Reduction in mortality from HIV-related CNS infections in routine care in Africa (DREAMM): a before-and-after, implementation study

BACKGROUND

Four decades into the HIV epidemic, CNS infection remains a leading cause of preventable HIV-related deaths in routine care. The Driving Reduced AIDS-associated Meningo-encephalitis Mortality (DREAMM) project aimed to develop, implement, and evaluate pragmatic implementation interventions and strategies to reduce mortality from HIV-related CNS infection.

METHODS

DREAMM took place in five public hospitals in Cameroon, Malawi, and Tanzania. The main intervention was a stepwise algorithm for HIV-related CNS infections including bedside rapid diagnostic testing and implementation of WHO cryptococcal meningitis guidelines. A health system strengthening approach for hospitals was adopted to deliver quality care through a co-designed education programme, optimised clinical and laboratory pathways, and communities of practice. DREAMM was led and driven by local leadership and divided into three phases: observation (including situational analyses of routine care), training, and implementation. Consecutive adults (aged ≥18 years) living with HIV presenting with a first episode of suspected CNS infection were eligible for recruitment. The primary endpoint was the comparison of 2-week all-cause mortality between observation and implementation phases. This study completed follow-up in September, 2021. The project was registered on ClinicalTrials.gov, NCT03226379.

FINDINGS

From November, 2016 to April, 2019, 139 eligible participants were enrolled in the observation phase. From Jan 9, 2018, to March 25, 2021, 362 participants were enrolled into the implementation phase. 216 (76%) of 286 participants had advanced HIV disease (209 participants had missing CD4 cell count), and 340 (69%) of 494 participants had exposure to antiretroviral therapy (ART; one participant had missing ART data). In the implementation phase 269 (76%) of 356 participants had a probable CNS infection, 203 (76%) of whom received a confirmed microbiological or radiological diagnosis of CNS infection using existing diagnostic tests and medicines. 63 (49%) of 129 participants died at 2 weeks in the observation phase compared with 63 (24%) of 266 in the implementation phase; and all-cause mortality was lower in the implementation phase when adjusted for site, sex, age, ART exposure (adjusted risk difference -23%, 95% CI -33 to -13; p<0·001). At 10 weeks, 71 (55%) died in the observation phase compared with 103 (39%) in the implementation phase (-13%, -24 to -3; p=0·01).

INTERPRETATION

DREAMM substantially reduced mortality from HIV-associated CNS infection in resource-limited settings in Africa. DREAMM scale-up is urgently required to reduce deaths in public hospitals and help meet Sustainable Development Goals.

FUNDING

European and Developing Countries Clinical Trials Partnership, French Agency for Research on AIDS and Viral Hepatitis.

TRANSLATIONS

For the French and Portuguese translations of the abstract see Supplementary Materials section.

Vaccine safety surveillance in Kenya using GAIA standards: A feasibility assessment of existing national and subnational research and program systems

BACKGROUND

Active surveillance systems for monitoring vaccine safety among pregnant women address some of the limitations of a current passive surveillance approach utilized in low- and middle-income countries (LMIC). However, few active surveillance systems in LMIC exist. Our study assessed the feasibility of utilizing three existing data collection systems in Kenya for active surveillance of maternal immunization and to assess the applicability of Global Alignment of Immunization Safety Assessment in pregnancy (GAIA) case definitions that were initially developed for clinical trials within these systems.

METHODS

We assessed applicability of GAIA case definition for maternal Tetanus Toxoid exposure, stillbirth, low birth weight, small for gestational age, Neonatal Invasive Blood Stream Infection (NIBSI), prematurity and neonatal death in two routine web-based health information systems (Kenya EMR and DHIS-2), and a web-based population-based pregnancy research platform (ANCOV1) in Kenya.

RESULTS

All three HIS were capable of reporting selected outcomes to varying degrees of GAIA certainty. The ANCOV platform was the most robust in collecting and collating clinical data for effective maternal pharmacovigilance. The utilization of facility- and district-aggregated data limits the usefulness of DHIS-2 in pharmacovigilance as currently operationalized. While the Kenya EMR contained individual level data and meets the key considerations for effective pharmacovigilance, it was used primarily for HIV care and treatment records in a small proportion of health facilities and would require additional resources to expand to all antenatal care facilities and to link maternal and infant records.

DISCUSSION

Population-based research studies may offer a responsive short-term option for implementing maternal vaccine pharmacovigilance in LMICs. However, the foundation exists for long-term capacity building within the national health electronic data systems to provide this critical service as well as ensure participation of the country in international studies on maternal vaccine safety.

