An Atypical Source of Persistent Fungemia in the Intensive Care Unit.

BACKGROUND Candidemia is a common complication of critically ill and immunocompromised patients, with more than 50% associated mortality. Typical etiologies include valvular vegetations, intra-abdominal fluid collections, and central venous catheters. Treatment often entails surgical excision, but anticoagulation may be sufficient. CASE REPORT Our case was a 63-year-old woman with diabetes mellitus, left hip osteoarthritis status after hemiarthroplasty, and alcohol use disorder, admitted to the Intensive Care Unit with diabetic ketoacidosis (DKA) and hemorrhagic shock from an upper gastrointestinal bleed. Complicating her course was the development of Candida species fungemia. An extensive workup including transthoracic echocardiography, computed tomography of the chest, abdomen, and pelvis, ocular examination, and hip aspiration was unrevealing in determining the etiology. Despite early line removal and appropriate antifungal therapy, the fungemia persisted. A broader evaluation revealed a venous thromboembolism, which ultimately was thought to be the source. Subsequent initiation of anticoagulation and continued antifungal therapy led to clearance of blood cultures with overall clinical improvement. CONCLUSIONS In critically ill patients at higher risk for development of venous thromboembolism, septic thrombi should be considered in the differential diagnosis when evaluating for source control in a patient with fungemia.

Medicaid expansion and infant mortality, revisited: A difference-in-differences analysis.

OBJECTIVE: To determine the association between Medicaid expansion and infant mortality rate (IMR) in the United States. DATA SOURCES: State-level aggregate data on US IMR, race, and sex were abstracted from the US Center for Disease Control and Prevention's Wide-ranging Online Data for Epidemiologic Research. STUDY DESIGN: The association between Medicaid expansion and IMR adjusted for race and sex was assessed with multiple linear regression models using difference-in-differences estimation and Huber-White robust standard errors. PRINCIPAL FINDINGS: Difference-in-differences regression found no association between Medicaid expansion status and change in national IMR from 2010 to 2017 (Coef. = 0.04; 95% CI: -0.39, 0.46). However, among Hispanics, the program was found to be associated with reduction in IMR (Diff-in-Diff Coef. = -0.53; 95% CI: -1.02, -0.03). CONCLUSIONS: Overall, the Affordable Care Act-induced Medicaid expansion was not associated with IMR reduction in expansion states relative to nonexpansion states. However, the program was associated with a significant IMR decline among Hispanics.

Equestrian injuries in children.

PURPOSE: Equestrian activities are regarded by some as high-risk sports, and our recent experience suggested this to be true. We undertook this study to review our experience with pediatric equestrian injuries. METHODS: After institutional review board approval, we reviewed emergency department and hospital admissions for children 0 to 18 years, with equestrian trauma, over an 11-year period. RESULTS: There were 164 encounters with 135 girls and 29 boys. Most injuries (82%) occurred after falling or being thrown from the animal, and only 12% occurred during jumping or rodeo competitions. The remaining injuries were secondary to being trampled, kicked, or trapped under the animal. Eighty-seven children required hospital admission. Lacerations and contusions (58%) or orthopedic injuries (31%) were most common in the emergency department cohort. In the admission cohort, injury sites included orthopedic (34%), head (23%), abdomen (21%), and chest (11%). Multiple injuries occurred in 13%. A significant number of children required surgical interventions, including 19 orthopedic procedures, 4 laparotomies, 3 facial reconstructions, and 2 craniotomies. The average length of stay was nearly 4 days, with 60% of the children requiring intensive care admission. There were no deaths. One child was discharged to rehab, the rest were sent home. CONCLUSIONS: In our experience, more than one third of the children admitted after sustaining injuries in horse-related sports required surgical interventions. Children participating in equestrian activities are at risk for substantial injury, and pediatric care providers must maintain a high index of suspicion when evaluating these children.