Dilpesh Agrawal

Higher infliximab trough levels are associated with perianal fistula healing in patients with Crohn's disease

Infliximab has been found to be efficacious in the treatment of fistulas in the setting of Crohns disease, even though some patients do not benefit from therapy.

Pharyngeal Peristaltic Pressure Variability, Operational Range and functional Reserve

The present understanding of pharyngeal motor function remains incomplete. Among the remaining gaps of knowledge in this regard is the magnitude of variability of pharyngeal peristaltic pressure amplitude. Although variability can pose difficulty in interpretation of manometric findings, its magnitude can inform the operational range and reserve of the pharyngeal contractile function. We aimed to define the intra- and intersubject and intersession variability of select pharyngeal manometric parameters and, using this information, determine the number of swallow repetitions for acquiring reliable pharyngeal manometric data. We recorded pharyngeal peristalsis in 10 healthy subjects (age: 50 ± 25 yr, 5 women) by high-resolution manometry during two separate sessions of 20 sequences of 0.5-ml water swallows. Two-way ANOVA showed significant variation in the mean peak peristaltic pressure value across sites (P < 0.0001) as well as within the data at each site (P < 0.0001). Similarly, the pharyngeal contractile integral exhibited significant inter- (P = 0.003) and intrasubject (P < 0.001) variability. The Shapiro-Wilk normality test showed mixed results, in that some sites showed normally distributed data, whereas others did not. A robust Monte Carlo simulation showed that the nominal sample size was different for various tested metrics. For a power of 0.8, commonly accepted as an adequate threshold for acceptable statistical power, the optimal sample size for various peristaltic parameters ranged between 3 and 15. There is significant intra- and intersubject variability in site-specific and integrated parameters of pharyngeal peristalsis. The observed variance indicates a significant operational range and reserve in pharyngeal contractile function while necessitating parameter-specific sample size for reliable results.NEW & NOTEWORTHY Intra- and intersubject variability are significant and different at various sites within the contractile pharynx. In addition, significant swallow-to-swallow and subject-to-subject variability exists in pharyngeal contractile integral. The range of intrasubject variability indicates the existence of broad operational range and reserve. Lastly, our variability studies informed Monte Carlo and power analyses, yielding estimates of sample size that would ensure accurate representation of pressure metric variability.

Portal annular pancreas: the pancreatic duct ring sign on MRCP

Portal annular pancreas is a rare pancreatic variant in which the uncinate process of the pancreas extends and fuses to the dorsal surface of the body of the pancreas by surrounding the portal vein. It is asymptomatic, but it can be mistaken for a pancreatic head mass on imaging and could also have serious consequences during pancreatic surgery, if unrecognized. We report this case of a 53-year-old female patient who was diagnosed to have portal annular pancreas on the basis of an unusual course (ring appearance) of the main pancreatic duct on magnetic resonance cholangiopancreatography, not described earlier in the radiology literature.

Tu1282 Azothioprine or 6-Mercaptopurnine Dose Does Not Effect Serum Infliximab Level or Rate of Antibody to Infliximab Formation

Background: Combined immunomodulator (IMM) and biologic therapy is superior to either therapy alone in inflammatory bowel disease (IBD) patients. This is thought to be a result of increased serum infliximab (IFX) level and decreased rates of antibody to infliximab (ATI) formation in combination therapy patients. A previous study did not show an association of IMM dose to serum IFX levels or ATI formation; rather only 6 TG levels were predictive of IFX levels and ATI formation. Our aim was to determine if IMM dose influenced IFX level and ATI formation in a larger IBD cohort. Methods: This was a retrospective analysis at a single tertiary care IBD center. Patients with a history of IFX use for IBD who had serum IFX levels tested using Prometheus serum IFX/ATI assay were included in the study. Demographic information, disease type, SIBDQ score, IBD activity score, IBD duration to PROMETHEUS date, IFX duration, IMM type, IMM daily dose, IMM mg/kg dose, and albumin closest to IFX test were recorded. Serum IFX levels did not follow a normal distribution so data was divided into quartiles for analysis: low/undetected IFX 19.55 ug/mL. Results: Overall, 269 patients were included. There was no significant difference in demographic or disease characteristics between serum IFX quartiles (table 1). There were 99 AZA/6MP users with average weight-based dose 0.95 mg/kg (range 0.2-2.4 mg/kg). The low/undetectable IFX quartile had a larger percentage of patients not using IMMs, compared to other quartiles (p=0.01). AZA/6MP users were in higher proportion in therapeutic and high/medium high groups than in low/undetected group (p=0.05). Also, MTX users were in a greater proportion in higher IFX level quartiles (p=0.04). There was no difference in AZA/6MP daily dose or weight based (mg/kg) dose between quartiles (p=0.49 and p=0.73). Regression analysis of AZA dose showed no correlation with serum infliximab levels (p= 0.88). Patients on any dose of IMM were less likely to develop ATI than patients not on IMM (10 % vs. 24%; p=0.03). The greatest proportion of patients with ATI were in the low/undetectable IFX quartile (p =0.001). Serum albumin levels were similar among serum IFX level quartiles (p=0.07) but showed a very weak correlation with serum IFX levels (cor= 0.13, p=0.048) (table 2). Conclusions: Our study found that IBD patients on any dose of IMM are less likely to have a low serum IFX level or develop ATI than those not on IMM therapy. Our trial confirms a prior studys results that IMM dose does not affect IFX level or ATI formation rates. These findings suggest that even low dose concomitant IMM therapy may be effective at maintaining adequate serum IFX levels and preventing ATI development. Table 1

Swallow strength training exercise for elderly: A health maintenance need

Recent studies have shown high prevalence of oropharyngeal dysphagia associated with frailty‐ and age‐related muscle weakness. Strength training exercises have been advocated for locomotive health maintenance in the elderly and have shown positive outcomes. As muscles involved in oropharyngeal phase of swallowing are also comprised of striated muscles, the aim of this study was to determine biomechanical effect of a novel resistance exercise program, Swallowing Against Laryngeal Restriction (SALR), on pharyngeal phase swallowing in the healthy elderly.