COVID-19 in Multiple Sclerosis: Clinically reported outcomes from the UK Multiple Sclerosis Register

BACKGROUND

In March 2020, the United Kingdom Multiple Sclerosis Register (UKMSR) established an electronic case return form, designed collaboratively by MS neurologists, to record data about COVID-19 infections in people with MS (pwMS).

OBJECTIVES

Examine how hospital admission and mortality are affected by disability, age and disease modifying treatments (DMTs) in people with Multiple Sclerosis with COVID-19.

METHODS

Anonymised data were submitted by clinical teams. Regression models were tested for predictors of hospitalisation and mortality outcomes. Separate analyzes compared the first and second 'waves' of the pandemic.

RESULTS

Univariable analysis found hospitalisation and mortality were associated with increasing age, male gender, comorbidities, severe disability, and progressive MS; severe disability showed the highest magnitude of association. Being on a DMT was associated with a small, lower risk. Multivariable analysis found only age and male gender were significant. Post hoc analysis demonstrated that factors were significant for hospitalisation but not mortality. In the second wave, hospitalisation and mortality were lower. Separate models of the first and second wave using age and gender found they had a more important role in the second wave.

CONCLUSIONS

Features associated with poor outcome in COVID-19 are similar to other populations and being on a DMT was not found to be associated with adverse outcomes, consistent with smaller studies. Once in hospital, no factors were predictive of mortality. Reassuringly, mortality appears lower in the second wave.

Molecular Pharming for low and middle income countries

Interest in applications and benefits that Molecular Pharming might offer to Low and Middle Income Countries has always been a potent driver for the research discipline, and a major reason why many scientists entered the field. Although enthusiasm remains high, the reality is that such a game-changing innovation would always take longer than traditional uptake of new technology in developed countries, and be complicated by external factors beyond technical feasibility. Excitingly, signs of increasing interest by LMICS in Molecular Pharming are now emerging. Here, three case studies from Thailand, South Africa and Brazil are used to identify some of the key issues when a new investment into Molecular Pharming manufacturing capacity is under consideration. At present, academic research is not necessarily addressing these issues. Only by understanding the concerns, can members of the academic community contribute to helping the development of Molecular Pharming for LMICs by focusing their research efforts appropriately.

Long-term Adherence to Colorectal Cancer Screening; 5-Year Results from the Systems of Support to Increase Colorectal Cancer Screening Trial

Colorectal cancer (CRC) is the second-leading cause of cancer deaths. Mortality could be rapidly reduced through higher uptake and adherence to CRC screening. Information on long-term screening adherence comes from organized programs that lack a comparison group. Objective: Systems of Support to Increase Colorectal Cancer Screening is an ongoing trial testing a centralized mailed and phone-based program to increase long-term CRC screening adherence. We hypothesized that compared to usual care (UC) intervention-arm patients would have more time in compliance with CRC screening guidelines over 5 years. Methods: The setting was an integrated healthcare organization in Washington State. UC included patient-centered medical home with clinic-based strategies to increase screening. Participants included 4675 individuals initially aged 50–74, not current for CRC screening. Intervention arms combined were compared to UC. The primary outcome was the percent of time covered for CRC screening over 5 years of follow-up. Screening tests contributed covered time based on national guidelines for screening intervals. All participants contributed data, but were censored at disenrollment, death, age 76, or CRC diagnosis. Interventions: Patients were randomly assigned to receive UC, or one of three stepped care interventions: 1. Mailings including mailed fecal tests, a call-in number if colonoscopy or sigmoidoscopy was preferred; 2. Mailings plus brief telephone assistance; 3. Mailings and telephone assistance plus nurse navigation. In year 3, intervention group participants still CRC screening-eligible were randomized to stopped or continued mailed interventions only. Results: Compared to UC, intervention participants had 31% more time not in need of CRC testing (adjusted rate ratio, weighted for exposure time 1.31 [1.25–1.37], 47.2% vs. 62.0% covered time) over 5 years. Fecal testing was responsible for almost all additional covered time. Compared to intervention participants, UC individuals were more likely never to have completed any CRC testing over 5 years (17.4% vs. 10.3%, net difference 7.2%, P &lt; 0.001) Conclusions: An organized mail and phone program led to increased CRC screening adherence over 5 years, mainly because of regular fecal testing uptake.

