First Manifestation Of Disease Research Articles

Sudden cardiac death as first manifestation of cardiovascular disease - a Danish nationwide study

Abstract Background and objective Sudden cardiac death (SCD) is a leading cause of death and previous studies have shown that approximately half of all cases have no known history of cardiovascular disease (CVD). Epidemiological studies of SCD cases of all ages are sparse. The aim of this study was to examine differences in incidence rates, clinical characteristics, comorbidities, and socioeconomic status between SCD cases with and without a known history of cardiovascular disease. Methods All 54,028 deaths in Denmark in 2010 were reviewed. Autopsy reports, death certificates, discharge summaries, and nationwide health and social registries were reviewed to identify cases of SCD. Information on previous history of CVD was extracted from the comprehensive Danish nationwide health and social registries. Results A total of 6,867 SCD cases were identified, of which 3,056 (44.5%) had no history of cardiovascular disease and 3,811 (55.5 %) had a history of CVD. Incidence rates of SCD increased with age and were higher in cases of SCD with a history of CVD across all age groups. The difference in incidence of SCD between persons with and without history of cardiovascular disease decreased with increasing age with incidence rate ratios ranging from 11.7 (95 % CI: 5.51 – 25.00) to 3.19 (95 % CI: 2.79-3.64) in those age 0-29 years and >90 years, respectively. Persons living in a low-income household (OR: 0.76, 95 % CI: 0.58-0.98, p=0.037), persons living in rural municipalities (OR: 0.87, 95 % CI: 0.78-0.98, p=0.021), and persons living in single-person households (OR: 0.73, 95 % CI: 0.66-0.82, p=0.037) had a lower likelihood of having a CVD prior to SCD. Conclusion This is the first nationwide study of SCD cases with and without history of CVD across all ages. SCD cases with no known CVD were significantly younger, more female and had less comorbidities. Although a substantial amount of SCD cases occur in persons with no known CVD, SCD is more common in the populations of persons with a history of CVD. Socioeconomic factors such as low income, living alone and living in rural communities were associated with a lower risk of having a cardiovascular diagnosis prior to SCD.Crude numbers and incidence rates of SCDIncidence rate ratios

Oral health and multimorbidity: is diet the chicken or the egg?

Oral health is a critical component of overall health and well-being, not just the absence of disease. The objective of this review paper is to describe relationships among diet, nutrition and oral and systemic diseases that contribute to multimorbidity. Diet- and nutrient-related risk factors for oral diseases include high intakes of free sugars, low intakes of fruits and vegetables and nutrient-poor diets which are similar to diet- and nutrient-related risk factors for systemic diseases. Oral diseases are chronic diseases. Once the disease process is initiated, it persists throughout the lifespan. Pain and tissue loss from oral disease leads to oral dysfunction which contributes to impaired biting, chewing, oral motility and swallowing. Oral dysfunction makes it difficult to eat nutrient-dense whole grains, fruits and vegetables associated with a healthy diet. Early childhood caries (ECC) associated with frequent intake of free sugars is one of the first manifestations of oral disease. The presence of ECC is our 'canary in the coal mine' for diet-related chronic diseases. The dietary sugars causing ECC are not complementary to an Eatwell Guide compliant diet, but rather consistent with a diet high in energy-dense, nutrient-poor foods - typically ultra-processed in nature. This diet generally deteriorates throughout childhood, adolescence and adulthood increasing the risk of diet-related chronic diseases. Recognition of ECC is an opportunity to intervene and disrupt the pathway to multimorbidities. Disruption of this pathway will reduce the risk of multimorbidities and enable individuals to fully engage in society throughout the lifespan.

A Combined Cyto- and Histopathological Diagnostic Approach Reduces Time to Diagnosis and Time to Therapy in First Manifestation of Metastatic Spinal Disease: A Cohort Study.

