Congenital Pyloric Atresia: Experience with a Series of 11 Cases and Collective Review.

INTRODUCTION: Pyloric atresia is a rare cause of congenital gastric outlet obstruction. It is often associated with epidermolysis bullosa (EB). Rarity and experience with 11 cases are the reason for this publication. AIMS AND OBJECTIVES: The aim and objective of this study is to present our experience of 11 cases of congenital pyloric atresia and correlate with available literature. MATERIALS AND METHODS: This was retrospective cohort of 11 cases correlative comparative study. Data of all the 11 cases from 1982 to 2019 were collected, reviewed, and analyzed. The parameters studied included age, gender, antenatal diagnosis, postnatal diagnosis, preoperative management, intraoperative findings, postoperative course outcome, associated anomalies, and any genetic studies if done. All these parameters were compared with published data. RESULTS: There were 11 cases in the present series with six boys and five girls. Most of them presented at varying periods from birth to day 1 of life. DISCUSSION: Congenital pyloric atresia may be isolated or associated with EB. Three varieties of pyloric atresia were described. Association with EB increases the mortality. CONCLUSIONS: Review and analysis of 11 cases of pyloric atresia compared with published literature is being reported.

Predictors of Mortality in Neonatal Pneumonia: An INCLEN Childhood Pneumonia Study.

BACKGROUND: Neonatal pneumonia contributes significantly to mortality due to pneumonia in the under-five age group, but the predictors of mortality are largely unknown. OBJECTIVES: To evaluate the clinical and microbiological characteristics and other risk factors that predict mortality in neonates admitted with pneumonia in tertiary care centres. STUDY DESIGN: Prospective observational cohort study. PARTICIPANTS: Term and preterm (32 weeks to 36 6/7 weeks) neonates (<28 days of life) admitted with clinical and radiological features suggestive of pneumonia. INTERVENTION: Baseline sociodemographic data, clinical details, blood culture and nasopharyngeal swabs for virologic assay (RT PCR for RSV, Influenza) were collected at admission and the neonates were observed throughout their hospital stay. OUTCOME: The primary outcome was predictors of mortality in neonatal pneumonia. RESULTS: Five hundred neonates were enrolled in the study. Out of 476 neonates with known outcomes, 39 (8.2%) died. On multivariate analysis, blood culture positive sepsis was independently associated with mortality (adjusted OR 2.51, 95% CI1.23 to 5.11; P-0.01). CONCLUSIONS: Neonates with blood culture positive pneumonia positive are at a higher risk of death.

"Neo-PIRO": Introducing a Novel Grading System for Surgical Infections of Neonates.

INTRODUCTION: Quantification of surgical sepsis was never done beyond superficial, subfascial, and deep surgical site infection (SSI). Invasive surgical sepsis with systemic manifestation has not been tried to be quantified in general and pediatric surgery in particular. Hence, this attempts to develop a novel grading system to quantify neonatal surgical infections. MATERIALS AND METHODS: Predisposing factors, infection, response, and organ failure (PIRO) is being used in critical care institutions for medical sepsis; it was modified with neonate-specific surgical parameters. Authors have developed a grading of these parameters into Grade I, II, and III. RESULTS: A blinded statistical test was performed and results were put to test. Extended Mantel-Haenszel Chi-square test validated linear relationship with grade and outcome, hospital stay, deep SSI, and organ dysfunction. Analysis of variance also showed the significant relationship of changing trends in grade and outcome. (1) Higher the grade indicated the probability of death. (2) Grade I patients had less duration of hospital stay compared to Grade II and III (P = 0.04). (3) The requirement of organ support and SSI were also more in Grade III. (4) Grade I patients had less increase in trends compared to Grade II and III (F = 4.86). Authors therefore feel Neo-PIRO seems to be the first scoring system that shows a linear relationship between scores and grade. CONCLUSION: Neo-PIRO is a novel grading system with surgical neonate-specific parameters. Future versions to include molecular parameters, as well as parameters selected by regression analysis.

The Role of Routine Measurement of Intra-abdominal Pressure in Preventing Abdominal Compartment Syndrome.

