The Use of Sucroferric Oxyhydroxide Prior to Sigmoidoscopy in Patients With End-Stage Kidney Disease: A Case Report.

Rationale: Sucroferric oxyhydroxide is an iron-based phosphate-binding medication that has been approved for the treatment of hyperphosphatemia in patients with end-stage kidney disease. Given the low overall iron release from the polynuclear iron(III)-oxyhydroxide molecule, recommendations regarding its use prior to colonoscopy/sigmoidoscopy have not been developed. Presenting concerns of the patient: A 51-year-old male with a known history of end-stage renal disease treated with hemodialysis was referred to Gastroenterology for consideration of colonoscopy to rule out malignancy because of a history of rectal bleeding. This was to be completed prior to proceeding with a living-donor kidney transplant. Diagnoses: Flexible sigmoidoscopy done after non-diagnostic colonoscopy demonstrated diffuse "charcoal-like" material that prevented adequate visualization of the bowel despite standard bowel preparation. The findings were believed to be secondary to the use of sucroferric oxyhydroxide prescribed for hyperphosphatemia. Interventions: The patient was subsequently instructed to discontinue sucroferric oxyhydroxide for 2 weeks prior to his repeat sigmoidoscopy procedure. Outcomes: The patient's repeat sigmoidoscopy after discontinuing sucroferric oxyhydroxide allowed for adequate bowel visualization that revealed only a benign lipoma. Teaching Points: This case demonstrates the potential for sucroferric oxyhydroxide use to result in poor bowel preparation and resulting inadequate visualization on lower gastrointestinal endoscopy. It serves to highlight the clinical implications leading to the need for repeated procedures, which contributes to resource waste and unnecessary costs to the healthcare system, as well as delays in diagnostic evaluation required for transplantation; patient frustration was evident.

Justification: L'oxyhydroxyde sucro-ferrique, un médicament à base de fer liant le phosphate, a été approuvé pour le traitement de l'hyperphosphatémie chez les patients atteints d'insuffisance rénale terminale. La molécule polynucléaire fer (lll) ­ oxyhydroxyde ne libérant qu'une faible quantité globale de fer, aucune recommandation n'a été développée concernant son utilisation avant une coloscopie/sigmoïdoscopie. Présentation du cas: Un homme de 51 ans connu pour insuffisance rénale terminale et traité par hémodialyse a été orienté en gastroentérologie pour subir une coloscopie afin d'exclure une tumeur maligne en raison d'antécédents de saignement rectal. L'examen devait être complété avant de procéder à la greffe de rein par donneur vivant. Diagnostic: Une sigmoïdoscopie souple réalisée après une coloscopie non diagnostique a révélé une matière diffuse de type « charbon de bois ¼ qui empêchait de bien voir l'intestin malgré une préparation intestinale adéquate. Ce résultat a été jugé secondaire à l'utilisation d'oxyhydroxyde sucro-ferrique prescrit pour traiter l'hyperphosphatémie. Intervention: On a demandé au patient d'interrompre le traitement par oxyhydroxyde sucro-ferrique pendant deux semaines avant de répéter la procédure de sigmoïdoscopie. Résultats: La sigmoïdoscopie répétée après l'arrêt de l'oxyhydroxyde sucroferrique a permis une visualisation adéquate de l'intestin qui n'a révélé qu'un lipome bénin. Enseignements tirés: Ce cas démontre que l'utilisation d'oxyhydroxyde sucro-ferrique peut entraîner une mauvaise préparation intestinale et entraver la visualisation lors d'une endoscopie gastro-intestinale basse. Il met en évidence les répercussions cliniques qui justifient des procédures répétées, lesquelles contribuent au gaspillage des ressources et entraînent des coûts inutiles pour le système de santé, ainsi que les retards dans l'évaluation diagnostique requise pour la transplantation; dans ce cas, la frustration du patient était évidente.

Scoping review of evidence for managing postnatal hypoglycaemia.

OBJECTIVES: To identify what is known empirically about the screening, treatment and harm of exposure to neonatal hypoglycaemia. DESIGN: Scoping review that applied a preregistered protocol based on established frameworks. DATA SOURCES: Medline and Embase, up to 12 May 2020. STUDY SELECTION: Comparative and case-series studies, as well as guidelines, published in English or French, on the topic of immediate inpatient postnatal glucose screening in newborns. DATA GATHERING: Article selection and characterisation were performed in duplicate using predefined data extraction forms specific to primary studies and guidelines. RESULTS: 12 guidelines and 74 primary studies were included. A neurodevelopmental outcome was primary in 32 studies: 30 observational studies followed up posthypoglycaemic, and the 2 intervention studies included 1 randomised controlled trial (RCT) about treatment thresholds. Three other RCTs assessed dextrose gel (two) and oral sucrose (one). 12 of 30 studies that evaluated non-neurodevelopmental primary outcomes were intervention studies. Only one cohort study compared outcomes in screened vs unscreened newborns. The guidelines did not arrive at a consensus definition of postnatal hypoglycaemic, and addressed potential harms of screening more often than primary studies. CONCLUSIONS: The primary literature that informs hypoglycaemia screening is a series of studies that relate neurodevelopmental outcomes to postnatal hypoglycaemia. Further research is needed to better define an optimal threshold for hypoglycaemia that warrants intervention, based on long-term neurodevelopmental outcomes and a better delineation of potential screening harms.

Embryonal Tumor With Multilayered Rosettes of the Parietooccipital Region: A Case Report.

Embryonal tumor with multilayered rosettes is a rare and highly malignant early childhood brain tumor. We report a case of embryonal tumor with multilayered rosettes in the parietooccipital region of a 2-year-old girl. Histopathology of the tumor demonstrated amplification of the 19q13.42 locus and strong positivity for LIN28A. Treatment was multimodal and included 3 surgical resections, adjuvant chemotherapy with autologous stem cell rescue, and focal radiotherapy. The use of the agents vorinostat and isotretinoin, and the addition of focal radiation have not been extensively described in this patient population, but may attribute to our patient's sustained remission at 2.5-years follow-up.

Neighbourhood Walkability and Risk of Diabetes: Causal Relationship or Epidemiologic Association?

PURPOSE OF REVIEW: We aim to evaluate whether the current literature supports (i) a causal relationship between neighbourhood walkability and risk of diabetes or instead (ii) a strictly epidemiologic association. RECENT FINDINGS: Both cross-sectional and longitudinal studies have reported that neighbourhoods that are scored as having higher levels of walkability have lower rates of prevalent and incident diabetes, respectively. However, other studies have been inconclusive, with more nuanced findings suggesting that this association may be limited to particular demographic groups defined by age and socio-economics. Key factors limiting this literature include disparities in the measurement of walkability, the necessary reliance on observational study designs (recognizing the infeasibility of randomized controlled trials for addressing this question), and the difficulty of disentangling the potential concomitant effects of other components of the built environment. At this time, causality cannot be ascertained in the relationship between neighbourhood walkability and risk of diabetes.