Malignant spinal lesions (MSLs) are frequently the first manifestation of malignant disease. Spinal care, diagnostic evaluation, and the initiation of systemic therapy are crucial for outcomes in patients (pts) with advanced cancer. However, histopathology (HP) may be time consuming. The additional evaluation of spinal lesions using cytopathology (CP) has the potential to reduce the time to diagnosis (TTD) and time to therapy (TTT). CP and HP specimens from spinal lesions were evaluated in parallel in 61 pts (CP/HP group). Furthermore, 139 pts in whom only HP was performed were analyzed (HP group). We analyzed the TTD of CP and HP within the CP/HP group. Furthermore, we compared the TTD and TTT between the groups. The mean TTD in CP was 1.7 ± 1.7 days (d) and 8.4 ± 3.6 d in HP (p < 0.001). In 13 pts in the CP/HP group (24.1%), specific therapy was initiated based on the CP findings in combination with imaging and biomarker results before completion of HP. The mean TTT in the CP/HP group was 21.0 ± 15.8 d and was significantly shorter compared to the HP group (28.6 ± 23.3 d) (p = 0.034). Concurrent CP for MSLs significantly reduces the TTD and TTT. As a result, incorporating concurrent CP for analyzing spinal lesions suspected of malignancy might have the potential to enhance pts' quality of life and prognosis in advanced cancer. Therefore, we recommend implementing CP as a standard procedure for the evaluation of MSLs.

A family case of fabry disease in the practice of a pediatric rheumatologist

Fabry disease is a rare hereditary disease related to lysosomal storage diseases, linked to the X chromosome. Fabry disease leads to disruption of glycosphingolipid metabolism due to deficiency or absence of the enzyme α-galactosidase A. Fabry disease is a multisystem progressive disease. One of the first clinical manifestations of Fabry disease is pain in the fingers, toes, palms and feet, and sometimes imitates rheumatological diseases, which requires rheumatologists to have sufficient knowledge about this pathology. The article presents a family case of diagnosis of Fabry disease in the practice of a pediatric rheumatologist.

Erección prolongada dolorosa

Priapism is a prolonged and painful penile erection, which occurs without prior sexual stimulation. There are two main types, high-flow priapism and low-flow priapism. Although on most occasions the underlying cause will be unknown, it may be the first manifestation of serious disease. In the pediatric patient with prolonged erection we must differentiate between recurrent penile erection and the different types of priapism since each entity requires a specific management and implies a different prognosis.

ATOPIC DERMATITIS

Abstract:Atopic dermatitis (AD) is a chronic, pruritic, inflammatory skin disease with a wide range of severity, and is usually the first manifestation of atopic disease. It is one of the most common skin disorders in developed countries, affecting approximately 20% of children and 1–3% of adults. Symptoms such as eczematous papules, plaques, and itch, and their associated consequences, such as sleep disturbance, can significantly impact the quality of life of the patient and family. Key words: atopic dermatities, epidemiology,phenotypes,clinical features

Abstract 17673: Sudden Cardiac Death as the First Manifestation of Heart Disease

Background: Clinical risk stratification is most challenging in the subgroup of individuals who present with sudden cardiac death (SCD) as the first manifestation of heart disease (SCD-FM) and there is a lack of current era population-based data. Hypothesis: Occurrence of SCD-FM SCD differs by ethnicity and access to health care. Methods: Consecutive out-of-hospital cases of SCD attended by emergency medical services were ascertained prospectively from a large ongoing population-based study in the Southwest US (population ~ 850K, 2015-2022) using an established multi-source ascertainment and adjudication process. A detailed review was conducted of the lifetime clinical record and available autopsy data, for each individual. SCD-FM cases were defined as SCD with no prior heart disease diagnosis. We calculated annual age-standardized incidence of overall SCD and SCD-FM per 100,000 residents using US census data. Ethnicity-stratified incidence of SCD-FM was calculated. Occurrence of all health care visits prior to SCD was evaluated. Results: From a total of 2681 SCD cases (age 71 ± 16, female 35%) age adjusted incidence of SCD was 40[38-41] per 100,000 out of which SCD-FM was 15[14-16] per 100,000 (n=1019 (38%), age 67±18, female 33%). There was no difference in SCD-FM incidence between Hispanic and non-Hispanic residents (15 [13-17] vs 15 [14-17], p=0.84). Individuals younger than 65 yr were more likely to have SCD-FM compared to those older than 65 yr (50% vs 33%, p &lt;0.001). We observed that 91% of SCD-FM had visited healthcare providers and 3% had cardiac evaluations performed. Conclusion: A significantly higher proportion of SCD-FM were age &lt;65 but the proportion of SCD-FM did not differ by ethnicity. The vast majority of SCD-FM (91%) underwent health care visits prior to SCD but cardiac evaluations were rare (3%). These findings highlight the need to discover and develop user-friendly, cost-effective pre-screening methods to reduce SCD-FM in the general population.