INTRODUCTION: Abdomen, a closed compartment, is prone to raised intra-abdominal pressure (IAP) in the postoperative period. After a critical value of ≥ 15 cm of water, IAP produces abdominal compartment syndrome (ACS). ACS leads to reduced venous return, reduced cardiac output, and domino effect of organ dysfunction, leading to death. Hence, it is the need of hour to monitor IAP to pick up intra-abdominal hypertension (IAH) and ACS. This routine facilitates early institution of treatment measures. AIMS AND OBJECTIVES: To study IAP in abdominal operations in neonates, infants, and older children and to promote concept of routine measurement of IAP as standard care. MATERIALS AND METHODS: Intravesical route was used to measure IAP in this prospective observational study. Seventy-nine pediatric abdominal surgeries met with criteria of availability of complete data for analysis and formed the cohort of the study. All major, infective, traumatic, tumor-related abdominal surgeries were included in the study. Outcome, C-reactive protein (CRP), procalcitonin, platelet counts, Simplified Sequential Organ Failure Assessment Score, and Acute Physiology and Chronic Health Evaluation II (APACHE II) score were the parameters analyzed. The World Society of ACS grading was adopted in the study with subdivision of normal into low-normal and high-normal subgroups. RESULTS: Extended Mantel-Haenszel Chi-square statistical tool when applied for linear relationship showed a linear relationship with outcome (P < 0.05), CRP (P < 0.05), procalcitonin (P < 0.05), Simplified Sequential organ failure Assessment Score, and APACHE II. Platelet counts (P > 0.05) were not significantly correlated. Decision for laparotomy was delayed in cases of ACS. CONCLUSION: Routine measure of IAP facilitates early recognition of IAH. This facilitates therapeutic measures to be initiated to reduce IAP. Early decision to decompress by laparotomy/laparostomy saves lives. Hence, routine IAP measurement should be a part of standard care in pediatric abdominal surgery.

Highly sensitive UHPLC-MS/MS method for the simultaneous estimation of propafenone and its metabolites 5-hydroxypropafenone and N-depropylpropafenone on human dried blood spots technique and application to a pharmacokinetic study.

A highly sensitive, rapid and selective UHPLC-MS/MS method has been developed and validated for quantification of the propafenone (PF), 5-hydroxypropafenone (5-OHPF) and N-depropylpropafenone (N-DPF) on human dried blood spot (DBS). The assay procedure involves a solid-liquid extraction of PF, 5-OHPF and N-DPF and amlodipine (internal standard, I.S.) from dried human DBS cards using water and acetonitrile. The chromatographic resolution was achieved on a BEH C18 column using a gradient mobile phase consisting of 0.1% formic acid in water and acetonitrile with 0.1% formic acid at flow rate of 0.6mL/min. The UHPLC-MS/MS was operated under the multiple-reaction monitoring mode using electrospray ionization. Total run time of analysis was 1.1min and elution of PF, 5-OHPF, N-DPF and I.S. occurred at 0.69, 0.6, 0.68 and 0.73min, respectively. A detailed method validation was performed as per the regulatory guidelines and the standard curves found to be linear in the range of 5.11-1000ng/mL for PF and 5-OHPF and 0.51-100ng/mL for N-DPF with a correlation coefficient of ≥0.99 for all the drugs. The intra- and inter-day accuracies were in the range of 95.6-107 and 93.5-103; 93.4-106 and 96.3-107 and 87.9-103 and 96.5-102%, for PF, 5-OHPF and N-DPF, respectively. The intra- and inter-day precisions were in the range of 2.50-5.52 and 3.38-5.18; 2.16-6.34 and 3.23-4.94 and 2.63-7.55 and 1.56-10.2%, for PF, 5-OHPF and N-DPF, respectively. The validated assay method was successfully applied to a pharmacokinetic study in humans. The key pharmacokinetic parameters AUC0-∞ and Cmax were 6057±1526, 2002±515 and 525±202 ng*h/mL and 653±183, 295±37.5 and 68.4±13.6ng/mL for PF, 5-OHPF and N-DPF, respectively.

UPLC-MS/MS method for determination of sofosbuvir in human plasma.

