History Of Significant Trauma Research Articles

Validation of a Tamil Version of the Five Facet Mindfulness Questionnaire Using Rasch Analysis

Background: Various assessment tools that explore and assess mindfulness are available. Keeping in view both the origin of and the literature surrounding mindfulness assessment tools, this study aimed to evaluate the workability of one widely researched tool, the Five Facet Mindfulness Questionnaire (FFMQ), for establishing cross-cultural generalizability and utility in the Indian context. Methods: We recruited 303 adults over 18 with proficiency in the Tamil language and no history of significant neurological trauma and/or psychiatric history. They completed a version of the 39-item FFMQ, which we had translated into Tamil (FFMQ-T). The psychometric properties of this scale were tested using the Partial-Credit model of Rasch analysis. Results: Iterative Rasch analysis could not resolve consistent misfit of the Observe facet items. Using a subtest approach, a higher-order fit of the FFMQ-T could be achieved after the deletion of additional items from each of the remaining four facets. The resulting final model for the FFMQ-T questionnaire was a four-factor solution with 22 items. Conclusions: This study concluded the usability of the new 22-item FFMQ-T. These results are not dissimilar to the other versions in similar populations, such as the Hindi version of the FFMQ. The ordinal-to-interval conversion tables provided here ensure that the FFMQ-T can be used with enhanced precision and parametric statistics.

Outcomes following total ankle total talus replacement: A systematic review

BackgroundProsthetic substitution of the talus presents a significant challenge to the foot and ankle surgeon. The shear and compressive forces on the talus and its tenuous blood supply lead to high rates of avascular necrosis and eventual talar collapse. The purpose of this systematic review is to evaluate whether total ankle total talus replacement (TATTR) leads to improved clinical and radiographic outcomes with appropriate safety metrics in patients with a history of avascular necrosis or significant trauma. MethodsWe searched the concepts of talus, prosthesis, and arthroplasty in MEDLINE (PubMed), Embase (Elsevier), CINAHL Complete (EBSCOhost), and Scopus (Elsevier) from the database's inception through March 9, 2023. Inclusion Criteria were 1) previous trauma to the talus, 2) post-traumatic arthritis to the tibiotalar joint, 3) avascular necrosis of talus, 4) multiple failed prior interventions, 5) degenerative osteoarthritis to the tibiotalar joint, and 6) inflammatory arthropathy to tibiotalar joint. Patients less than 18 years of age and manuscripts in non-English languages were excluded. ResultsOf the 7625 references, 16 studies met the inclusion criteria, yielding data from 136 patients (139 ankles). The studies varied in design, with case reports and retrospective case series being predominant. The overall weighted average modified Coleman Methodology Score (mCMS) was 70.4 out of 100, indicating moderate flaws in study design that may be subject to various forms of bias and possible confounders. Demographics showed a diverse range of etiologies, with alumina ceramic being the primary prosthesis material. Functional scores demonstrated improvements in dorsiflexion and plantarflexion, although patient-reported outcome measures (PROs) were inconsistently reported. Complications included fractures, heterotopic ossification, prolonged wound healing, and infections. Revision details were sparsely reported. ConclusionTATTR is a promising treatment modality for improving short-term functional outcomes for patients with avascular necrosis or trauma-related issues. However, this systematic review underscores the need for standardized reporting, longer-term follow-ups, and further research to establish the procedure’s efficacy and safety, particularly in comparison to other treatment modalities. Level of EvidenceIII, Systematic Review of Level IV Studies

Protocol of a cross-sectional, multicentre and multidisciplinary study describing phenotype and burden of a midfacial segment pain

Background: Midfacial segment pain is a term used in the past in the diagnosis of patients mainly from ear, nose and throat clinics. This type of pain cannot be attributed to other primary or secondary facial pain, but is to a large extent similar to tension-type headache with midfacial location. The purpose of this study is to describe midfacial segment pain phenotype, burden and comorbidities in a multicentre and multidisciplinary setting. The ultimate goal is a comprehensive description of this type of pain allowing for its implementation in future classifications. Methods: This cross-sectional study is designed to describe midfacial segment pain in a clinical setting. Patients from rhinologic, headache and facial pain or oral medicine/dentistry secondary care centres will be recruited during a 1 year period. Individuals with other facial pain according to current classification such as sinonasal disorders, neoplasms, local infections, history of significant trauma associated with pain onset will be excluded. Data will be collected through a structured questionnaire covering pain characteristics, coexisting diagnoses, pain-related burden and consequences, physical examination and paranasal sinuses imaging.

