Boletin De La Asociacion Medica De Puerto Rico[JOURNAL]
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200 papers
Role of Helicobacter pylori infection in Hispanic patients with anemia.
Ortiz M, Rosado-Carrión B, Bredy R
Bol Asoc Med P R · 2014 · PMID 25065045
Pernicious anemia represents the final phase of a process that begins with Helicobacter pylori-associated gastritis and evolves through progressive levels of atrophy until loss of parietal cell mass. Numerous studies hav...
Pernicious anemia represents the final phase of a process that begins with Helicobacter pylori-associated gastritis and evolves through progressive levels of atrophy until loss of parietal cell mass. Numerous studies have suggested an association between H. pylori infection, unexplained iron deficiency anemia and cobalamin deficiency. Our research question was to determine whether there is an association between with H. pylori infection and development of anemia in Hispanic patients. This cross sectional pilot study involved data analysis of individual from years 2010-2012 examining the association between H. pylori infection and hemoglobin levels in patients with Hispanic ethnicity. A total of 189 records were evaluated, of which 33 fulfilled the inclusion criteria. The study sample was divided in two groups. Group-A: 5 subjects with H. pylori infection and anemia; Group-B: 28 patients with H. pylori without anemia. Fisher exact test applied between categorical variables to determine the statistical significance of symptoms comparing anemic vs. non-anemic H. pylori infected patients yielded a p = 0.0027. In addition, restoration of anemia in two subjects following eradication therapy without previous iron or cobalamin replacement therapy suggested a potential role of this bacterium in the development of anemia in Hispanics. In conclusion, from the results of this study a potential association between Helicobacter pylori infection and anemia in Hispanic patients is suggested. Restoration of hemoglobin after eradication of bacteria further supports this concept.
Anemia management among hemodyalisis patients at the University Hospital in Puerto Rico.
Ocasio HE, Diaz H, Cangiano JL … +2 more , Báez R, Suárez E
Bol Asoc Med P R · 2014 · PMID 25065044
End-stage renal disease is frequently complicated with anemia. Iron deficiency anemia occurs in most hemodialysis patients secondary to increased iron demand driven by the accelerated erythropoiesis that occurs when stim...
End-stage renal disease is frequently complicated with anemia. Iron deficiency anemia occurs in most hemodialysis patients secondary to increased iron demand driven by the accelerated erythropoiesis that occurs when stimulating agents are administered as treatment of the anemia. The purpose of this study was to determine the prevalence of anemia and iron stores in patients undergoing hemodialysis at our unit; identify their treatment and effectiveness. Medical records of fifty-three patients undergoing ambulatory hemodialysis were evaluated for three months. Patient's hemoglobin, ferritin, iron, total iron binding capacity and percent transferrin saturation were recorded. 91% patients had arterial hypertension and 62% were diabetic. The prevalence of anemia was 34%, 57% and 47% during the three-month period respectively. Only 21% of the population had transferrin saturation less than 20% and none had ferritin below 200 ng/ml. Throughout the study, the majority of patients were managed with combination of iron and erythropoietin stimulating agents (ESAs). The prevalence of anemia remained elevated despite treatment with iron and ESAs. However, 56% of anemic patients throughout the three months showed an increase in hemoglobin levels by the end of the observation period. 53% of patients were treated with iron alone or with ESAs for the three consecutive month periods and only two had transferrin saturation less than 20%. In our population, ESAs low responsiveness is not related to iron deficiency but to the morbidity of their disease.
[Epidemiologic descriptive study of the clinical characteristics of acute bronchiolitis in patients hospitalized at the pediatric unit of the Manatí Medical Center Hospital].
Colón Blanco ZM, Colón Rivera CS, Matos González M … +4 more , Pérez Valentín BL, Rivera Fernández R, Santiago Méndez I, Cintron V
Bol Asoc Med P R · 2014 · PMID 25065043
Acute respiratory infections are the main reason for pediatric visits both to physician's offices and emergency departments. Bronchiolitis is an acute viral respiratory disease that affects about 10% of infants each year...