Intraconal Tumor-like mass as first manifestation of IgG4-related disease

Intraconal Tumor-like mass as first manifestation of IgG4-related disease

Recommendations for the Management of Cardiomyopathy Mutation Carriers: Evidence, Doubts, and Intentions.

Cardiomyopathies may be hereditary and associated with a familial predilection. Morbidity and mortality can be caused by heart failure, sudden death, or arrhythmias. Sometimes these events are the first manifestations of cardiovascular disease. Hypertrophic cardiomyopathy and arrhythmogenic cardiomyopathy are perhaps most thoroughly studied in that context. Dilated cardiomyopathy, although most frequently of secondary etiology, has a significant familial cluster. Noncompaction of the left ventricle can sometimes be seen in healthy individuals and, in other instances, is associated with severe LV dysfunction. Genetic testing is of utmost importance, since it might allow for the identification of individuals carrying mutations predisposing them to these diseases. In addition, certain variants may benefit from tailored therapeutic regimens, and thus searching for a causal mutation can impact clinical practice and is recommended for all patients with HCM or ACM. Patients with DCM and positive family history should be included as well. Regular follow-ups are advised, even in those with negative phenotypes, because these disorders are often age dependent. During pregnancy and in the case of athletes, special consideration should be made as well. We intend to summarize the most current evidence regarding their management.

Pulmonary embolism after delivery as the first manifestation of Cushing disease in pregnancy.

Pulmonary embolism after delivery as the first manifestation of Cushing disease in pregnancy.

Papel do Exercício Físico na Prevenção de Fraturas Vertebrais Osteoporóticas

Vertebral fractures are often the first manifestation of osteoporotic disease and are associated with significant morbidity and mortality. Osteoporosis and sarcopenia are key risk factors for osteoporo¬tic vertebrae fractures, both of which can be treated physical exercise. The importance of the effect of load on osteogenic stimulation, as well as muscle strengthening are explained and debated in this article. It is currently considered that physical exercise, adapted to each patient, is effective in preventing osteoporotic vertebral fractures and can reduce its incidence by up to 50%. We present a set of recommendations for exercise programs and the mechanisms by which they may be used for muscle and bone stimulation in this context.

BI04 Cutaneous cryptococcosis: a post-transplant cat among the pigeons

Abstract Cryptococcosis is an infection caused by the encapsulated yeasts Cryptococcus neoformans and Cryptococcus gattii, which are opportunistic pathogens that mainly affect immunocompromised individuals. Infection is primarily by inhalation and causes pulmonary disease; haematogenous dissemination may affect other organs, particularly the central nervous system, with 10% of disseminated cryptococcosis affecting the skin. Primary cutaneous cryptococcosis due to direct skin inoculation is less common and rarely disseminates. We describe a kidney transplant recipient with disseminated cryptococcosis who presented with skin lesions in the early post-transplant period. As previously observed in a transplant patient with primary cutaneous cryptococcosis under our care, we propose that a history of close contact with urban pigeons was the source of infection. A 48-year-old man who had been transplanted in 2014 presented in May 2022 with a 3-cm-diameter, well-demarcated ulcer on his right shoulder which had been slowly enlarging over 6 weeks in close proximity to his recent COVID-19 vaccination site. Swab was positive for C. neoformans, serology was positive for cryptococcal antigen, chest X-ray showed a 14-mm nodule in the right lung and magnetic resonance imaging of the brain was normal. He was admitted by the transplant team and treated for presumed disseminated cryptococcal infection with intravenous AmBisome® and flucytosine for 2 weeks, and subsequently oral fluconazole. In view of his atypical presentation, we directly questioned him about previous skin disorders and possible sources of infection. It emerged that 6 months earlier, he had noticed multiple lesions on his legs but did not report this as they spontaneously resolved. Mobile phone images showed 0.5–1-cm umbilicated, red–purple nodules consistent with possible primary cutaneous cryptococcosis. We discovered that his balcony was covered in pigeons and their droppings, and he had unsuccessfully asked his local council to provide bird netting. This was the most likely source of his infection, although it is uncertain whether his skin involvement was primary, secondary or both, due to ongoing pigeon exposure. A 54-year-old female patient under our care who had previously presented 3 months post-transplant with extensive noduloulcerative umbilicated lesions confirmed on biopsy to be primary cutaneous cryptococcosis also had close contact with pigeons and their droppings in the immediate post-transplant period. The incidence of cryptococcosis in immunocompromised patients is increasing and cutaneous involvement may be the first manifestation of disseminated disease. The clinical spectrum of skin lesions is highly polymorphic, making diagnosis challenging. However, it should be considered in immunocompromised patients presenting with atypical skin lesions, particularly in the early post-transplant period.