Spontaneous Rupture of the Spleen: A Case Report

Spontaneous splenic rupture is a rare yet life-threatening condition often overlooked during the diagnosis of abdominal pain. This case report presents a 61-year-old male who reported to the emergency department with sudden abdominal pain and vomiting, resembling a previous episode experienced a month prior. Despite a lack of significant medical or trauma history, the patient's clinical examination revealed signs of internal bleeding. Imaging studies, including ultrasound and contrast-enhanced CT scan, confirmed an enlarged and disrupted spleen. Hemoglobin levels further supported the diagnosis, along with the retrieval of bloody ascitic fluid during paracentesis. The patient remained clinically stable throughout observation and vigilant monitoring. This case underscores the importance of considering spontaneous splenic rupture in patients presenting with acute abdominal pain, especially when no other plausible cause can be identified and aims to enhance the understanding and management of this rare condition, ultimately aiding in the improved prognosis of future patient.

Assessment of Comorbid Obsessive-Compulsive Disorder and Posttraumatic Stress Disorder.

Obsessive-compulsive disorder (OCD) and posttraumatic stress disorder (PTSD) are commonly comorbid and share prominent features (e.g., intrusions, safety behaviors, and avoidance). Excellent self-report and clinician-administered assessments exist for OCD and PTSD individually, but few assess both disorders, and even fewer provide instruction on differential diagnosis or detection of comorbid OCD and PTSD. To address this gap in the literature, the current paper aims to (1) highlight diagnostic and functional similarities and differences between OCD and PTSD to inform differential diagnosis, (2) outline assessment recommendations for individuals with suspected comorbid OCD and PTSD, OCD with a significant trauma history or posttraumatic symptoms, or PTSD with significant obsessive-compulsive symptoms, and (3) explore future directions to evaluate and improve methods for assessing co-occurring OCD and PTSD.

Behavioral and neurocognitive factors distinguishing post-traumatic stress comorbidity in substance use disorders

Significant trauma histories and post-traumatic stress disorder (PTSD) are common in persons with substance use disorders (SUD) and often associate with increased SUD severity and poorer response to SUD treatment. As such, this sub-population has been associated with unique risk factors and treatment needs. Understanding the distinct etiological profile of persons with co-occurring SUD and PTSD is therefore crucial for advancing our knowledge of underlying mechanisms and the development of precision treatments. To this end, we employed supervised machine learning algorithms to interrogate the responses of 160 participants with SUD on the multidimensional NIDA Phenotyping Assessment Battery. Significant PTSD symptomatology was correctly predicted in 75% of participants (sensitivity: 80%; specificity: 72.22%) using a classification-based model based on anxiety and depressive symptoms, perseverative thinking styles, and interoceptive awareness. A regression-based machine learning model also utilized similar predictors, but failed to accurately predict severity of PTSD symptoms. These data indicate that even in a population already characterized by elevated negative affect (individuals with SUD), especially severe negative affect was predictive of PTSD symptomatology. In a follow-up analysis of a subset of 102 participants who also completed neurocognitive tasks, comorbidity status was correctly predicted in 86.67% of participants (sensitivity: 91.67%; specificity: 66.67%) based on depressive symptoms and fear-related attentional bias. However, a regression-based analysis did not identify fear-related attentional bias as a splitting factor, but instead split and categorized the sample based on indices of aggression, metacognition, distress tolerance, and interoceptive awareness. These data indicate that within a population of individuals with SUD, aberrations in tolerating and regulating aversive internal experiences may also characterize those with significant trauma histories, akin to findings in persons with anxiety without SUD. The results also highlight the need for further research on PTSD-SUD comorbidity that includes additional comparison groups (i.e., persons with only PTSD), captures additional comorbid diagnoses that may influence the PTSD-SUD relationship, examines additional types of SUDs (e.g., alcohol use disorder), and differentiates between subtypes of PTSD.