INTRODUCTION: A sensitive and rapid method for quantitation of Sofosbuvir in human plasma has been established using ultra performance liquid chromatography-electrospray ionization tandem mass spectrometry (UPLC-ESI-MS/MS). MATERIALS AND METHODS: Sofosbuvir d3 was used as an internal standard. Sofosbuvir and internal standard in plasma sample were extracted using ethyl acetate (liquid liquid extraction). A centrifuged upper layer was then evaporated and reconstituted with the mobile phase of 0.5% formic acid: methanol (30:70, v/v). The reconstituted samples were injected into a Gemini C18 (50×4.6mm, 5µm) column. RESULTS: Using MS/MS in the multiple reaction monitoring mode, Sofosbuvir and Sofosbuvir d3 were detected without severe interferences from human plasma matrix. Sofosbuvir produced a protonated precursor ion ([M+H]+) at m/z 428.35 and a corresponding product ion at m/z 279.26. The internal standard produced a protonated precursor ion ([M+H]+) at m/z 431.38 and a corresponding product ion at m/z 282.37. The calibration curves for the analyte was linear (R2≥0.9956, n=4) over the concentration range of 4.063-8000.010ng/mL. Stability studies revealed that Sofosbuvir was stable in plasma during bench top (7h at room temperature), in injector (20h), at the end of five successive freeze and thaw cycles and long term at -70°C±15°C for 15 days. CONCLUSION: The developed method was validated as per the guidelines of USFDA and the obtained results were found to be within the limits and could be successfully employed for the determination of Sofosbuvir in human plasma for regular and pharmacokinetic studies.

Elucidating pharmacodynamic interaction of silver nanoparticle - topical deliverable antibiotics.

In order to exploit the potential benefits of antimicrobial combination therapy, we need a better understanding of the circumstances under which pharmacodynamic interactions expected. In this study, Pharmacodynamic interactions between silver nanoparticle (SNP) and topical antibiotics such as Cefazolin (CEF), Mupirocin (MUP), Gentamycin (GEN), Neomycin (NEO), Tetracycline (TET), Vancomycin (VAN) were investigated using the MIC test, Combination assay followed by Fractional Inhibitory concentration Index and Agar well diffusion method. SNP + MUP, SNP + NEO, SNP + VAN combinations showed Synergism (SN) and SNP + CEF, SNP + GEN, SNP + TET showed Partial synergism (PS) against Staphylococcus aureus. Four combinations (SNP + CEF, SNP + MUP, SNP + GEN, SNP + VAN) showed SN, SNP + TET showed PS and Indifferent effect (ID) were observed for SNP + NEO against Pseudomonas aeruginosa. SN was observed for SNP + CEF, SNP + GEN, SNP + NEO, SNP + TET and SNP + MUP showed ID, SNP + VAN showed PS against Escherichia coli. In addition, we elucidated the possible mechanism involved in the pharmacodynamic interaction between SNP-topical antibiotics by increased ROS level, membrane damage following protein release, K(+) leakage and biofilm inhibition. Thus, our findings support that conjugation of the SNP with topical antibiotics have great potential in the topical formulation when treating complex resistant bacterial infections and where there is a need of more concentration to kill pathogenic bacteria.

New Validated Stability-Indicating Rp-HPLC Method for Simultaneous Estimation of Atorvastatin and Ezetimibe in Human Plasma by Using PDA Detector.

PURPOSE: This paper describes a simple, precise and accurate RP-HPLC method for simultaneous estimation of atorvastatin and ezetimibe in plasma. METHODS: The chromatographic separation of the drugs were performed on an X-Terra C8 (4.6 x 150 mm, 3.5 mm), with phosphate buffer [pH 3.5 with Ortho Phosphoric Acid] - acetonitrile 40:60 (v/v) as mobile phase. The detection was performed at 235 nm. The flow rate was maintained at 1.2 mL/min. The run time was 8.0 min. RESULTS: The accuracy and reliability of the method was assessed by evaluation of linearity (5-25 µg/mL for both atorvastatin calcium and ezetimibe), precision (intra-day RSD 0.57 % and inter-day RSD 0.02 % for atorvastatin calcium and intra-day RSD 0.56 % and inter-day RSD 0.1 % for ezetimibe), accuracy (100.08- 100.84 % for atorvastatin calcium and 100.56- 101.00 % for ezetimibe), and specificity, in accordance with ICH guidelines. The LLOQ obtained by the proposed method were 1.294 and 1.384 µg/mL for atorvastatin and ezetimibe respectively. CONCLUSION: Overall the proposed method was found to be suitable and accurate for the quantitative determination in plasma. The method was effectively separated the drug from plasma.