Cytology-histology correlation, time to diagnosis and time to therapy when cytology is performed in addition to biopsies in malignant spinal lesions of previously unknown malignant disease.

e14007 Background: Metastatic spinal lesions are the first manifestation of malignant disease in up to 30% of patients (pts). Spinal care, diagnostic evaluation and initiation of systemic therapy are crucial for outcome in pts with advanced cancer. Histopathology (HP) from bone specimens is time consuming and decalcification procedure can hamper diagnostic information. The additional evaluation of spinal lesions by cytopathology (CP) has the potential to reduce time to diagnosis (TTD) and time to therapy (TTT). Therefore, we performed simultaneous analysis of CP and HP specimens from suspected malignant spinal lesions to evaluate the diagnostic value of additional CP. This work was supported by the German Society for Spine Surgery (DWG). Methods: We obtained CP specimens by transpedicular, intralesional aspiration through a Yamshidi needle or touch preparation from solid tissue samples. CP and HP specimens from spinal lesions were evaluated in parallel in 54 pts (CP/HP group). We analyzed sensitivity and specificity of CP in reference to HP. Furthermore, we compared the TTD and TTT of CP/HP group with a retrospective cohort of 103 patients in whom only HP was performed (HP group). Results: The collection of CP samples was feasible without elongation of surgery time or any complications for the pts. In 52/54 (96%) pts a CP-specimen was successfully obtained. Of the 52 pts analyzed, multiple myeloma was diagnosed in 10 pts, solid malignancy in 34, 1 pt had lymphoma and 7 did not show malignancy. The most common solid malignancies were prostate cancer (n=9), breast cancer (n=5) and adenocarcinoma of the lung (n=5). The sensitivity and specificity of CP in reference to HP is 98% and 71%, respectively. The concordance of CP and HP in differentiating between hematologic or solid neoplastic lesions is 94.2%. TTD in the CP/HP group was significantly shorter compared to HP group (1.7±1.8 and 8.6±3.6 d, respectively; p&lt;0.001). In addition, TTT in the CP/HP group was significantly shorter than in the HP group (19.3±14.4 d and 31.4±24.7 d; p=0.003). In 24.1% of pts a specific tumor therapy was initiated based on CP diagnosis before obtaining the results of HP. Conclusions: The evaluation of CP from malignant spinal lesions shows high sensitivity and concordance with HP and reduced TTD and TTT. Therefore, CP in addition to HP from spinal lesions of suspected malignancy has the potential to improve quality of life and prognosis in pts with advanced cancer. We therefore recommend the implementation of additional CP to HP in previously undiagnosed malignant spinal lesions.

Vasculiti facili e difficili: cosa deve sapere e saper fare un pediatra

Vasculitis is defined by a state of inflammation of the blood vessel walls. It can result in formation of either aneurysms or stenosis with ischemia and necrosis. The heterogeneity of clinical presentation depends on the type and size of the vessels involved, which leads to different patterns of organ damage. The skin is usually involved but not necessarily as a first manifestation of disease. Indeed, significant organ damage may occur at any time in the disease course and may precede other symptoms with significant morbidity and mortality, especially in case of diagnostic delay. The most common vasculitides in childhood are IgA-associated vasculitis (Schönlein-Henoch purpura) and Kawasaki disease. Other vasculitides are much rarer, often arising with insidious symp- toms that make them life-threatening. This paper aims to review the literature on paediatric vasculitides providing a practical guide to disentangle between different diagnoses. It also provides an overview that underlines the key differences in vasculitis presentation, management and follow-up.