Microphthalmos with elongated ciliary processes

A 12-year-old female patient came to our outpatient department with complaints of low vision in both eyes since childhood. There was no significant history of ocular trauma or family history of similar disease.

(423) A Case Series of Successful Off-label Use of Flibanserin

Abstract Introduction Flibanserin was the first FDA approved drug for hypoactive sexual desire disorder (HSDD) in premenopausal women, but was initially studied as an antidepressant without concern for age or gender. Flibanserin acts as partial agonist at the serotonin receptor 1A and antagonist at serotonin 2A receptor. The mechanism of action is thought to be due to an increase in dopamine and norepinephrine. Post hoc analysis during the pivotal trials showed improvement not just in desire, but in all domains of the Female Sexual Function Index (FSFI) including orgasm, arousal, lubrication and satisfaction. Off label use of flibanserin therefore is of interest to sexual medicine providers. Objective Described here, are four off label uses for flibanserin with successful outcomes in patient’s symptoms and quality of life, including post-orgasmic illness syndrome (POIS), low libido in a eugonadal male, a postmenopausal female with HSDD, and a patient with post-finasteride syndrome (PFS). Methods The first case is of a 40-year-old male patient who presented with a 10 year history of acquired POIS, with significantly debilitating symptoms lasting 1 week after orgasm. After trying a number of different multimodal treatment approaches he finally was on a regimen of Bupropion, Lexapro, Silodosin, Ritalin and Tramadol with a reduction in the duration of his symptoms from 1 week to 4 days, without a change in symptom intensity. Patient was then trialed on 200mg gabapentin nightly and 100mg flibanserin nightly, with progressive discontinuation of prior medications. The second patient, is a 77-year-old hypersexual, postmenopausal woman with a significant trauma history, who presented with gradually worsening HSDD despite adequate lubrication on estring, who was started on 100mg flibanserin nightly. Patient 3 is a 51-year-old male who presented with a 1 year history of low libido and mild erectile dysfunction despite normal testosterone levels and minimal improvements with sildenafil, who was trialed on 100mg flibanserin nightly. The fourth case involves a 26-year-old male presenting with PFS symptoms of erectile dysfunction, decreased libido, genital shrinkage, testicular pain, anxiety and brain fog. Patient had some improvement of erections post discontinuation of finasteride, but was only able to achieve full erection with use of tadalafil. Patient was trialed on 2 months of 100mg flibanserin. Results All four of these patients experienced significant improvement in their presenting symptoms after starting flibanserin nightly. Patient 1, with POIS, had markedly reduced symptom intensity and reduced duration of POIS from 7 days to 1 day. Patient 2 and 3 regained prior libido and quality of life within 2-3 months. Lastly, patient 4 experienced marked improvement in sleep, brain fog, libido and erectile function. Conclusions These cases indicate that flibanserin may be useful to more than premenopausal women and should be studied as a medication with additional pro-sexual affects like bupropion and buspar. Disclosure No

Stress fracture of femoral dyaphysis mimics osteosarcoma

Stress fractures of the femur are relativly uncommon. They can mimic other pathological entities, such as tumors, and can be the sourse of some diagnostic problems. The cause of stress fractures is often multifactorial and various modifiable and non-modifiable factors have been proposed to play a role: ethicity, high bone turnover, vitamin D insufficiency, nicotine and alcohol abuse, steroid use, low bone density, low adult weight, anorexia, or bisphosphonate therapy. Hence they might be missed in other groups of patients that present with anterior thigh pain without history of significant trauma. We report a stress fracture that mimicked tumoral process of the long bone, but patho-histological analysis revealed that it was a non-specific inflammation. Symptoms often mislead the clinicians, and because they mimic other conditions, a high index of suspicion/indication is required to uncover the true diagnosis. The importance of early detection and management needs to be conveyed, with a view to prevent complete fracture and bonedisplacement or, asin our reported case, to avoid un-necessery exploration. 

