Azathioprine in refractory sprue: results from a prospective, open-label study

OBJECTIVE: Refractory sprue is a rare and severe malabsorptive disorder that mimics celiac disease but is refractory to a gluten-free diet and is without initial evidence of overt lymphoma. Treatment is largely empiric and often ineffective, with steroids and immunosuppression being the mainstream therapeutic options. The aim of this study was to evaluate prospectively the effect of azathioprine on a group of patients diagnosed with refractory sprue. METHODS: We studied seven consecutive patients (five women and two men) with a well-defined diagnosis of refractory sprue and a lack of response to oral or parenteral steroids. At diagnosis, five patients had endoscopic evidence of ulcerative jejunitis, and five underwent exploratory laparotomy for exclusion of malignancies. The characteristic monoclonal TCR gene rearrangement was shown in five of six patients studied. Patients were treated for a mean of 11 months (range 8–12 months), and clinical, biochemical, molecular, and histological parameters were reassessed at the end of the trial. The study was a prospective, open-label, non–placebo-controlled study using azathioprine (2 mg/kg/ day) plus oral prednisone (1 mg/kg/day). A gluten-free diet (n 7) as well as enteral (n 6) and parenteral nutrition (n 5) were administered during the trial. RESULTS: After treatment, five patients had a complete clinical remission, and biochemical and nutritional parameters were significantly improved. Steroids were tapered after the onset of azathioprine, and no patient was on steroids at the end of the trial. Intestinal histology improved significantly in all cases (normal histology in three cases and minor infiltration in the lamina propria in two). Two patients did not respond to treatment at any time and died in months 10 and 9, of an irreversible ventricular fibrillation and sepsis, respectively. No overt lymphoma was demonstrated during the follow-up. CONCLUSIONS: The present study confirms earlier anecdotal reports on the efficacy of azathioprine in refractory sprue, with clear clinical and histological improvement shown in most patients. However, monoclonality persisted after treatment. We consider that a larger number of patients should be evaluated before a definitive recommendation is adopted for use of this drug in refractory sprue.Fil: Maurino, Eduardo. Gobierno de la Ciudad de Buenos Aires. Hospital de Gastroenterología "Dr. Carlos B. Udaondo"; Argentina. Universidad del Salvador; ArgentinaFil: Niveloni, Sonia Isabel. Gobierno de la Ciudad de Buenos Aires. Hospital de Gastroenterología "Dr. Carlos B. Udaondo"; ArgentinaFil: Cherñavsky, Alejandra Claudia. Universidad de Buenos Aires. Facultad de Medicina. Hospital de Clínicas General San Martín. Laboratorio de Inmunogenética; Argentina. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Houssay. Instituto de Inmunología, Genética y Metabolismo. Universidad de Buenos Aires. Facultad de Medicina. Instituto de Inmunología, Genética y Metabolismo; ArgentinaFil: Pedreira, Silvia. Gobierno de la Ciudad de Buenos Aires. Hospital de Gastroenterología "Dr. Carlos B. Udaondo"; ArgentinaFil: Mazure, Roberto. Gobierno de la Ciudad de Buenos Aires. Hospital de Gastroenterología "Dr. Carlos B. Udaondo"; ArgentinaFil: Vazquez, Daniel Horacio. Gobierno de la Ciudad de Buenos Aires. Hospital de Gastroenterología "Dr. Carlos B. Udaondo"; ArgentinaFil: Reyes, Hugo. Gobierno de la Ciudad de Buenos Aires. Hospital de Gastroenterología "Dr. Carlos B. Udaondo"; ArgentinaFil: Fiorini, Alcira. Gobierno de la Ciudad de Buenos Aires. Hospital de Gastroenterología "Dr. Carlos B. Udaondo"; ArgentinaFil: Smecuol, Edgardo. Gobierno de la Ciudad de Buenos Aires. Hospital de Gastroenterología "Dr. Carlos B. Udaondo"; ArgentinaFil: Cabanne, Ana. Gobierno de la Ciudad de Buenos Aires. Hospital de Gastroenterología "Dr. Carlos B. Udaondo"; ArgentinaFil: Capucchio, Monica. Universidad de Buenos Aires. Facultad de Medicina. Hospital de Clínicas General San Martín. Laboratorio de Inmunogenética; ArgentinaFil: Kogan, Zulema. Gobierno de la Ciudad de Buenos Aires. Hospital de Gastroenterología "Dr. Carlos B. Udaondo"; ArgentinaFil: Bai, Julio C.. Gobierno de la Ciudad de Buenos Aires. Hospital de Gastroenterología "Dr. Carlos B. Udaondo"; Argentina. Universidad del Salvador; Argentin

Training on work and environmental conditions for doctors union leaders of Buenos Aires city

Artículos originales[ES] Objetivo: presentar la experiencia que la Asociación de Médicos Municipales (A.M.M) de la Ciudad de Buenos Aires desarrolló en materia de formación de delegados gremiales en prevención. Materiales y métodos: La AMM convocó a un grupo técnico especializado que diseñó, desarrolló y evaluó el primer curso de formación de delegados en prevención de riesgos laborales en CyMAT para médicos. Se presenta la programación general de dicho curso, sus contenidos y actividades, y los resultados de su evaluación. Resultados: Se presentan los resultados de las actividades de observación de los coordinadores del curso, los de una encuesta de evaluación a cargo de los alumnos y los emergentes cualitativos generales. Se han identificado: la toma de conciencia por parte de los delegados médicos sobre los riesgos a los que se encuentran expuestos en su ámbito laboral, haber establecido vínculos y adquirido conocimiento de otras realidades, y el reconocimiento de la responsabilidad del empleador. Asimismo, surgieron propuestas de acción colectiva que se comenzaron a desarrollar como parte de las acciones gremiales. Conclusión: Esta experiencia verifica la posibilidad de generar conocimiento traducido en acciones gremiales en el Sector Salud mediante el compromiso de los principales sujetos: los trabajadores médicos. [EN] Objectives: to present the experience of the Asociación de Médicos Municipales (AMM) from the city of Buenos Aires developed for teaching and training of union delegates in prevention. Materials and methods: The AMM convened a group of specialists for this goal, who have developed and evaluated this first training course for delegates at preventing occupational hazards in work-related environment and conditions of job for physicians. We present a general planning of the course and its schedule, its contents and activities, and the results of its assessment. Results: The results of the monitoring activities by the coordinators of course, the scores of the survey answered by the delegates and emerging qualitative issues. It have been identified some features: the awareness within delegates doctors about the risks to which they are exposed in their workplace, the links between themselves about their different realities and the acquired knowledge, and the recognition of the responsibility of the employer over the health of their workers. It also emerged that proposals for collective action began to develop as part of union action. Conclusion: This experience demonstrates the ability to optimize the in health knowledge and use it in union action within the workers of the Health Sector.N