Spontaneous choledochoduodenal fistula with tuberculous duodenal ulceration

Spontaneous choledochoduodenal fistulas (CDFs) are rare. The most common aetiology is penetrating duodenal ulcers, observed in 80% of cases. Even in areas where acid peptic disease is common, tuberculosis should be considered as a cause, especially in developing countries like India, where tuberculosis is common. The management of CDF due to acid peptic disease is predominantly surgical while healing of tuberculous CDF has been reported with antitubercular treatment. A preoperative diagnosis of tuberculous CDF by endoscopic biopsy from the duodenal ulcer or image guided fine needle aspiration if abdominal lymph nodes are present can eliminate the need for surgery and achieve a cure with antitubercular treatment. The CDF in this case was due to caseation of periduodenal lymph nodes rupturing into the duodenum and the bile duct.

Congenital complete heart block in Klippel-Feil syndrome

A 36-year-old man with a short neck, low hairline, and mild kyphoscoliosis, presented with history of syncope. Chest radiography revealed a diaphragmatic hernia. Computed tomography demonstrated fusion of C2-C6 vertebral bodies, Electrocardiography indicated complete heart block. Ultrasonography showed a right pelvic kidney. He was diagnosed with Klippel-Feil syndrome and underwent permanent pacemaker implantation and corrective surgery for the congenital diaphragmatic hernia.

Jejuno-jejunal intussusception secondary to small-bowel lipomatosis: a case report

Intussusception is usually a disease of children aged between 6 months and 4 years, in which a part of a bowel telescopes into another part of the bowel. We report a case in a 60-year-old man who required resection and anastomosis. Although intussusception is unusual in adults, awareness of the differences in symptoms and causes should be borne in mind when adults present with intestinal obstruction.

Aneurysm of sinus of Valsalva: uncommon presentation

A 28-year-old man presented with acute onset of chest pain. Transthoracic echocardiography confirmed an aneurysm of the sinus of Valsalva dissecting into the interventricular septum. During the next 12 h, the aneurysm enlarged to involve the entire interventricular septum, and the patient developed features of cardiac tamponade. He underwent successful surgical repair.

Gastric teratoma

Gastric teratoma accounts for less than 1% of all teratomas occurring in children, usually males. These tumors may be benign or malignant and complete excision of the tumor in either case carries a good prognosis. This rare case is an addition to the few cases of gastric teratomas in females reported in world literature and presenting as an exophytic & endophytic growth.

Type four fracture of the medial epicondyle: a true indication for surgical intervention

Fourteen consecutive cases with type 4 fracture of the medial epicondyle were evaluated following open reduction and internal fixation of the displaced medial epicondyle. The mean age was 9.7 years (range 6-16) and the mean follow-up was 17.2 months (range 12-24). Operative treatment yielded excellent results with no loss of functional range of motion, residual deformity or instability. There were three cases with pre-operative symptoms of ulnar nerve injury which made a good recovery following neurolysis of the ulnar nerve. Type 4 fractures are commonly associated with intra-articular entrapment of the ulnar nerve and result from serious damage to the soft tissues on the medial side of the elbow. Assessing instability is therefore of key importance, as is the intra-operative gravity stress-valgus test in assessing instability.

Characterization of the biphasic blood pressure response to alpha-methyl-5-hydroxytryptamine in anaesthetized rats

The aim of the present study was to investigate the mechanism of the biphasic blood pressure response to the 5-hydroxytryptamine2 (5-HT2) receptor agonist, alpha-methyl-5-HT (alpha-Me-5-HT) in anaesthetized rats. In conscious rats, 5-HT (2.5-15 micrograms/kg, i.v.) produced typical triphasic blood pressure responses at the higher doses. In anaesthetized rats, 5-HT produced only hypotensive responses at all doses. In conscious rats, i.v. injections of alpha-Me-5-HT (5-125 micrograms/kg) produced dose-dependent increases in mean arterial pressure with concomitant bradycardia. However, in inactin-anaesthetized rats, alpha-Me-5-HT produced biphasic blood pressure responses consisting of an initial pressor response followed by a longer lasting depressor phase. In anaesthetized rats, the 5-HT1A antagonist, spiroxatrine (1 mg/kg), and the 5-HT3 receptor antagonist, MDL72222 (0.3 mg/kg), selectively diminished the hypotensive phase without affecting the pressor phase. The 5-HT1/5-HT2 antagonist, methysergide (0.5 mg/kg), and the selective 5-HT2 antagonist, ketanserin (50 micrograms/kg), completely abolished all responses to alpha-Me-5-HT. Pretreatment with the 5-HT-selective uptake inhibitor, fluoxetine (1 mg/kg), produced a significant attenuation of the hypotensive response whilst enhancing the pressor response. Pretreatment with the 5-HT depletor, p-chlorophenylalanine (3 x 100 mg/kg/day), produced an attenuation of the hypotensive phase while the pressor response was augmented. The selective 5-HT2/5-HT2C agonist, 1-(2,5-dimethoxy-4-iodophenyl)-2- amino-propane (5-200 micrograms/kg, i.v.), produced dose-dependent pressor responses in anaesthetized rats but no hypotensive responses were observed. The results show that the 5-HT2 agonist, alpha-Me-5-HT, produces a biphasic blood pressure response in anaesthetized rats which is not seen in conscious rats. The hypotensive response is due to a nonselective activation of 5-HT1 and 5-HT3 receptors through release of 5-HT.