Does the phaco TIp position during clear corneal Phacoemulsification Surgery adversely affect corneal endothelium? TIPS study protocol for a randomised, triple-masked, parallel-group trial of bevel-up versus bevel-down phacoemulsification.

Introduction: Globally, at least 30 million cataract surgeries are required annually to prevent cataract-related blindness. Corneal endothelial decompensation is one of the most common causes of poor visual outcome following cataract surgery, particularly in those with predisposing factors. The increasing ageing population and reduced visual impairment threshold for cataract surgery have resulted in rising cataract surgical rates and hence, an increase in corneal endothelial decompensation is expected. The role of phaco tip position on corneal endothelial damage is ambiguous. Previous studies have reported contradictory results and were also underpowered to detect a significant difference due to small sample sizes. With no consensus regarding the most cornea-friendly phaco tip position (bevel-up versus bevel-down) during phacoemulsification, we propose a randomised clinical trial with a robust design using direct chop phaco-technique. Objective: To compare the effect of phaco tip position (bevel-up vs. bevel-down) on corneal endothelial cell count during phacoemulsification. Methods: A randomised, multicentre, parallel-group, triple-masked (participant, outcome assessor, and statistician) trial with 1:1 allocation ratio is proposed. By adopting stratified randomisation (according to cataract grade), we will randomly allocate 480 patients aged >18 years with immature cataract into bevel-up and bevel-down groups at two centres. History of significant ocular trauma, previous intraocular surgery, shallow anterior chamber, low endothelial cell count, pseudoexfoliation syndrome, intraocular inflammation, and corneal endothelial dystrophy are the key exclusion criteria. The primary outcome is postoperative endothelial cell count at one month. Secondary outcomes are central corneal thickness on postoperative days 1, 15, and 30, and intraoperative complications. Trial registration: Clinical Trial Registry of India CTRI/2019/02/017464 (05/02/2019).

Participant recruitment and retention from vulnerable populations in clinical trials is a matter of trust

Clinical research sites can struggle with recruiting and retaining vulnerable populations. Vulnerable research participants often have significant trauma histories making traditional approaches to recruitment and retention tenuous. Due to these difficulties, vulnerable populations are often intentionally excluded from clinical research due to the additional time and work involved. While it is important to provide protections for any participant that has decreased autonomy or increased susceptibility to coercion, it is equally important to assure that individuals in vulnerable populations have access to any clinical research that might pertain to them. In addition, the new trends in the drug development industry including early-stage development, risk-identification, preventative care, and disease spread modeling are likely to include health disparate patient populations that have increased probability of vulnerability. In this article we discuss the roots of many vulnerabilities and how to foster trust for more effective recruitment and retention of vulnerable populations.

A CASE OF HEMATAOCELE MIMICKING TESTICULAR MALIGNANCY

Hematoceles are usually associated with a history of scrotal trauma, are usually painful and rarely have an idiopathic origin. We describe the peculiar case of a hematocele mistaken for a testicular cancer. It is a case of 70-year-old male with no significant history of trauma with complaints of testicular swelling for 18 months presented to hospital. Ultrasound and High-dose contrast-enhanced computed tomography were unable to rule out malignancy hence proceeded with inguinal orchidectomy. MRI and ultrasound may help in diagnosis but final diagnosis is confirmed by histological analysis. Blood evacuation or orchidectomy include the management of this condition.

"It hurt but it helped": A mixed methods audit of the implementation of trauma- focused cognitive-behavioral therapy for psychosis.