PREDICTING VISUAL FIELD DEFECTS FOLLOWING SELECTIVE TRANSSYLVIAN AMYGDALOHIPPOCAMPECTOMY

Introduction

Surgery for refractory temporal lobe epilepsy can cause postoperative visual field defects (VFD). This study aimed to predict personalised risk of VFDs for patients undergoing selective transsylvian amygdalohippocampectomy.

Methods

Preoperative reconstruction of the optic radiations (OR) using diffusion tensor-based tractography was completed on two patients. The ‘average resection model’ uses a template from postoperative structural scans of five patient scans to predict an average resection in the patient. The OR tractography was compared with the resection margins to determine fibre involvement. The ‘multiple individual comparison model’ compared individual postoperative scans with the preoperative tractography to determine risk of VFD.

Results

In Patient 1 the average resection overlapped the OR, so an average resection would be expected to produce a VFD. In 3/5 postoperative scans the resection intersected with the OR, indicating that 60% of prior resections would have caused a defect. In Patient 2 no overlap between resection and OR was found in either model. Perimetry confirmed VFD in patient 1 but not in patient 2.

Discussion

This pilot study demonstrates that the risk of postoperative VFDs can be predicted. The two models provide qualitatively different form of quantitative risk which could inform the discussion between patient and clinician.

Why MSM in rural South African communities should be an HIV prevention research priority

Research into HIV and men who have sex with men’s (MSM) health in South Africa has been largely confined to the metropolitan centres. Only two studies were located making reference to MSM in rural contexts or same-sex behaviors among men in the same. There is growing recognition in South Africa that MSM are not only disproportionately affected by HIV and have been underserved by the country’s national response, but that they contribute significantly to sustaining the high number of new infections recorded each year. We argue that to meet the objectives of the country’s national strategic plan for HIV, STI and TB it is important we know how these behaviours may be contributing to the sustained rural HIV epidemic in the youngest age groups and determine what constitutes appropriate and feasible programmatic response that can be implemented in the country’s public sector health services.

Self-reported menopausal symptoms in a racially diverse population and soy food consumption

OBJECTIVES

Evaluate the association of self-reported vasomotor symptom (VMS) frequency with race/ethnicity among a diverse midlife US population and explore menopause symptom differences by dietary soy isoflavone (genistein+daidzein) consumption.

STUDY DESIGN

Cross-sectional population-based study of peri- and postmenopausal women, ages 45-58.

OUTCOMES

Recent VMS frequency, VMS ever; recent symptom bother (hot flashes, night sweats, headache and joint-ache).

RESULTS

Of 18,500 potentially eligible women, 9325 returned questionnaires (50.4% response); 3691 were excluded (premenopausal, missing data, taking hormones). Of 5634 remaining women, 82.1% reported hot flashes ever, 73.1% reported night sweats ever; 48.8% and 38.6% reported recent hot flashes or night sweats, respectively. Compared with White women, Chinese, Japanese, Vietnamese, other Asian (each p<0.001) and Filipino (p<0.01) women less commonly reported ever having hot flashes; Asian women less commonly reported recent VMS bother (p<0.001). Black women more commonly reported hot flashes ever (p<0.05) and recent VMS bother (p<0.05). Compared with non-Hispanic White women, Hispanic women were less likely to report hot flashes (p<0.05) or night sweats (p<0.001) ever. Women were classified by isoflavone consumption: (1) none (n=1819), (2) 0.01-4.30 mg/day (n=1931), (3) 4.31-24.99 mg/day (n=1347) and (4) ≥ 25 mg/day (n=537). There were no group differences in recent VMS number/day: (1) 7.0 (95% CI 6.5, 7.5); (2) 6.4 (95% CI 6.0, 7.1); (3) 7.0 (95% CI 6.3, 8.2); and (4) 6.8 (95% CI 6.1, 7.7).

CONCLUSIONS

Menopausal symptoms, independent of isoflavone intake, varied considerably by race/ethnicity and were least common among Asian races.

Acute bilineal leukemia: a rare disease with poor outcome

Most cases of acute leukemia can be assigned to the myeloid, B or T lineage. In a few cases, definitive assignment cannot be achieved because blasts express antigens of more than one lineage. A subset of these, referred to as acute bilineal leukemias (aBLLs), is characterized by the presence of more than one population of blasts, each comprising a single lineage. We identified 19 cases of aBLL, including 10 mixed T and myeloid (T-My) and nine mixed B and myeloid (B-My); no mixed B and T cases were identified. Cytogenetic data were available for 16 patients. Three of seven patients with B-My had a t(9;22)(q34q11.2), two had 11q23 translocations and one had del(9). Two of nine patients with T-My had 2p13 translocations; five had other unrelated abnormalities. Of 16 patients with outcome data, only six achieved complete remission and only two remain free of disease 2.5 and 4.5 years after chemotherapy or stem cell transplantation. aBLL is a rare disease that combines B or T and myeloid blasts. Cytogenetic abnormalities of t(9;22) and 11q23 are common in, and may be restricted to, B-My cases, while T-My cases have frequent but generally non-recurring abnormalities. Both types of aBLL are associated with poor outcome.

