SummaryWe present another case of delayed intracerebral hemorrhage after a ventriculoperitoneal (VP) shunting procedure. In this case, a right occipital intraparenchymal hematoma and associated intraventricular hemorrhage occurred six days after the operation for hydrocephalus secondary to subarachnoid hemorrhage in a 64 year old woman. It is a rare complication of VP shunting, with few cases reported previously in the literature. The presumed mechanism is the erosion of a cerebral blood vessel secondary to a close contact with the ventricular catheter; bleeding disorder, vascular malformation, head trauma or brain tumor were excluded in this patient.KEY WORDS: Intracerebral hemorrhage. Ventriculoperioneal shunt. Hydrocephalus. Postoperative complication. Ventricular catheter.Hemorragia intracerebral tardía tras la colocación de una derivación ventriculoperitoneal. Caso clínico y revisión de la literatura Resumen Presentamos un caso de hemorragia intracerebral tardía tras la colocación de una derivación ventriculoperitoneal. Una paciente de 64 años de edad, con hidrocefalia secundaria a una hemorragia subaracnoidea, sufre una hemorragia intraparenquimatosa occipital derecha con hemorragia intraventricular secundaria seis días después de la intervención quirúrgica. Se trata de una complicación rara de la derivación ventriculoperitoneal, con pocos casos publicados anteriormente. El mecanismo supuesto es la erosión de un vaso sanguíneo secundaria a un íntimo contacto con el catéter proximal de la derivación; trastornos sanguí-neos, malformaciones vasculares cerebrales, traumatismo craneal o tumor cerebral fueron excluidos en esta paciente.PALABRAS CLAVE: Hemorragia intracerebral. Derivación ventriculoperitoneal. Hidrocefalia. Complicación postquirúrgica. Catéter ventricular.

Forestier's disease or diffuse idiophatic skeletal hyperostosis is a systemic reumathological abnormality of unknown etiology. It produces calcificationossification of the anterior longitudinal ligament. The low dorsal region is the most affected in the raquis. These patients are tipically asymptomatic or with few symptoms (minimal joint pain, spinal pain, stiffness). Dysphagia is the most common symptom when the disease affects the cervical spine; less frequent is dyspnea, both secondary to extrinsic compression of the esophagus and trachea. Neurological complaints are quite rare. In the 1970s Resnick described specific radiological criteria for the diagnosis of Forestier's disease that are still used today. It affects men more frequently than women (2:1); the peak occurrence is in patients in their 60s. We present two cases diagnosed by severe difficulty with deglution, a 84 years-old woman and a 54 years-old man; we operated on them for surgical decompression of the esophagus with resection of osteophytes C3-C4 and C5-C6 respectively through a conventional anterolateral neck approach. Relief of difficulty in swallowing was immediately ensued.

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Background:There is a well-known risk of developing adverse drug reactions (ADR) in rheumatology due, mainly, to the Disease Modifying Antirheumatic Drugs (DMARD) used. There is no doubt about their efficacy in Rheumatoid Arthritis (RA), but it is necessary to increase our knowledge of their ADR, especially those that lead to discontinuationObjectives:To describe the incidence and characteristics of ADR related with DMARD in patients with incident RA as well as the factors involved in their developmentMethods:Observational retrospective longitudinal study between April 15th 2007 and December 31st 2016. Inclusion criteria: patients diagnosed with RA between April 15th 2007 and June 31st 2011 followed until December 31st 2016 whom started any DMARD. Primary endpoint: development of an ADR that required discontinuation of the DMARD (moderate: discontinuation; severe: discontinuation with hospitalization or death). Co-variables: sociodemographic; clinical and therapy. Statistical analysis: incidence rates of discontinuation (IR) per 100 patient-years were estimated using survival techniques with their respective 95% confidence interval [CI]. Comparisons between associated factors were run by Cox bivariate and multivariate regression models. Results were expressed by hazard ratio (HR) and [CI]Results:We included 1054 courses of DMARD treatment in 405 patients (2277.9 patient-years). 78.3% were women with a mean age at diagnosis of 57±15 years. During follow-up, 16.3% of patients were taking biological DMARD, 73.3% were using monotherapy and 89% were taking corticoids. There were 369 ADR in 212 patients, 88.9% moderate. Gastrointestinal was the most frequent cause of ADR (26.3%), followed by infections (12.2%). IR are shown in table 1 and the multivariate analysis in table 2. Regarding type of DMARD, Abatacept had the highest risk of ADR development (HR:4.9[2.1–11.2]) compared to the other drugs followed by Gold (HR:1.6[1–2.6]) and Leflunomide (HR:1.4[1.1–1.9]). Methotrexate was the safest drug compared with the others (0.6[0.5–0.8])Table 1GlobalWomenMen2277.91835.4442.53692967316.216.116.514.6–17.914.4–18.113.1–20.7 By therapy regimenMonotherapyDouble therapyTriple therapy 1609.5568.999.4 20013237 12.423.237.2 10.8–14.319.6–27.526.9–51.4By type of DMARDSyntheticBiological 2048.3229.5 32643 15.918.7 14.3–17.713.9–25.3By drugAbataceptAdalimumabAntimalarialsAzathioprineCertolizumabEtanerceptGolimumabInfliximabLeflunomideMethotrexateGoldRituximabSulfasalazine 8.381.5749.7191665.29.118.4340.41463.583.626.3154 5101573412568520633145 60.612.320.915.724.818.454.932.72514.139.53.829.2 25.2–145.56.6–22.817.9–24.55.1–48.89.3–66.210.5–32.422.9–131.914.7–72.720.2–30.912.3–16.128–55.50.5–2721.8–39.1Table 2MonotherapyDouble therapyTriple therapy12 4.2-1.5–2.52.6–6.8-0 0 Congestive heart failure1.81.2–2.70.002Liver disease21.2–3.30.012Conclusions:The IR of ADRwas 16.2%, being similar in all age categories. Gastrointestinal was the main cause of ADR followed by infections. We have found differences in discontinuation rates among DMARD ...

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