BackgroundEmerging evidence supports the safety, acceptability, and efficacy of trauma therapies for people experiencing post-traumatic stress and psychosis, despite common concerns about iatrogenic harm when processing trauma memories for this population. However, to date there have been no mixed-method studies examining whether trauma-focused therapy can be implemented in routine care. This study reports an audit of a post-traumatic stress in psychosis clinic based in an inner-city trust in the U.K. National Health Service.Materials and methodsPeople under the care of psychosis community mental health teams with a significant history of past trauma were referred to the clinic by their multidisciplinary clinicians. Referral outcomes were recorded, including the proportion of people for whom trauma-focused cognitive-behavior therapy for psychosis was indicated. Post-traumatic stress symptoms were assessed pre- and post-therapy for clinically significant change on the Post-traumatic Stress Checklist (version 4) and Post-traumatic Stress Checklist (version 5). A subgroup of service users was also interviewed about their experience of therapy, with transcripts analyzed using inductive thematic analysis.ResultsSeventy one service-users were referred to the clinic between 2014 and 2018, of which 51 (71.8%) attended an assessment. Of these, 20 (39.2%) were identified as having clinically significant PTSD symptoms with re-experiencing and were offered trauma-focused cognitive-behavior therapy for psychosis. Sixteen (80%) accepted and completed therapy, with no dropouts, and received a mean of 17.54 sessions (SD = 17.60, range = 12–91). There were no serious adverse events related to therapy. Clinically significant change was observed in 68.8% (n = 11) of the therapy group and post-therapy six people (37.5%) no longer met the threshold for clinically significant PTSD. Six service users completed an interview about their therapy experiences with findings organized within four main themes and associated subthemes: (1) Perseverance, (2) Establishing safety, (3) The challenges of therapy, and (4) Rebuilding one’s life after trauma.ConclusionTrauma-focused cognitive-behavior therapy for psychosis can be safe, acceptable, and effective when implemented in routine care. Lived experience perspectives highlight the emotional demands of therapy and long-term impact of trauma, thus underscoring the necessity of sufficient support and continuity of care both during and after therapy.

Outcomes Following Total Talus Replacement: A Systematic Review

Category: Ankle; Hindfoot; Trauma Introduction/Purpose: Prosthetic substitution of the talus presents a unique challenge to the foot and ankle surgeon. The shear and compressive forces on the talus and its tenuous blood supply lead to high rates of avascular necrosis with possible talar collapse. The purpose of this systematic review is to evaluate whether total talus replacements (TTR) lead to improved clinical outcomes with appropriate safety metrics in patients with a history of avascular necrosis or significant trauma. Methods: Concepts of talus and arthroplasty were searched in MEDLINE (PubMed), Embase (Elsevier), CINAHL Complete (EBSCOhost), and Scopus (Elsevier) from the database's inception through November 4, 2021. Inclusion Criteria were 1) previous trauma to the talus, 2) post-traumatic or degenerative arthritis to the tibiotalar joint, 3) avascular necrosis of talus, 4) multiple failed prior interventions, 5) degenerative osteoarthritis to the tibiotalar joint, and 56) inflammatory arthropathy to tibiotalar joint. Manuscripts in non-English languages or those with concomitant total ankle arthroplasty or revision arthroplasty were excluded. All study designs were eligible according to the Journal of Bone and Joint Surgery criteria level I-IV. The modified Coleman Methodology Score was used to evaluate study quality and the Methodological Index for Non-Randomized Studies criteria was used to assess risk of bias. Results: Twenty-two studies of 191 patients (196 tali) at an average age of 50 (14-80) years were included (Figure 1a). Nineteen studies utilized third generation implants, two studies used first generation (n=9), and one study used second generation implants (n = 14) made of ceramic (n=82), cobalt chrome (n=49), or titanium (n=23) (Figure 1b). Radiographic and patient-reported outcomes are outlined in Figure 1c. The most common adverse outcome was osteosclerosis of the tibia (n=24), calcaneus (n=19), and navicular (n=5). Additionally, hindfoot varus (n=3), ankle discomfort (n = 3), decreased subtalar motion (n=7), periprosthetic fracture (n=1), calcaneal fracture (n=1), delayed wound healing (n=3), hindfoot valgus (n=1), prosthetic stem sunken into the talar neck (n=1), superficial peroneal nerve neuroma (n=1), loosening (n=2) were reported. Eight revisions were reported. Conclusion: TTR is an appealing option to maintain range of motion through the tibiotalar joint and allow for maintenance of more normal foot and ankle biomechanics. Given promising early- and mid-term outcomes, TTR is becoming more widely used in the setting of talar collapse. Still, high complication rates, especially adjacent joint osteoarthritis, may remain under-reported in the literature given inadequate long-term follow-up. Future research should aim to expand upon the indications of TTR, elucidate survivorship and complication rates, and directly compare TTR to existing forms of salvage options for advanced talar avascular necrosis.