Malrotation of midgut in adults, an unsuspected and neglected condition--An analysis of 64 consensus confirmed cases.

INTRODUCTION: Malrotation of midgut is considered to be a condition of childhood. This study evaluated malrotation in adults with recurrent abdominal pain (RAP). METHODS: Sixty-four consensus-confirmed cases of intestinal malrotation were reviewed. The diagnosis was based on radiological criteria, and the consensus was arrived at by at least three of the five authors in any individual case. RESULTS: Abnormal duodenojejunal junction (DJJ) was a consensus finding in 64 cases referred for RAP. Most were in their fourth decade of life, and 12 were beyond 60 years. Besides RAP, intolerance to food was the next common symptom. Acute intestinal obstruction was seen in 16. Forty-two of 64 patients consented for surgery. Ladd's procedure was the commonest. All patients who underwent surgery were symptom free except for two, of which, one had liver cyst and the other had hernia. Of those who refused surgery (22), all had continued symptoms and 10 patients took alternative therapies. On follow up of initially unwilling patients (for surgery) with abnormal DJJ, only eight consented for surgery; three underwent open Ladd's procedure, and one had laparoscopic Ladd's done. CONCLUSION: Malrotation is not uncommon as a cause of RAP in adults.

A multicenter prospective hospital-based surveillance to estimate the burden of rotavirus gastroenteritis in children less than five years of age in India.

BACKGROUND: Rotavirus is the leading cause of severe, dehydrating diarrhea in children aged <5 years globally, with an estimated 25 million outpatient visits and 2 million hospitalizations attributable to rotavirus infections each year. The aim of this hospital-based surveillance was to summarize the local epidemiological and virological features of rotavirus and to estimate the disease burden in the population under surveillance in India. METHODS: During the 16 months surveillance period from April 2011 through July 2012, a total of 4711 children under the age of 5 years were admitted with acute diarrhea at 12 medical centers attached to medical schools throughout India. Stool samples were randomly collected from 2051 (43.5%) subjects and were analyzed for rotavirus positivity using commercial enzyme immunoassay kit (Premier Rotaclone Qualitative Elisa) at the respective study centers. Rotavirus positive samples were genotyped for VP7 and VP4 by reverse-transcription polymerase chain reaction (RT-PCR) at a central laboratory. RESULTS: During the study period, maximum number of rotavirus related hospitalizations were reported from December 2011 through February 2012. Out of the 2051 stool samples tested for rotavirus, overall 541 (26.4%) samples were positive for rotavirus VP6 antigen in stool. The highest positivity was observed in the month of December, 2011 (52.5%) and lowest in the month of May, 2011 (10.3%). We found that majority of the rotavirus positive cases (69.7%) were in children <24 months of age. The most common genotypes reported were G1 (38%), G2 (18%), G9 (18%), G12 (9%) and mixed strains (17%). CONCLUSIONS: The results of this study confirm the significant burden of acute rotavirus gastroenteritis as a cause of hospitalizations in under five children in India.

New Validated RP-HPLC Analytical Method for Simultaneous Estimation of Atorvastatin and Ezetimibe in Bulk Samples as Well in Tablet Dosage Forms by Using PDA Detector.

This paper describes a new RP-HPLC method for simultaneous quantification of these compounds in the bulk sample drug as well as in tablet dosage forms. The chromatographic separation was performed on an XTerra C8 (4.6 x 250 mm; 5 µm), with phosphate buffer [pH 3.5] and acetonitrile in the ratio of 40:60 (v/v) as mobile phase. The detection was carried out at 240 nm. The accuracy was found to be 99.59% and 98.98% for atorvastatin and ezetimibe respectively. The linearity was 5-25 µg/ml for both the drugs. The intra-day RSD was 0.57% and inter-day RSD was 0.13% for atorvastatin calcium and intra-day RSD was 0.56% and inter-day RSD was 0.09% for ezetimibe. The validation of method was carried out utilizing ICH-guidelines.

Liquid chromatography-tandem mass spectrometric assay for the light sensitive calcium channel antagonist lacidipine in human plasma.

