We analysed the morbidity, mortality and outcome of cervical spine injuries in patients over the age of 65 years. This study was a retrospective review of 107 elderly patients admitted to our tertiary referral spinal injuries unit with cervical spine injuries between 1994 and 2002. The data was acquired by analysis of the national spinal unit database, hospital inpatient enquiry system, chart and radiographic review. Mean age was 74 years (range 66-93 years). The male to female ratio was 2.1:1 (M = 72, F = 35). The mean follow-up was 4.4 years (1-9 years) and mean in-hospital stay was 10 days (2-90 days). The mechanism of injury was a fall in 75 and road traffic accident in the remaining 32 patients. The level involved was atlanto-axial in 44 cases, sub-axial in 52 cases and the remaining 11 had no bony injury. Multilevel involvement occurred in 48 patients. C2 dominated the single level injury and most of them were type II odontoid fractures. Four patients had complete neurology, 27 had incomplete neurology, and the remaining 76 had no neurological deficit. Treatment included cervical orthosis in 67 cases, halo immobilization in 25, posterior stabilization in 12 patients and anterior cervical fusion in three patients. The overall complication rate was 18.6% with an associated in-hospital mortality of 11.2%. The complications included loss of reduction due to halo and Minerva loosening, non-union and delayed union among conservatively treated patients, pin site and wound infection, gastrointestinal bleeding and complication due to associated injuries. Among the 28.9% patients with neurological involvement, 37.7% had significant neurological recovery. Outcome was assessed using a cervical spine outcome questionnaire from Johns Hopkins School of Medicine. Sixty-seven patients (70%) completed the form, 20 patients (19%) were deceased at review and 8 patients (7%) were uncontactable. Functional disability was more marked in the patients with neurologically deficit at time of injury. Outcome of the injury was related to increasing age, co-morbidity and the severity of neurological deficit. Injuries of the cervical spine are not infrequent occurrence in the elderly and occur with relatively minor trauma. Neck pain in the elderly patients should be thoroughly evaluated to exclude C2 injuries. Most patients can be managed in an orthosis but unstable injuries require rigid external immobilization or surgical stabilization.

Most of the problems encountered were logistic in nature. Early evacuation of the victims remains pivotal in saving lives. The major causes of death in peripheral patients was hypovolemic shock, sepsis, and hypothermia. Mortality and morbidity can be enhanced by ample fluid resuscitation, tetanus prophylaxis, and proficient first aid at the site of injury.

Bezoars are conglomerates of undigested organic matter, which forms a mass in the gastrointestinal tract. This report describes a patient who developed a gastric bezoar from ingesting a large number of metal objects in order to "treat" his pulmonary tuberculosis.

of oral sildenafil therapy. Conclusions: Increased arterial inflow is the primary hemodynamic event in the development of penile erection. NO acts as a messenger molecule stimulating guanylate cyclase, and leading to the formation of cyclic guanosine monophosphate (cGMP). cGMP then acts through calcium-gated potassium channels to cause vascular smooth muscle relaxation. Phosphodiesterases (PDE) are an integral component of cyclic nucleotide signaling. PDE5 is found in high concentration within the smooth muscle of the pulmonary vasculature and corpus cavernosum. Therefore, PDE5 inhibitors such as sildenafil. known to improve erectile dysfunction. have also been used in the treatment of PPHN. We hypothesize that the NO administered in the first case and the oral sildenafil given in the second case resulted in a high flow state leading to prolonged penile erection. By the proposed mechanism, hypoxia and acidosis would not occur. The clinical course of PPE of the newborn differs greatly from that of priapism. In most instances, spontaneous detumescence occurs, and therefore observation rather than surgical therapy is advocated.

A 37-year-old man presented with a 7-year history of severe paroxysmal pain in the left index finger. The symptoms were worse in winter and were triggered by trauma and contact with cold water. He was otherwise healthy.On examination, he had a tender lesion, 6 · 4 mm in size, on the lateral aspect of the distal phalanx of the left index finger. The overlying skin seemed normal (Fig. 1a). A radiograph of the affected finger showed a soft-tissue lesion eroding the adjacent bone (Fig. 1b). A globular, encapsulated, greyish white lesion was completely excised under local anaesthesia (Fig. 1c), and the symptoms subsided after surgery.

BackgroundSymptomatic congenital CMV infections are associated with significant complications with mortality rates as high as 12%, frequently with evidence of organ involvement in the reticuloendothelial, CNS and hepatobiliary systems. Congenital CMV with severe pulmonary hypertension is rarely reported in the literature and the optimum treatment in this scenario is unknown.Case ReportA 3 month old female, born to a 22 years old primigravida at 34+ weeks, was admitted with vomiting, diarrhea, dehydration and respiratory distress requiring intubation. Mother's prenatal evaluation was significant for CMV infection diagnosed after amniotic fluid was obtained at 24-26 weeks of pregnancy. Postnatal course was significant for thrombocytopenia, intermittent respiratory distress, FTT, hepatosplenomegaly, elevated transaminases, recurrent diarrhea and vomiting, and pulmonary hypertension diagnosed 3 weeks prior to admission. At birth, urine CMV culture and urine for inclusions were negative. However, because of the clinical findings and prenatal evaluation, diagnosis of congenital CMV was made. Patient received blood transfusion postnatally and was sent home on O2 by nasal canula. On admission, echocardiogram revealed severe pulmonary hypertension. Patient received fluid boluses, 100% oxygen, milrinone, sodium bicarbonate and nitrous oxide. CMV antigenemia revealed 252 positive cells/150,000. Ganciclovir at a dose of 5 mg/kg/qo 12 hours was started on day 4. Open lung biopsy on day 6 revealed grade I vascular changes of pulmonary hypertension, cellular interstitial pneumonitis, chronic peribronchiolitis and adventitial chronic perivasculitis with focal localization of CMV antigen in airspaces and in the media and adventitia of muscular pulmonary arteries on immunohistochemistry stains. IV ganciclovir was given for 6 weeks with improvement in respiratory status and 50 days after hospitalization, CMV antigenemia had decreased to 6 cells/150,000.ConclusionsCongenital CMV infections can be associated with pulmonary hypertension and ganciclovir may be considered for severely symptomatic infants. Larger studies are needed to evaluate the association of pulmonary hypertension with congenital CMV, as well as the appropriate therapy for symptomatic infants.