Massed cognitive processing therapy for posttraumatic stress disorder in women survivors of intimate partner violence.

Survivors of intimate partner violence (IPV) report significant trauma histories, high rates of posttraumatic stress disorder (PTSD), head injuries and comorbid disorders, and multiple barriers to treatment that often preclude the regular attendance and engagement required in typical therapy protocols. The significant challenges faced by IPV survivors needing treatment may be ameliorated by condensing effective treatments for PTSD, such as cognitive processing therapy (CPT), in an accelerated delivery timeline. Using a multiple subject, single case design of six matched pairs of 12 female IPV survivors, we preliminarily tested the relative effectiveness of individual massed CPT delivered over 5 days (mCPT) as compared with standard CPT (sCPT) delivery in women IPV survivors. Assessments included full psychiatric diagnostic interviews, clinical interviews assessing trauma history and head injury prior to treatment, symptom monitoring during treatment, and full repeat assessments at 1 month and 3 months following treatment. No treatment group effect was found for PTSD severity between mCPT and sCPT among intention-to-treat, F(1, 10) = .01, p = .93. Both mCPT and sCPT were associated with significant improvement in PTSD, F(2, 20) = 45.05, p < .001, ds = 1.32-2.38). Overall, findings indicate mCPT appears effective in reducing psychological symptoms for women IPV survivors and suggest that condensed treatment is both palatable and feasible. Accelerated treatment delivery in this population may provide a necessary lifeline for women with IPV-related PTSD. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Proneness for and aversion to self-conscious emotion in posttraumatic stress.

Theory suggests that self-conscious emotions (guilt and shame) may play a role in the development/maintenance of posttraumatic stress. Propensities to experience these emotions (i.e., proneness) may confer risk for posttraumatic stress, while difficulties tolerating or coping with them (i.e., aversion) may maintain or exacerbate symptoms. However, no research to date has examined the importance of guilt aversion or shame aversion in posttraumatic stress. A total of 336 participants provided open-ended information on their experience of potentially traumatic events; a team of trained raters determined that a final sample of 186 participants had a clinically significant history of trauma. These participants completed measures of posttraumatic stress, along with measures of proneness for and aversion to both guilt and shame. Negative affect and experiential avoidance were assessed as covariates. Zero-order correlations indicated that guilt-proneness and guilt aversion were not associated with posttraumatic stress. By contrast, shame-proneness was associated with posttraumatic stress over and above trait negative affect and experiential avoidance. Moreover, a significant interaction revealed that shame-proneness was only associated with posttraumatic stress when shame aversion was high. Results suggest that people high in shame-proneness, and therefore likely to experience shame in response to traumatic events, may experience greater posttraumatic stress if they are shame averse. If this is the case, addressing shame directly and teaching better skills for regulating it may be an important treatment goal for some individuals with posttraumatic stress. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