Acute respiratory infections are the main reason for pediatric visits both to physician's offices and emergency departments. Bronchiolitis is an acute viral respiratory disease that affects about 10% of infants each year and mostly those under age two. The aim of this study was to identify demographic, epidemiological characteristics and risk factors associated with cases of bronchiolitis admitted to the Manati Medical Center (MMC). In addition, we tried to establish the basis for the development of strategies to prevent of hospitalizations and complications in our Institution. A retrospective descriptive study was conducted in the pediatric wing of MMC in Manati, Puerto Rico between January and December 2009. A total of 508 children were included, 58 % of them male. The average age and weight were 12 +/- 5.3 months and 8.1 +/- 1.4 kg, respectively. We observed a higher predisposition among males as well as a statistically significant relationship between breastfeeding and protection from the disease. No relationship was observed between preterm birth and the parents' smoking habit and the development of the disease. However, the latter factor influences the length of hospital stay. The risk of bronchiolitis was seasonal with a peak between October and November. The presence of respiratory syncitial virus was confirmed in 67 % of the cases.
Uterine curettage post-partum patients with severe preeclampsia: removal of trophoblastic tissue can alter the progression of this condition.
Ponton AC, Flores IS, Rivera-Viñas JI … +1 more , Schwarz S
Bol Asoc Med P R · 2014 · PMID 24791370
Reviewing the literature to evaluate the effect of postpartum uterine curettage in the maternal recovery time of patients with refractory severe preeclampsia determined that uterine curettage can be of benefit in select...
Reviewing the literature to evaluate the effect of postpartum uterine curettage in the maternal recovery time of patients with refractory severe preeclampsia determined that uterine curettage can be of benefit in select cases and should be included in hospital protocols to avoid further maternal complications.
[Neuro-critical management of glycemia in spontaneous intracerebral hemorrhage: review of the literature].
Navas-Marrugo SZ, Alvis-Miranda HR, Moscote-Salazar LR
Bol Asoc Med P R · 2014 · PMID 24791369
Spontaneous cerebral hemorrhage or intracranial hemorrhage represents between 10 and 15% of all cerebrovascular events. Intracerebral hemorrhage is far less frequent than ischemic stroke, but leads to increased morbidity...
Spontaneous cerebral hemorrhage or intracranial hemorrhage represents between 10 and 15% of all cerebrovascular events. Intracerebral hemorrhage is far less frequent than ischemic stroke, but leads to increased morbidity and mortality, one of the leading causes of severe disability. Several changes have been identified in the field of intracerebral hemorrhage, including endocrine. These stress-mediated mechanisms exacerbate secondary injury. Deep knowledge of the injuries that are directly involved in the alterations of glucose in the context of an intracerebral hemorrhage, offers a vision of how the cytotoxicity, neuronal death and metabolic disturbances alter the prognosis of patients with spontaneous intracerebral hemorrhage.
Wandering spleen torsion causing acute abdominal pain in a child: case report and review of literature.
Llorens Marina CI, Cedeño A, Lugo-Vicente H … +3 more , Chapel C, Rivera G, Diaz A
Bol Asoc Med P R · 2014 · PMID 24791368
Wandering spleen is a rare occurrence where the spleen normal fixation to the abdominal wall is lost and thus allowed to change in position. We report a case of a child who presented with acute abdominal pain secondary t...
Wandering spleen is a rare occurrence where the spleen normal fixation to the abdominal wall is lost and thus allowed to change in position. We report a case of a child who presented with acute abdominal pain secondary to a wandering spleen complicated by torsion of its vascular pedicle. The diagnosis was promptly made using computed tomography and managed with splenectomy.
An unusual case of a borderline Brenner tumor associated with bilateral serous cystadenoma and endometrial carcinoma.
Cruz-Galarza D, Pérez-Rodríguez O, Laboy-Torres J … +1 more , Gutiérrez-Rivera S
Bol Asoc Med P R · 2014 · PMID 24791367
Brenner tumor accounts for 1.5 to 2.5% of ovarian tumors. Nearly all are benign and 1% malignant. Less than twenty-five cases of borderline Brenner tumor have been reported worldwide. Our case is the first one related to...
Brenner tumor accounts for 1.5 to 2.5% of ovarian tumors. Nearly all are benign and 1% malignant. Less than twenty-five cases of borderline Brenner tumor have been reported worldwide. Our case is the first one related to a bilateral ovarian serous cystadenofibroma and endometrioid adenocarcinoma. This unusual case increases the limited data for borderline Brenner tumors.
Young female with acromegaloid features and pituitary macroadenoma: what is your diagnosis?
