Background & Aims Thiopurines (azathioprine and 6-mercaptopurine) can induce life threatening myelosuppression. To help develop rational monitoring guidelines, this study determined the frequency, timing, and outcomes of mild and severe myelosuppression following initiation of thiopurine therapy. Methods This retrospective cohort study of patients with inflammatory bowel disease patients who were new users of thiopurines; those tested for thiopurine methyltransferase levels before therapy were excluded. Patients were followed from their first thiopurine prescription until the earliest of severe leucopenia [white blood count <1.0 × 109/L], severe thrombocytopenia (platelets<20 × 109/L), the end of therapy, the first gap in therapy, disenrollment, or December 31, 2006. Results Among 1997 new users, the incidence of severe leucopenia per 100 person-months was 0.16 (95% CI 0.03-0.29, n=6) in weeks 0-8, 0.00 in weeks 9-24, and 0.01 (95% CI 0-0.03, n=3) after week 26 of therapy. The incidence of severe neutropenia and severe thrombocytopenia per 100 person-months during the first 8 weeks of therapy was 0.51 (95% CI 0.31 – 0.80, n=19) and 0.08 (0.02 – 0.23, n=3), respectively. During the first 8 weeks, the median duration from a normal white blood count to severe leucopenia was 13 days (range 8-26 days) and to severe neutropenia was 14 days (range 7 to 23 days). Conclusions The high incidence of severe myelosuppression justifies frequent monitoring (weeklyx4 then biweeklyx2) during the first 8 weeks of therapy. After 8 weeks, the rate of severe myelosuppression and the proportion of patients that progress from mild to severe myelosuppression decline, justifying less-frequent monitoring.

This article examines the value of René Girard's thoughts concerning the relationship between violence and the sacred for those involved in any kind of violence. It analyses the three essential dimensions of the Girardian insight, including the mimetic nature of desire, the working of the scapegoat mechanism in the process of humanization, and the prophetic critique of sacrifice. Against the common misapprehensions about Girard's thought with regard to its falsifiability and ideological totality, this article proposes that Girardian thought could serve as a as resource for self-criticism for those involved in contexts of violence. The article outlines various moments of this process: heartbreak, including the realization of sameness instead of difference; truthfulness, or the slow process of exiting mendacity; the losing of an addiction to cheap meaning; and finally the setting free of a healthy imagination.