SURGICAL MANAGEMENT OF PATHOLOGICAL FRACTURE OF DISTAL FEMORAL DIAPHYSIS WITH METASTASIS - A CASE REPORT

Introduction: The femur is the most common bone affected by a metastatic carcinoma and subsequently resulting into a pathological fracture of the bone which directly affects the daily activities of the cancer patient. Pathological fractures caused by metastatic events usually occur in late stage of the disease which are also accompanied by symptoms like severe pain, instability and loss of function. Several factors are considered in the treatment of femoral metastasis, including the location of the lesion, estimated prognosis, nature of the fracture – complete or impending and general condition of the patient. case report: We have a case of a62-year-old male patient who presented to us with the chief complaint of pain in the left thigh since 5 months with no history of significant trauma was found to have distal third femur shaft pathological fracture with a metastatic lesion on MRI who was operated with intra-medullary interlock nail. The patient was started with partial weight bearing walker mobilization on POD3. The patient was able to bear full weight over the operated limb and there was significant reduction in the pain after 1 week post op and the follow up x-ray after 2 months of surgery showed some signs of bridging callus over the lesionand the patient was sent for further evaluation of the suspected unknown primary. Conclusion: As is evident from the above case,patients with a pathological femur fracture operated with an intra-medullary implant were shown to have a significant achievement of pre operative goals of our surgical intervention in the form of reduction of pain, regaining of the range of motion of the affected joints, full weight bearing over the affected limb and a better quality of life with improvement in performance of activities of daily living.

"Am I Not Allowed to be Comfortable?" The Doubled Edged Sword of Benzodiazepine Prescriptions in Older Adults

<h3>Introduction</h3> The treatment of anxiety, panic, depression, and insomnia symptoms in late life pose many challenges. The use of benzodiazepines for these symptoms offers often rapid relief in some domains but clearly poses risks. Second only to opioids, benzodiazepine prescriptions have become a major focus of public health concern and scrutiny. The use of electronic data base reporting and FDA warnings regarding abuse potential and withdrawal have lead to a movement to both deprescribe and not initiate benzodiazepine treatment in older adults. It is clear that concerns regarding side effects of falls, fractures, acute and chronic confusional states, abuse potential and drug-drug interactions are of great concern to clinicians. Patients often cite concerns regarding tapering of these agents including fear of relapse of anxiety and panic and a wish to maintain feelings of comfort with what is percieved as a stable medication regime in their advanced years of life. A challenge to clinicians is to work with aging patients over a treatment plan which balances medication safety with the therapuetic benefits of these agents. Management of older adults who have been treated chronically, often for many decades, with benzodiazepines poses a significant challenge. Many community providers no longer want to care for these patients and as a result, they present to hospital based clinics with stigma and disappointment over prior treatment. <h3>Methods</h3> Cases were identified from the patient population at Mount Sinai Beth Israel, an urban medical center serving a multicultural and socioeconomically diverse population. Mount Sinai Beth Israel has been serving the popultaion of Manhattan since 1889 and provides comprehensive behavioral health care services. Patients were identified from those who presented to the ambulatory care geriatric psychiatry service with care needs that included chronic benzodiazepine use. <h3>Results</h3> Case presentations: Ms. A: A 69 year old woman with history of Generalized Anxiety Disorder and Dysthymia whopresented for treatment after her long-term provider could no longer see her. Medication regime includes Citalopram 40mg once daily, Clonazepam 2.5mg daily in divided doses, Gabapentin 400mg daily in divided doses and Zolpidem 10mg at bedtime. The patient presents with complaints of nervousness and anxiety which impair her function. She is resistive toward any changes in her regime and also she is reluctant to engage in psychotherapy. Ms. B: A 69 year old woman has been enrolled in the clinic for many years. She has a history of Generalized Anxiety Disorder, Panic Disorder, Alcohol Use Disorder in sustained remission and Opioid Use Disorder in remission on Methadone 45mg daily. The patient has been treated with Mirtazapine 60mg at bedtime, Clonazepam 1mg three times daily and Gabapentin 200mg at bedtime. Her course has been complicated by her goal of ending her Opioid Treatment Program and undergoing a taper of her Methadone dose over time. She presents with many complaints of anxiety, abdominal pain and GI upset. While she is able to describe a history of significant childhood trauma and abuse, engaging in truama focused care has been a challenge and her visits focus on dose increases in current medications. Ms. C: A 70 year old woman with a history of Major Depressive Disorder and Generalized Anxiety Disorder has been stable for many years. He current medication regime incldues Venlafaxine 100mg daily, Gabapentin 100mg daily and Clonazepam 0.75mg daily in divided doses. The patient is very devoted to her medication regime, with specific times of the day when she takes her pills and how she divides the Clonazepam doses. She explains that she is very satisifed with this regime, has tolerated reduction from a higher does of Clonazepam in the past and feels does not want to risk any relapse at present. <h3>Conclusions</h3> The risk potential of benzodiazepines is exponentially higher in geriatric patients compared to younger adults. This does not imply that these medications should always be discontinued among those who have been treated chronically. It is clear that despite Beers Criteria inclusion and FDA warnings, patients and providers both have difficulties making long term treatment plans regarding individual risk verus benefit decisions. A finding from our hospital-based clinic population includes an increasing number of patients who enter treatment after prior providers have refused to continue prescribing controlled substances. This fracture in a prior relationship creates greater challenges in fostering the therapuetic alliance necessary to gain trust, offer adjuntive therapies and adequately discuss medication risks and benefits. Finding the best balance for the patient in mitigating risk while maintaining quality of life requires individual assessment and shared treatment goals. We want to reduce polypharmacy, maintain patient comfort and safety with a focus on harm reduction. <h3>This research was funded by</h3> Mount Sinai Beth Israel Department of Psychiatry