Hernán Martínez J, Figueroa-Núñez C, Mansilla-Letelier P … +9 more , Palermo-Garofalo C, Santiago M, Torres O, Trinidad R, Mangual-García M, Sánchez A, Gutierrez M, Miranda Mde L, González E
Bol Asoc Med P R · 2014 · PMID 24791366
Pseudoacromegaly is a extremely rare condition previously described and characterized by acromegaloid changes, tissue overgrowth, without elevations in insulin-like growth factor or growth hormone as seen in Acromegaly....
Pseudoacromegaly is a extremely rare condition previously described and characterized by acromegaloid changes, tissue overgrowth, without elevations in insulin-like growth factor or growth hormone as seen in Acromegaly. We present the case of a young female seen initially with acromegaloid features and a pituitary microadenoma. After work-up the patient was diagnosed as insulin-mediated pseudoacromegaly. Only a few cases of pseudoacromegaly has been reported and should always be considered when evaluating patients for acromegaloid features with negative biochemical and hormonal levels.
Just a flare---the Pandora's box approach.
Moreno M, Laboy Ortíz IE, Vélez FA … +4 more , Sánchez A, Rodríguez A, Colón M, Hernán Martínez J
Bol Asoc Med P R · 2014 · PMID 24791365
Systemic lupus erythematosus is a chronic inflammatory autoimmune disease characterized by autoantibodies specific for highly conserved nuclear antigens, such as double-stranded DNA, histones and ribonuclear proteins. Th...
Systemic lupus erythematosus is a chronic inflammatory autoimmune disease characterized by autoantibodies specific for highly conserved nuclear antigens, such as double-stranded DNA, histones and ribonuclear proteins. The course of the disease is unpredictable and nine times more common in females. Among the neurological manifestations of collagen vascular diseases is the most commonly recognized and better studied disease. Central nervous system lupus is a serious and potentially treatable illness presenting as difficult diagnostic challenge. This is a case report of a patient that suffered central nervous system manifestations of severe active lupus. Early recognition of this entity is essential to expedite appropriate to treatment and avoid future complications.
Pasteurella multocida: a nightmare for a replaced joint and the challenge to save it.
Vélez FA, Laboy Ortíz IE, López R … +3 more , Sánchez A, Colón M, Hernán Martínez J
Bol Asoc Med P R · 2014 · PMID 24791364
Pasteurella multocida a small gram-negative coccobacilli is primarily found as normal flora of cats and dogs. These organisms can cause a variety of infections in humans, usually the result of scratches, bites and licks...
Pasteurella multocida a small gram-negative coccobacilli is primarily found as normal flora of cats and dogs. These organisms can cause a variety of infections in humans, usually the result of scratches, bites and licks by percutaneous inoculation of the organism. Most cases of septic arthritis involve a cat or dog bite distal to the involved joint without direct penetrating injury to the joint. On scenarios were Pasteurella infection is suspected within a prosthetic joint, aggressive surgical debridement and/or removal of the prosthesis with intravenous antibiotics is recommended. Prosthetic joint infections secondary to animal bites are an extremely rare complication and few cases have been reported in the literature. This is a case report of a patient that suffered a cat's bite of his right prosthetic knee and against all odd was able to save it without surgical intervention.
Abrupt onset of muscle dysfunction after treatment for Grave's disease: a case report.
Hernán Martínez J, Sánchez A, Torres O … +8 more , Palermo C, Santiago M, Figueroa C, Trinidad R, Mangual M, Gutierrez M, González E, Miranda Mde L
Bol Asoc Med P R · 2014 · PMID 24791363
Myopathy is a known complication of hypothyroidism, commonly characterized by an elevation in Creatine Kinase (CPK) due to increase capillary permeability proportional to the hypothyroid state. Thyroid hormone is importa...
Myopathy is a known complication of hypothyroidism, commonly characterized by an elevation in Creatine Kinase (CPK) due to increase capillary permeability proportional to the hypothyroid state. Thyroid hormone is important for the expression of fast myofibrillar proteins in the muscle. In hypothyroidism the expression of these proteins are deficient and there is an increase accumulation of slow myofibrillar proteins. A rapid or abrupt descend in thyroid hormones caused by radioiodine therapy after prolonged hyperthyroidism can lead to local hypothyroid state within the muscle tissue, resulting in CPK elevation and hypothyroid myopathy. Hormone replacement leads to resolution of symptoms and normalization of muscle enzymes serum levels.