Monoclonal nicotine-specific antibodies reduce nicotine distribution to brain in rats: dose- and affinity-response relationships

Vaccination against nicotine is being studied as a potential treatment for nicotine dependence. Some of the limitations of vaccination, such as variability in antibody titer and affinity, might be overcome by instead using passive immunization with nicotine-specific monoclonal antibodies. The effects of antibodies on nicotine distribution to brain were studied using nicotine-specific monoclonal antibodies (NICmAbs) with K(d) values ranging from 60 to 250 nM and a high-affinity polyclonal rabbit antiserum (K(d) = 1.6 nM). Pretreatment with NICmAbs substantially increased the binding of nicotine in serum after a single nicotine dose, reduced the unbound nicotine concentration in serum, and reduced the distribution of nicotine to brain. Efficacy was directly related to antibody affinity for nicotine. Efficacy of the highest affinity NICmAb, NICmAb311, was dose-related, with the highest dose reducing nicotine distribution to brain by 78%. NICmAb311 decreased nicotine clearance by 90% and prolonged the terminal half-life of nicotine by 120%. At equivalent doses, NICmAb311 was less effective than the higher affinity rabbit antiserum but comparable efficacy could be achieved by increasing the NICmAb311 dose. These data suggest that passive immunization with nicotine-specific monoclonal antibodies substantially alters nicotine pharmacokinetics in a manner similar to that previously reported for vaccination against nicotine. Antibody efficacy is a function of both dose and affinity for nicotine.

Infertility rates following POMB/ACE chemotherapy for male and female germ cell tumours - a retrospective long-term follow-up study

The risk of chemotherapy-induced infertility in male and female germ cell tumour (GCT) survivors is unclear, but may correlate with cisplatin dose. Here, we examine a large series of GCT patients for the effect of chemotherapy on those attempting to have children. Our GCT database was screened for nonseminomatous GCT patients who had (1) received POMB/ACE chemotherapy (cisplatin, vincristine, methotrexate, bleomycin alternating with actinomycin D, cyclophosphamide and etoposide) and (2) stage I male GCT patients who were untreated between 1977 and 1996. Fertility was assessed by questionnaire and medical records. A total of 64 of 153 treated and 35 of 115 untreated men attempted to have children. In all, 28% (18 out of 64) receiving POMB/ACE were unsuccessful. Radiotherapy (six), atrophic remaining testis (one) or prior infertility (three) were implicated in 10 cases, so chemotherapy-induced infertility may have occurred in only 11% (eight out of 64). Strikingly, 26% (nine out of 35) of untreated stage I patients also failed to have children (three had radiotherapy, three prior infertility). Moreover, in treated men, no association was seen between cisplatin dose and infertility. In contrast, radiotherapy significantly increased male infertility (P=0.001). Of 28 treated women who attempted to have children, 25% (seven out of 28) were unsuccessful. One previously had infertility and one subsequently had successful IVF so chemotherapy-induced infertility potentially occurred in only 18% (five out of 28) and was not related to cisplatin dose. In conclusion, the risk of chemotherapy-induced infertility is low in both male and female GCT patients and does not clearly correlate with the cumulative cisplatin dose.

Generation of a recombinant Fab antibody reactive with the Alzheimer's disease-related Abeta peptide

A recombinant Fab antibody, designated 1E8-4b, which reacts with the Alzheimer's disease (AD)-related Abeta peptides, Abeta[1-40], Abeta[1-42] and Abeta[1-43] has been developed. The 1E8-4b Fab was constructed by cloning the V(H)C(H1) and V(L)C(L) domains from the parent hybridoma 1E8 antibody, reported previously to recognize these Abeta peptides. Briefly, a C-terminal Flag tag sequence was incorporated into this construct, which was ligated into the vector pHFA2 and expressed in Escherichia coli. Following purification on an M2 anti-Flag affinity column, the 1E8-4b recombinant Fab antibody was shown to bind plaques within sections of brain tissue from CERAD-defined AD patients by immunohistochemistry. ELISA, epitope mapping and immunoblotting confirmed the recognition of the Abeta1-40/42/43] peptides by the 1E8-4b Fab. The 1E8-4b Fab did not recognize APP695 or APP770 which contain the Abeta sequence. The Abeta specificity of the recombinant 1E8-4b Fab antibody was identical to the parent 1E8 monoclonal antibody.