Cardiopulmonary Resuscitation Induced Posterior Rib Fractures in Nontraumatic Pediatric Deaths.

Posterior rib fractures are considered suspicious for nonaccidental injury when observed in infants without significant trauma history or underlying bone disease. The biomechanical mechanism postulated for causing posterior rib fractures is anterior/posterior compression of the chest with posterior levering of the rib head over the transverse process of the vertebra creating a focal area of stress. The recommended "2-thumb" cardiopulmonary resuscitation method involves the administrator placing both thumbs on the sternum of the patient, encircling the chest with the hands, and placing the finger tips lateral to the spine. From this position, the administrator compresses the chest in an anterior/posterior direction by pressing on the sternum. Theoretically, the 2-thumb method should focus all force on the sternum while the back is supported by the fingers limiting posterior levering of the ribs and reducing the risk of posterior rib fractures. However, posterior rib fractures have been found during the autopsy of infants who received 2-thumb cardiopulmonary resuscitation, had no traumatic history, had a nontraumatic cause of death, and had no indication of underlying bone disease. This case study series presents the demographics, birth histories, circumstances surrounding death, and autopsy findings of four such medical examiner cases.

Mucoid degeneration of the anterior cruciate ligament: A case study

Mucoid degeneration of anterior cruciate ligament (ACL) is a rare pathological condition characterized by knee pain and restriction of movements. In this condition, ACL is infiltrated by mucoid (glycosaminoglycans) like material within its substance. We discuss the case and present a review of literature including clinical and radiological features and management options. We encountered a 33-year-old female complaining of increasing pain in right knee since last 6 years with difficulty in squatting and sitting cross-legged. There was no history of significant trauma or instability of the knee. Clinical examination demonstrated pain on deep knee flexion, negative Lachman, and anterior drawer test. Plain radiograph of knee suggested early onset degenerative changes of knee in the form of medial joint space reduction. Magnetic resonance imaging (MRI) showed hyperintense signal in ACL substance in T1W and T2W images which is classically described as Celery Stalk appearance on T2 STIR images. This was often mistaken as partial tear of ACL. Patient was planned for diagnostic arthroscopy. During arthroscopy, ACL was occupying the whole intercondylar notch. It was hypertrophied, homogenous, and firm. Arthroscopic debulking of ACL was done cautiously and mucoid tissue was removed. The specimen was sent for histopathological examination which confirmed the diagnosis of mucoid degeneration. Post-operatively patient was relieved of symptoms and was doing well without any specific complaints like instability till last follow up at 18 months. Repeat MRI was not done as patient was not symptomatic. Mucoid ACL degeneration affects active persons in third to fourth decade of life without significant trauma. MRI is the most useful tool for diagnosis with specific findings. If this disease is considered preoperatively, it can be diagnosed early. Treatment with debulking or partial resection shows good functional results.