[Sensorineural deafness and vertebral artery aneurysm: endovascular management].
Zeneno M, Moscote-Salazar LR, Alvis-Miranda H … +1 more , Lee A
Bol Asoc Med P R · 2014 · PMID 24791362
Sensorineural deafness and vertigo have different causes among them immunological, vascular and infectious. Vascular causes of sensorineural hearing loss are unusual and among them are the vertebral artery aneurysms. Kno...
Sensorineural deafness and vertigo have different causes among them immunological, vascular and infectious. Vascular causes of sensorineural hearing loss are unusual and among them are the vertebral artery aneurysms. Knowledge by neurosurgeons, neurointerventional and otolaryngologists aneurysms involving the development of sensorineural hearing loss is critical to establishing and determining a targeted therapeutics. We report the case of an adult handled with endovascular techniques and review the current literature of similar cases.
Meningeal melanocytoma: case report and literature review.
Kraft Roverea R, Dagnonia C, Gomes de Oliveiraa G … +1 more , Sapellia J
Bol Asoc Med P R · 2014 · PMID 24791361
We report a case of a 54-year-old female with progressive chronic pain in lower extremity, paraplegia and loss of function of the anal sphincter. MRI revealed an expansive solid intradural and intramedullar lesion locate...
We report a case of a 54-year-old female with progressive chronic pain in lower extremity, paraplegia and loss of function of the anal sphincter. MRI revealed an expansive solid intradural and intramedullar lesion located at the T6 to T9 levels. Histology of the lesion showed melanocytes with the results of immunohistochemistry consistent with a melanocytoma. Melanocytic tumors are rare tumors which present a diagnostic and management challenge for the modern neurosurgeon and neuro-oncologist since MRI and CT features are non-specific and there is scant data to standardise best strategic therapy.
Risk factors for hysterectomy in abnormal placentation at the University District Hospital.
Rivera-Rosado M, Flores-Pérez IS, Méndez K … +1 more , Rivera-Viñas JI
Bol Asoc Med P R · 2014 · PMID 24791360
UNLABELLED: The aim of this research was to study the relationship of abnormal placentation and cesarean hysterectomy risk factors at the University District Hospital. METHOD: A retrospective study was conducted using 60...
UNLABELLED: The aim of this research was to study the relationship of abnormal placentation and cesarean hysterectomy risk factors at the University District Hospital. METHOD: A retrospective study was conducted using 60 medical records of patients in the University District Hospital from 2001 to 2008 with a diagnosis of abnormal placentation. Descriptive statistics and chi square for associations were used for statistical analysis. RESULTS: The mean age in our population was 29 years and mean BMI was 29.6. 45 % of the patients had a previous history of cesarean, 1.7% of placenta previa and 26.7% of uterine curettage. We found that 33.3% had a cesarean hysterectomy and 41.7% had post-partum hemorrhage. Also 51.7% received blood transfusion. The mean hospital stay was 18.1 days. The probability of cesarean hysterectomy in patients with placenta previa was eleven times higher in patients with history of previous cesarean sections (OR 11, CI: 1.29-97.9, p value=0.01). There was no statistically significant difference in cesarean hysterectomy rate between obese (BMI>30) and nonobese patients (OR 3.8 CI: 0.69-20.5, p value=0.11). CONCLUSION: The probability of cesarean hysterectomy in patients with abnormal placentation was significantly increased in patients with previous cesarean sections. By decreasing the rate of cesarean section we can decrease the incidence of cesarean hysterectomy and its comorbidities.
[Endovascular management of cavernous sinus dural fistulas].
Zenteno M, Santos Franco J, Moscote-Salazar LR … +1 more , Lee A
Bol Asoc Med P R · 2014 · PMID 24791359
OBJECTIVE: Describe the outcomes of patients diagnosed with indirect carotid-cavernous fistula treated by endovascular methods. DESIGN: A retrospective case series. PARTICIPANTS: Twelve patients with dural cavernous sinu...