Informatics for Peru in the new millennium

INTRODUCTION

As efforts continue to narrow the digital divide between the North and South, a new biomedical and health informatics training effort has been launched in Peru. This report describes the first year of work on this collaborative effort between the University of Washington (Seattle) Universidad Peruana Cayetano Heredia and Universidad Nacional de San Marcos (Peru)

OBJECTIVES

To describe activities in the first year of a new International Research and Training Program in Biomedical and Health Informatics.

METHODS

Descriptive analysis of key activities including an assessment of electronic environment through observation and survey, an in country short course with quantitative evaluation, and first round of recruitment of Peruvian scholars for long-term training in Seattle.

RESULTS

A two-week short course on informatics was held in the country. Participants' success in learning was demonstrated through pretest/posttest. A systematic assessment of electronic environment in Peru was carried out and two scholars for long-term training were enrolled at the University of Washington, Seattle.

DISCUSSION

Initial activity in the collaborative training effort has been high. Of particular importance in this environment is orchestration of efforts among interested parties with similar goals in Peru, and integration of informatics skills into ongoing large-scale research projects in country.

The effect of early pregnancy following chemotherapy on disease relapse and foetal outcome in women treated for gestational trophoblastic tumours

Little literature exists on the safety of early pregnancy following chemotherapy. Here we assess the rate of relapse and foetal outcome in women who have completed single and multi-agent chemotherapy for gestational trophoblastic tumours. The records of 1532 patients treated for persistent gestational trophoblastic tumours at Charing Cross Hospital between 1969 and 1998 were reviewed. Patients were defined as receiving single agent or multi-agent treatment. Relapse rates and foetal outcome were reviewed in the 230 patients who became pregnant within 12 months of completing chemotherapy. In the single agent group 153 (22%) of 691 patients conceived early. Three subsequently relapsed. In the multi-agent group, 77 (10%) of 779 patients conceived early, two then relapsed. Relapse rates were 2% (3 out of 153) and 2.5% (2 out of 77) for each group compared to 5% and 5.6% in the comparative non-pregnant groups. Outcomes of 230 early pregnancies: 164 (71%) delivered at full term, 35 (15%) terminations, 26 (11%) spontaneous abortions, three (1.3%) new hydatidiform moles and two (1%) stillbirths. Early pregnancies were more common in the single agent group (P<0.001), but spontaneous miscarriages and terminations were more likely to occur in the multi-agent group (P=0.04 and 0.03, respectively). Of the full-term pregnancies, three (1.8%) babies were born with congenital abnormalities. Patients in either group who conceive within 12 months of completing chemotherapy are not at increased risk of relapse. Though, we still advise avoiding pregnancy within 12 months of completing chemotherapy, those that do conceive can be reassured of a likely favourable outcome. DOI: 10.1038/sj/bjc/6600041 www.bjcancer.comCopyright 2002 The Cancer Research Campaign

Oral health promotion evaluation--time for development

Increasing emphasis is now being placed upon the evaluation of health service interventions to demonstrate their effects. A series of effectiveness reviews of the oral health education and promotion literature has demonstrated that many of these interventions are poorly and inadequately evaluated. It is therefore difficult to determine the effectiveness of many interventions. Based upon developments from the field of health promotion research this paper explores options for improving the quality of oral health promotion evaluation. It is essential that the methods and measures used in the evaluation of oral health promotion are appropriate to the intervention. For many oral health promotion interventions clinical measures and methods of evaluation may not be appropriate. This paper outlines an evaluation framework which can be used to assess the range of effects of oral health promotion programmes. Improving the quality of oral health promotion evaluation is a shared responsibility between researchers and those involved in the provision of programmes. The provision of adequate resources and training are essential requirements for this to be successfully achieved.

Biomedical and Health Informatics Research and Education at the University of Washington

Although an extensive medical informatics research program as well as courses and training experiences in biomedical informatics have existed at the University of Washington (UW) for many years, a formal home did not exist until 1997 when the Division of Biomedical Informatics was created in the Department of Medical Education, School of Medicine. Since that time the expansion of the research, service and teaching programs has been rapid with a key milestone being a university commitment to provide funding, space and faculty to support the development of a new graduate program in Biomedical and Health Informatics.