5-Carboxamidotryptamine attenuates the development of deoxycorticosterone acetate-salt hypertension in rats

The effect of chronic i.v. infusion of the 5-HT1 receptor agonist, 5-carboxamidotryptamine (5-CT), was evaluated during the development of deoxycorticosterone acetate-salt (DOCA-salt) hypertension in rats over 4 weeks. Vehicle-treated (n = 10) Sprague-Dawley rats given DOCA (100 mg/kg, s.c.) and 1% saline as drinking fluid developed hypertension with systolic blood pressure reaching 194.6 +/- 8.99 mm Hg at 27 days. In DOCA-salt rats treated with 5-CT infusions (15.0 micrograms/kg per day, n = 10) for 4 weeks via osmotic minimpumps, systolic blood pressure was significantly lower by 41.7 mm Hg at day 27 when compared to vehicle-treated DOCA-salt rats. Systolic blood pressure values on day 27 in 5-CT-treated DOCA-salt rats were however greater than those in vehicle-treated control rats which were not given DOCA. Systolic blood pressure in 5-CT-treated DOCA-salt rats was significantly lower by day 7 compared to vehicle-treated DOCA-salt rats and remained lowered for the rest of the observation period. Heart rate was significantly greater in 5-CT-treated DOCA-salt rats on day 7 when compared to vehicle-treated DOCA-salt rats. Baroreflex sensitivity on day 28 was significantly greater in 5-CT-treated DOCA-salt rats as compared to vehicle-treated DOCA-salt rats. On day 28, hypotensive responses to hexamethonium (20 mg/kg) in 5-CT-treated DOCA-salt rats were markedly reduced compared to those in vehicle-treated DOCA-salt rats.(ABSTRACT TRUNCATED AT 250 WORDS)

Differences in the chronic hypotensive mechanism of action of ketanserin in spontaneously hypertensive and Wistar-Kyoto rats

OBJECTIVE

To investigate the hypotensive effect and mechanism of action of chronic administration of ketanserin in spontaneously hypertensive rats (SHR) and in normotensive Wistar-Kyoto (WKY) rats.

METHODS AND RESULTS

SHR and WKY rats were given chronic ketanserin infusions via osmotic minipumps to minimize fluctuations in drug concentrations and receptor responsiveness. In SHR treated with intravenous infusions of 3.0 (n = 9) or 6.0 mg/kg per day (n = 8) ketanserin for 7 days, significant dose-dependent falls in systolic blood pressure (SBP) were observed during the infusion period. Heart rate did not change in either the vehicle- or the ketanserin-treated groups of SHR. In WKY rats intravenously infused with 3.0 (n = 9) or 6.0 mg/kg per day (n = 10) ketanserin, dose-dependent falls in SBP were also observed during the infusion period, with the changes reaching statistical significance at the 6.0 mg/kg per day dose. The changes in heart rate were not different from those in control rats. Pressor responses to the type 2 5-hydroxytryptamine (5HT2)-receptor agonist (+/-)-alpha-methyl-5-hydroxytryptamine (5.0-125.0 micrograms/kg), as assessed on day 7, were reduced dose-dependently in all ketanserin-infused rats. alpha 1-Adrenoceptor responses to 1.0-10.0 micrograms/kg intravenous phenylephrine were attenuated in only the WKY rats infused with 6.0 mg/kg per day ketanserin. In the SHR treated with ketanserin there was no change in the pressor responsiveness to phenylephrine. Baroreflex sensitivity on day 7 was significantly greater in the ketanserin-infused SHR than in their respective controls. Changes in baroreflex sensitivity were not significantly different in WKY rats following ketanserin infusion.

CONCLUSIONS

These results show that chronic administration of ketanserin lowers blood pressure in both SHR and WKY rats. In SHR the alpha 1-adrenoceptor-blocking effects of ketanserin are compensated for, and the reduction in blood pressure by day 7 is maintained predominantly by, 5HT2-receptor blockade. In WKY rats ketanserin-induced hypotension is associated with concomitant blockade of 5HT2- and alpha 1-receptors. The present study therefore suggests a differential mechanism of action of ketanserin in hypertensive and normotensive rats during chronic treatment.