Prevalence of concealed arrhythmogenic substrate for sudden cardiac arrest in the general population

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): US National Heart Lung and Blood institute National Institute of Health. Background Individuals who present with SCA as the first manifestation of heart disease (Concealed Substrate) present the greatest challenge for clinical risk stratification but population-based information in the current era is lacking. We hypothesized that improved awareness and access to health care has resulted in a reduction in prevalence of Concealed Substrate. Purpose We compared the overall prevalence, secular trends and SCA etiologies of Concealed Substrate in two geographically distinct US populations. Methods Consecutive cases of SCA were ascertained prospectively from 2 large ongoing US studies, the Population Cohort A (PopulationCohortA, 2002-2018) and Population Cohort B (PopulationCohortB, 2015-2022), total population 1.85 million residents. All out-of-hospital SCA events attended by emergency medical services were determined following an established multi-source ascertainment and adjudication process, and detailed lifetime clinical record evaluation conducted for each individual. This included the comprehensive electronic health record, evaluation of SCA survivors as well as all available autopsy information. Concealed Substrate cases were defined as SCA with no prior heart disease diagnosis. Results From a total of 5708 SCA cases (age 66.5 ± 18.2, female 35%), n=3390 (age 64.3 ± 18.8, female 34%) were identified in PopulationCohortA and n=2318 (age 71.6 ± 15.7, female 36%) in PopulationCohortB. In PopulationCohortA, prevalence of Concealed Substrate was 39% (n=1282, age 58.6 ± 21.7, 32% female) and decreased modestly over time (Figure; 37% in 2002-06 vs. to 33% in 2014-18; p=0.001). In PopulationCohortB, overall prevalence of Concealed Substrate was 41% (n=949, age 68.3 ± 17.6, 33% female) and did not change significantly over time (Figure; 2015-2022; p=0.06). Etiology of SCA was determined in a subgroup of overall cases (n=3210, 56%) of which n=2727 (85%) were ischemic SCA and n=483 (15%) non-ischemic SCA. Non-ischemic SCA was more commonly identified in Concealed Substrate (29% vs. 11%; p&amp;lt;0001) and ischemic SCA was more common in Revealed Substrate (89% vs. 72%; p&amp;lt;0.0001). Conclusion There was a modest reduction in prevalence over time, 33-41% of individuals continued to present with Concealed Substrate, with higher likelihood of non-ischemic SCA. These findings suggest that widely available and inexpensive tests such as the 12-lead ECG warrant further evaluation as a pre-screening method in the general population.

Association between the diagnostic classification of newly diagnosed coronary artery disease and future heart failure development.

The first clinical manifestation of coronary artery disease (CAD) varies widely from unheralded myocardial infarction (MI) to mild, incidentally detected disease. The primary objective of this study was to quantify the association between different initial CAD diagnostic classifications and future heart failure. This retrospective study incorporated the electronic health record of a single integrated health care system. Newly diagnosed CAD was classified into a mutually exclusive hierarchy as MI, CAD with coronary artery bypass graft (CABG), CAD with percutaneous coronary intervention, CAD only, unstable angina, and stable angina. An acute CAD presentation was defined when the diagnosis was associated with a hospital admission. New heart failure was identified after the CAD diagnosis. Among 28 693 newly diagnosed CAD patients, initial presentation was acute in 47% and manifested as MI in 26%. Within 30 days of CAD diagnosis, MI [hazard ratio (HR) = 5.1; 95% confidence interval: 4.1-6.5] and unstable angina (3.2; 2.4-4.4) classifications were associated with the highest heart failure risk (compared to stable angina), as was acute presentation (2.9; 2.7-3.2). Among stable, heart failure-free CAD patients followed on average 7.4 years, initial MI (adjusted HR = 1.6; 1.4-1.7) and CAD with CABG (1.5; 1.2-1.8) were associated with higher long-term heart failure risk, but an initial acute presentation was not (1.0; 0.9-1.0). Nearly 50% of initial CAD diagnoses are associated with hospitalization, and these patients are at high risk of early heart failure. Among stable CAD patients, MI remained the diagnostic classification associated with the highest long-term heart failure risk, however, having an initial acute CAD presentation was not associated with long-term heart failure.

