjusted serum calcium and eGFR (estimated glomerular filtration rate) or serum creatinine once a year, unless the person is taking cinacalcet*."]
[null,null,"If the person is taking cinacalcet, offer monitoring as set out in the summary of product characteristics."]
[null,null,"If the results of monitoring raise concerns, follow recommendation 1.1.4."]
[null,"If the person has osteoporosis, seek specialist opinion according to local pathways on monitoring.","Consider a DXA (dual-energy X‑ray absorptiometry) scan at diagnosis and every 2 to 3 years. "]
[null,null,"If the results of monitoring raise concerns, follow recommendation 1.3.1."]
[null,"If the person has renal stones, seek specialist opinion according to local pathways on monitoring.","Offer ultrasound of the renal tract at diagnosis, when presenting and if a renal stone is suspected (for recommendations on assessing and managing renal stones, see the NICE guideline on renal and ureteric stones). "]
[null,null,"If the results of monitoring raise concerns, follow recommendation 1.3.1."]
[null,"For people who have had parathyroid surgery for multigland disease, or have disease that recurs after successful surgery, seek specialist endocrine opinion on monitoring."]
[null,"For women who are pregnant, see the section on pregnancy in this guideline. "]
[null,"For all people with primary hyperparathyroidism, assess cardiovascular risk and fracture risk in line with the NICE guidelines on cardiovascular disease and osteoporosis."]
[null,"* At the time of publication (May 2019), cinacalcet did not have a UK marketing authorisation for use after unsuccessful surgery for primary hyperparathyroidism. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council’s Prescribing guidance: prescribing unlicensed medicines for further information."]