A novel, rapid and sensitive liquid chromatography/tandem mass spectrometry method was developed and validated for the quantification of calcium channel antagonist lacidipine in human plasma. Carbamazepine was used as an internal standard. Analyte and the internal standard were extracted from human plasma by solid-phase extraction technique. The reconstituted samples were chromatographed on a C(18) column by using a mixture of acetonitrile-ammonium acetate buffer (5 mM) (80:20, v/v) as the mobile phase at a flow rate of 1.0 mL/min. The calibration curve obtained was linear (r(2)≥0.9990) over the concentration range of 0.05-12.5 ng/mL. The multiple reaction-monitoring mode was used for quantification of ion transitions at m/z 456.2/354.2 and 237.1/194.1 for the drug and the internal standard, respectively. The results of the intra- and inter-day precision and accuracy studies were well within the acceptable limits. A run time of 2.2 min for each sample made it possible to analyze more than 300 plasma samples per day. The proposed method was found to be applicable to clinical studies.

A rapid and sensitive liquid chromatography-tandem mass spectrometric assay for moexipril, an angiotensin-converting enzyme inhibitor in human plasma.

A simple, rapid and sensitive liquid chromatography/tandem mass spectrometry method was developed and validated for the quantification of angiotensin-converting enzyme inhibitor, moexipril, in human plasma. Benazepril was used as an internal standard (IS). Analyte and IS were extracted from the human plasma by liquid-liquid extraction technique using ethyl acetate. The reconstituted samples were chromatographed on a C18 column by using a mixture of methanol and 0.1% formic acid buffer (85:15, v/v) as the mobile phase at a flow rate of 0.5 mL/min. The calibration curve obtained was linear (r ≥ 0.99) over the concentration range of 0.2-204 ng/mL. The multiple reaction-monitoring mode was used for quantification of ion transitions at m/z 499.4/234.2 and 425.2/351.1 for moexipril and IS, respectively. The results of the intra- and inter-day precision and accuracy studies were well within the acceptable limits. A run time of 2.0 min for each sample made it possible to analyze more than 400 plasma samples per day. The proposed method was found to be applicable to clinical studies.

Simultaneous determination of simvastatin, lovastatin and niacin in human plasma by LC-MS/MS and its application to a human pharmacokinetic study.

A simple, sensitive and specific LC-MS/MS method for simultaneous determination of simvastatin (SV), lovastatin (LV) and niacin (NIA) in human plasma was developed and validated on API-4000 in positive ion mode. Nevirapine was used as internal standard (IS). The assay procedure involved a simple one-step liquid-liquid extraction of SV, LV, NIA and the IS from plasma into ethyl acetate. Separation of SV, LV, NIA and the IS was achieved on an Alltima C18 column with a mobile phase consisting of 5 mm ammonium acetate (pH 4.5) and acetonitrile (20:80, v/v) pumped at a flow rate of 1 mL/min. Nominal retention times obtained for SV, LV, NIA and IS were 2.12, 1.67, 0.50 and 0.65 min, respectively. The lower limits of quantification (LLOQ) for SV, LV and NIA were 0.10, 0.10 and 25.2 ng/mL, respectively. The response function was established for the range of concentrations 0.10-101 ng/mL for SV and LV, and 25.2-5020 ng/mL for NIA, with a coefficient of correlation of >0.99 for all the compounds. Method validation was performed as per FDA guidelines and the results met the acceptance criteria. The proposed method was found to be applicable to clinical studies.

Simultaneous determination of pioglitazone and candesartan in human plasma by LC-MS/MS and its application to a human pharmacokinetic study.

A simple and rapid liquid chromatography-tandem mass spectrometric (LC-MS/MS) assay method has been developed and fully validated for simultaneous quantification of pioglitazone and candesartan in human plasma. Irbesartan was used as an internal standard. The analytes were extracted from human plasma samples by solid-phase extraction technique using a Strata-X 33 µm polymeric sorbent. The reconstituted samples were chromatographed on a C18 column by using a 80:20 (v/v) mixture of acetonitrile and 0.1% formic acid as the mobile phase at a flow rate of 0.8 mL/min. The calibration curves obtained were linear (r≥0.99) over the concentration range of 15-3000 ng/mL for pioglitazone and 5-608 ng/mL for candesartan. The results of the intra- and inter-day precision and accuracy studies were well within the acceptable limits. A run time of 2.7 min for each sample made it possible to analyze more than 300 plasma samples per day. The proposed method was found to be applicable to clinical studies.