Hallmarks of the biomedical and health informatics program at the University of Washington include:

- Strong shared belief that informatics research can contribute to the improvement of healthcare and health;

- Large, multidisciplinary faculty including faculty from computer science, library and information science as well as the health sciences schools (dentistry, medicine, nursing, pharmacy, and public health and community medicine);

- Comprehensive research and development partnership with the University of Washington Medical Centers information systems group and the UW Primary Care Network to move research from the laboratory to operational clinical systems;

- Extensive and diverse regional setting in which to study information needs and develop informatics solutions in primary care settings;

- Lack of barriers to interdisciplinary research and teaching.

The intact retroviral Env glycoprotein of human foamy virus is a trimer

Electron microscopy of negatively stained human foamy virus particles provides direct evidence for the trimeric nature of intact Env surface glycoproteins. Three-dimensional image reconstruction reveals that the Env trimer is a tapering spike 14 nm in length. The spikes were often arranged in hexagonal rings which shared adjacent Env trimers.

A conformational switch controlling HIV-1 morphogenesis

Assembly of infectious human immunodeficiency virus type 1 (HIV-1) proceeds in two steps. Initially, an immature virus with a spherical capsid shell consisting of uncleaved Gag polyproteins is formed. Extracellular proteolytic maturation causes rearrangement of the inner virion structure, leading to the conical capsid of the infectious virus. Using an in vitro assembly system, we show that the same HIV-1 Gag-derived protein can form spherical particles, virtually indistinguishable from immature HIV-1 capsids, as well as tubular or conical particles, resembling the mature core. The assembly phenotype could be correlated with differential binding of the protein to monoclonal antibodies recognizing epitopes in the HIV-1 capsid protein (CA), suggesting distinct conformations of this domain. Only tubular and conical particles were observed when the protein lacked spacer peptide SP1 at the C-terminus of CA, indicating that SP1 may act as a molecular switch, whose presence determines spherical capsid formation, while its cleavage leads to maturation.

Biomdecial and Health Informatics Research and Education at the University of Washington

Although an extensive medical informatics research program as well as courses and training experiences in biomedical informatics have existed at the University of Washington (UW) for many years, a formal home did not exist until 1997 when the Division of Biomedical Informatics was created in the Department of Medical Education, School of Medicine. Since that time the expansion of the research, service and teaching programs has been rapid with a key milestone being a university commitment to provide funding, space and faculty to support the development of a new graduate program in Biomedical and Health Informatics. Hallmarks of the biomedical and health informatics program at the University of Washington include: - Strong shared belief that informatics research can contribute to the improvement of healthcare and health; - Large, multidisciplinary faculty including faculty from computer science, library and information science as well as the health sciences schools (dentistry, medicine, nursing, pharmacy, and public health and community medicine); - Comprehensive research and development partnership with the University of Washington Medical Centers information systems group and the UW Primary Care Network to move research from the laboratory to operational clinical systems; - Extensive and diverse regional setting in which to study information needs and develop informatics solutions in primary care settings; - Lack of barriers to interdisciplinary research and teaching.

Allergic reactions to 6-mercaptopurine during treatment of inflammatory bowel disease

Hypersensitivity reactions to 6-mercaptopurine (6-MP) or azathioprine occur during the treatment of inflammatory bowel disease (IBD), raising significant diagnostic and therapeutic challenges. Charts of 591 patient with IBD treated with 6-MP in a single center were retrospectively reviewed. All allergic reactions were recorded along with results of rechallenge, desensitization, and subsequent course of IBD. Sixteen (2.7%) allergic reactions to 6-MP were noted, with fever being the most common (14 cases). Nine of these were rechallenged with 6-MP with recurrence of the same symptoms. Azathioprine was tried in six patients and in five the same symptoms recurred. Four patients underwent successful desensitization to either 6-MP or azathioprine; all four plus another patient who tolerated direct switch to azathioprine entered long-term remission. Among the remaining 11, 5 required surgery, 2 are well on methotrexate, and 4 have chronic symptoms while being treated with other medications. If an allergic reaction to 6-MP occurs during the treatment of IBD, direct switching to azathioprine is probably not justified. Instead, desensitization to either 6-MP or azathioprine should be attempted. Patients who can tolerate these medications after previous allergic reactions have improved outcomes compared with patients who resort to other forms of treatment.