OBJECTIVE: Describe the outcomes of patients diagnosed with indirect carotid-cavernous fistula treated by endovascular methods. DESIGN: A retrospective case series. PARTICIPANTS: Twelve patients with dural cavernous sinus fistula with important ophthalmologic involvement admitted and treated at the National Institute of Neurology and Neurosurgery between February 1990 and January 2005. INTERVENTION: Patients were managed by endovascular embolization for all fistulas. OUTCOME MEASURES: Angiographic controls to 24 hours and at 6 and 12 months were performed. RESULTS: 67 % were female and 33 % male. The mean age was 44 years. 67 % were spontaneous and 33% of traumatic origin. All patients had eye involvement with proptosis (92%) and involvement of the oculomotor nerve (67%). Headache and pulsatile tinnitus were not frequent ophthalmologic data. All were diagnosed by cerebral angiography, 33 % were type C, type D 67 %, and none of the type B classification Barrow. In 17 % of cases the distal arterial robbery showed severe. Predominance of anterior and superior venous drainage in 83 % and 42 % of cases occurred respectively. The surgical approach was arterial in 84% of cases, while in 17 % venous through the superior ophthalmic vein. Cyanoacrylate embolization material was used in 58 % of the cases, as it was associated with the use of removable ball with polyvinyl alcohol particles in 16 % in of venous approach cases. 17% detachable coils were utilized. There were no complications. After angiographic controls at 24 hours 100% occlusion was seen in patients treated with cyanoacrylate (58%) (p = 0.03). The remaining 42% were prescribed maneuver of manual compression. At 12-months angiography all patients had 100% occlusion of the carotid-cavernous fistula. CONCLSUIONS: This is the world's second largest series with indirect carotid-cavernous fistulas treated after trauma. 100 % of cases were cured with the use of a transarterial-controlled approach and N-butyl-cyanoacrylate after long-term observation.
Psychosocial factors associated with failure to use contraception among adolescents with repeat pregnancies in Puerto Rico.
Colón M, Martínez R, Tulla M … +3 more , Pérez J, Santaella Y, Laras L
Bol Asoc Med P R · 2014 · PMID 24791358
UNLABELLED: Social, medical, psychological and economic problems are often associated to teen pregnancy. This is a reality worldwide; Puerto Rico is not an exception, documented in statistics and previous research projec...
UNLABELLED: Social, medical, psychological and economic problems are often associated to teen pregnancy. This is a reality worldwide; Puerto Rico is not an exception, documented in statistics and previous research projects. There are many risks associated with pregnancies among adolescents, including increased maternal morbidity and infant morbidity. In Puerto Rico, the adolescent repeat births reed are 22% for a second child and 6% for a third child. Repeated teen pregnancy has a higher than expected incidence; therefore the investigation of psychosocial factors associated with failure to use contraception is needed,especially to address the intervention at clinics with this population of different needs, mainly when these patients with repeated teen pregnancies have been through the health care system already. METHODOLOGY: The project is a cross sectional survey study, seventy articipants between 12-19 years of age who attended obstetrics or postpartum clinics at an adult University Hospital. A self-administered questionnaire included some psychosocial factors that have been associated withthe failure to use contraceptives as well as demographics tion, education, socioeconomic status and support system. RESULTS: Their partner's age ranged from 15 to 38 years of age. Most participants lived with their partner. Their main activity at the time of the study was housework. Most had left school beforebecoming pregnant and received government help. Of all participants, a small number was legally married. The lack of use of contraceptive was found to be significantly associated to partner (p < 0.05). CONCLUSION: The lack of contraceptive use is a key factor in adolescent pregnancy. It is expected that this data can be helpful for documentation and intervention measurements something canbe done at an educational level, family planning and medical care.
Osteoporosis knowledge in patients with a first fragility fracture in Puerto Rico.
Díaz-Correa LM, Ramírez-García LM, Castro-Santana LE … +1 more , Vilá LM
Bol Asoc Med P R · 2014 · PMID 24791357
PURPOSE: To determine the level of knowledge about osteoporosis and factors associated with low level of knowledge in patients with a first osteoporotic fracture. METHODS: A cross-sectional study in adult patients with a...