MP-453090-5 SUDDEN CARDIAC ARREST AS THE FIRST MANIFESTATION OF HEART DISEASE IN THE GENERAL POPULATION

The subgroup of individuals who present with sudden cardiac arrest (SCA) as the first manifestation of heart disease (FM-SCA) present the greatest challenge to effective clinical risk stratification, but population-based data in the current era is lacking. We hypothesized that improved awareness and access to health care has resulted in a reduction in prevalence of FM-SCA. We compared the prevalence secular trends of FM-SCA in two geographically distinct US populations and evaluated distinguishing characteristics. Consecutive cases of SCA were ascertained prospectively from 2 large ongoing US studies, the Oregon Sudden Unexpected Death Study (OreSUDS, Portland OR, USA, 2002-2018) and Prediction of Sudden Death in Multi-ethnic Communities (PRESTO, Ventura CA, USA, 2015-2022), total population 1.85 million residents. All out-of-hospital SCA events attended by emergency medical services were determined following an established multi-source ascertainment and adjudication process, and a detailed review of the comprehensive lifetime clinical records was conducted for each individual. Both SCA survivors and non-survivors were included. FM-SCA cases were defined as SCA with no prior heart disease diagnosis. A multi-variable model using combined data from both cohorts was used to identify distinguishing characteristics of FM-SCA vs. other SCA. A total of 3390 SCA cases (age 64.3 ± 18.8, female 34%) were identified in OreSUDS and n=2318 (age 71.6 ± 15.7, female 36%) in PRESTO. In OreSUDS, prevalence of FM-SCA was 39% (n=1282, age 58.6 ± 21.7, 32% female) and decreased modestly over time (Figure; 37% in 2002-06 to 33% in 2014-18; p=0.001 for trend). In PRESTO, overall prevalence of FM-SCA was 41% (n=949, age 68.3 ± 17.6, 33% female) and did not change significantly over time (Figure; 2015-2022; p=0.06 for trend). In multivariate comparisons of FM-SCA vs. other SCA performed in the subset of individuals with healthcare visits, younger age, male sex and lower rates of diabetes, hypertension, seizure disorder, chronic obstructive pulmonary disease and chronic renal insufficiency were associated with FM-SCA (p <0.0001). There was a modest reduction in prevalence over time, but 33-41% of individuals continued to present with FM-SCA and were distinguished by younger age, male sex and lower rates of co-morbid conditions. These findings suggest the need to develop and investigate user-friendly and cost-effective pre-screening methods to reduce FM-SCA in the general population.

Perimandibularna metastaza karcinoma rektuma - prikaz slučaja

Introduction. Colorectal cancer is the third most common cancer and metastatic disease is an important and frequent clinical problem. Metastases in the oral and maxillofacial region are rare, comprising 1-2% of all malignant lesions, and clinically resemble common benign conditions. Case report. A 59-year-old woman diagnosed with rectal cancer developed perimandibular lesion as a first sign of metastatic process. Metastasis manifested clinically during the curative intent treatment of rectal cancer (preoperative chemo-irradiation) as a rapidly growing tumefaction close to the mandible angle. After the biopsy and histopathological examination of the lesion that clinically resembled abscess, metastasis of rectal cancer was diagnosed. Incidentally, a cerebral metastasis was diagnosed as well. Although it was oligometastatic rectal cancer, surgical treatment was not indicated due to extensive infiltrative characteristics of the perimandibular lesion. The patient was treated with chemotherapy, with good clinical response. Biological therapy was not available at that moment. Cerebral metastasis was treated with stereotactic neuroradiosurgery with gamma knife. Unfortunately, the patient died from cerebrovascular insult. Conclusion. Lesions in the oral and maxillofacial region may be the first manifestation of metastatic disease. Since early diagnosis of metastatic process has prognostic implications, any new formation in the oral and maxillofacial region in a patient with colorectal cancer requires cautious observation and histological examination.

Recurrent Planter Fasciitis as First Extraintestinal Manifestation of Inflammatory Bowel Disease [Crohn's Disease

Recurrent Planter Fasciitis as First Extraintestinal Manifestation of Inflammatory Bowel Disease [Crohn's Disease

Abstract #1318925: Femoral Neck Fracture as the First Manifestation of Celiac Disease

Celiac disease affects bone mineral metabolism by several mechanisms. The classic forms of celiac disease with evident malabsorption cause decreases in plasma calcium and vitamin D levels. These deficits lead to secondary hyperparathyroidism, which in turn increases the remodeling of the bone that result in decreased bone mass, changes the quality of bone, with the consequent decrease in strength of bone and increases the risk of fractures.