Antihypertensive effect of chronic i.v. administration of 5-carboxamidotryptamine in spontaneously hypertensive rats

The effects of chronic i.v. administration of the serotonin 5-HT1 receptor agonist, 5-carboxamidotryptamine (5-CT), on blood pressure (BP), heart rate (HR) and baroreflex sensitivity were studied in Wistar-Kyoto (WKY) and spontaneously hypertensive rats (SHR). Acute i.v. injection of increasing doses of 5-CT resulted in a dose-dependent reduction in mean arterial pressure (MAP) in SHR and WKY with concomitant tachycardia. In chronic experiments, 5-CT (15.0 micrograms/kg per day) or vehicle (24.0 microliters/day) was infused i.v. for 7 days, using osmotic minipumps. Systolic blood pressure (SBP) and HR were monitored daily before and during infusions. In SHR (n = 8) and WKY rats (n = 9) receiving 5-CT, a significant reduction in SBP was observed during the infusion period. HR was slightly increased in WKY rats on days 1 and 2. There were no HR changes in the SHR group. The fall in SBP was significantly larger in the SHR than in the WKY rats. Baroreflex sensitivity on day 7 was significantly greater in 5-CT-treated SHR than in control rats. There was no change in baroreflex sensitivity in WKY rats. Administration of a single dose of 5-CT (0.5 microgram/kg i.v.) on day 7 of infusion resulted in attenuated responses in WKY rats while SHR responded as their respective controls. Our data suggest that chronic administration of 5-CT results in a sustained antihypertensive effect. This is associated with an improved BRS in the SHR either as a consequence of a resetting of the baroreflex due to sustained lowering of BP or a direct action of 5-CT on baroreflex sensitivity.(ABSTRACT TRUNCATED AT 250 WORDS)

Differences in the acute and chronic antihypertensive mechanism of action of ketanserin in spontaneously hypertensive rats

The antihypertensive mode of action of the 5HT2 receptor antagonist, ketanserin (KET), is still a subject of controversy and has been evaluated predominantly in acute studies. Acute i.v. administration of KET (3.0 or 6.0 mg/kg) in spontaneously hypertensive rats resulted in dose-dependent reductions in mean arterial pressure accompanied by concomitant bradycardia. In these studies, the responses to single i.v. doses of the alpha-1 adrenoceptor agonist phenylephrine (10.0 micrograms/kg) and to the 5HT2 receptor agonist alpha-methyl-5-hydroxytryptamine (125.0 micrograms/kg) 30 min after injection of KET were blocked. In spontaneously hypertensive rats treated with KET infusions (3.0 mg/kg/day i.v., n = 9, or 6.0 mg/kg/day i.v., n = 8) for 7 days via osmotic minipumps, significant dose-dependent falls in systolic blood pressure were observed during the period of infusion. Heart rate did not change over the period of observation in both vehicle- and KET-treated groups. On day 7 of infusion, KET dose-dependently reduced responses to the 5HT2 agonist alpha-methyl-5-hydroxytryptamine (5.0-125.0 micrograms/kg i.v.) but did not affect responses to phenylephrine (1.0-10.0 micrograms/kg i.v.). Baroreflex sensitivity on day 7 was significantly greater in KET-infused rats as compared with control rats. These data confirm that the acute antihypertensive effects of KET are due to a combination of alpha-1 and 5HT2 receptor blockade. During chronic administration, however, the alpha-1 blocking effects of KET are compensated for, and the reduction in blood pressure by day 7 of KET chronic administration is maintained predominantly by persistent blockade of 5HT2 receptors.

Osteosarcoma of the craniofacial bones. A clinico-pathological study

Thirty-four cases of osteosarcoma involving the craniofacial bones over a period of 19 years were reviewed. They formed 6.2% of osteosarcomas occurring in the skeleton during the same period at the Tata Memorial Hospital. Mean age of occurrence was 30.9% years, with a range of 7 to 61 years. Male preponderance was noted in maxillary tumours (M:F = 2.6:1), while the mandibular tumours occurred with equal frequency in both sexes. The mandible was the bone of origin in 56%, maxilla in 32% and other craniofacial bones in 12% of patients. Histological sub-type did not affect the prognosis. Radical surgery with resection of adequate disease-free margins is the most effective mode of treatment. Morbidity and mortality is due to extensive local recurrence of disease, particularly with maxillary tumours. Metastasis to other organs occurs rarely. No statistically significant difference in survival was observed between tumours of the mandible and maxilla, or between patients above and below 20 years of age.