PURPOSE: To determine the level of knowledge about osteoporosis and factors associated with low level of knowledge in patients with a first osteoporotic fracture. METHODS: A cross-sectional study in adult patients with a first osteoporotic fracture admitted to the University Hospital of the Puerto Rico Medical Center, San Juan, Puerto Rico was performed. Socio-demographic parameters, clinical features, and pharmacologic treatment were examined. A validated questionnaire was used to assess subjects' level of knowledge about osteoporosis. Differences between study groups were evaluated using chi-square and Student's t tests, as appropriate. RESULTS: A total of 54 patients participated in the study. The mean (SD) age was 73.7 (10.7) years; 77.8% were females. Overall, 61.1% of the participants had a low level of knowledge about osteoporosis. Patients with low level of knowledge were more likely to have the Puerto Rico Government health insurance, lower level of education, and higher hip FRAX scores than those with mid/high level of knowledge. Also, they were less likely to receive osteoporosis counseling by their primary care physicians (PCP), have prior BMD measurement, receive bisphosphonates/raloxifene treatment, and to take calcium and vitamin D supplements. CONCLUSIONS: In this population of Hispanic patients with a first osteoporotic fracture, the majority had a low level of knowledge about osteoporosis. Low knowledge was associated with low socio-economic status, lack of counseling about osteoporosis by PCP, prior BMD measurement, and osteoporosis treatment. Better efforts should be undertaken to educate, identify, and manage patients at risk for osteoporotic fractures.
[CHRONIC SUBDURAL HEMATOMA: PHYSIOPATHOLOGY AND SURGICAL MANAGEMENT].
Alvis-Miranda HR, Alcalá-Cerra G, Rubiano AM … +1 more , Moscote-Salazar LR
Bol Asoc Med P R · 2014 · PMID 26148403
Chronic subdural hematoma is an encapsulated collection of blood underneath the Dura, essentially characterized by the presence of a membrane. It usually occurs in the elderly considered as a sentinel event. Simple brain...
Chronic subdural hematoma is an encapsulated collection of blood underneath the Dura, essentially characterized by the presence of a membrane. It usually occurs in the elderly considered as a sentinel event. Simple brain computed tomography is the current imaging aid of choice for the diagnosis of this entity. It should be suspected especially in patients who present with dementia syndrome. Although less frequent, it should be investigated in patients with transient neurologic deficit. There is still no consensus regarding the ideal surgical modality of treatment. The procedure that seems most recommended is closed suction drainage through burr holes. It has been controversial whether intraoperative washing of such collection improves outcomes.
[POTENTIALLY FATAL LYELL SYNDROME].
Agustín Godoy D, Alvarez E, Amigot A … +2 more , Di Napoli M, Massoti L
Bol Asoc Med P R · 2014 · PMID 26148402
Toxic epidermal necrolysis or Lyell's syndrome is a rare entity with strong compromise of immune system. It is a hypersensitivity reaction secondary to the use of specific drugs and other triggers. Erythematous lesions o...
Toxic epidermal necrolysis or Lyell's syndrome is a rare entity with strong compromise of immune system. It is a hypersensitivity reaction secondary to the use of specific drugs and other triggers. Erythematous lesions of bullous aspect characterize the clinical picture affecting all layers of the skin, scaly and widespread in distribution and progression. Sometimes life threatening, generate a severe inflammatory and systemic reaction with multiple organ dysfunction. Treatment encompasses three objectives: identification and suspension of triggers, general clinical support and therapy to the skin lesions. Immune therapy is controversial and not supported by solid scientific evidence. We report a case that summarizes all aspects of this potentially lethal disease.
A TRAUMATIC BILATERAL FEMORAL NECK FRACTURES IN A HEALTHY PREMENOPAUSAL FEMALE WITH HYPOVITAMINOSIS D.
Paraliticci G, Rodríguez Quintana D, Dávila A … +1 more , Otero-López A
Bol Asoc Med P R · 2014 · PMID 26148401
Bilateral atraumatic femur neck fractures in young adult are very rare. We report a young premenopausal female with osteormalacia secondary to vitamin D deficiency and spontaneous bilateral femur neck fractures. Patient...
Bilateral atraumatic femur neck fractures in young adult are very rare. We report a young premenopausal female with osteormalacia secondary to vitamin D deficiency and spontaneous bilateral femur neck fractures. Patient had no reported risk factors for osteomalacia but hypovitaminosis D was noted upon evaluation. Osteomalacia secondary to low serum levels of vitamin D may lead to stress and fragility fractures. Identification and treatment of such patients may decrease the incidence of stress fractures and- possible complications.
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