Objective To evaluate the prevalence of fungal infections (both pre- and post-cannulation) while on extracorporeal membrane oxygenation (ECMO) support and the associated morbidity and mortality. Design Retrospective cohort study. Patient and Methods The Extracorporeal Life Support Organization (ELSO) database is an international voluntary registry of clinical data for patients placed on ECMO. The database was queried for all patients on ECMO from 1997–2009. Patient and ECMO data collected included age, support type, length of support, infection status and organism code, discharge status, complications and component failures. Outcomes of interest were mortality, ECMO related patient complications, and mechanical component failures. Results From 1997–2009, there were 21,073 patient ECMO runs analyzed of which 12,933 were in the neonatal group (0–30 days), 6,073 were in the pediatric group (31 days-< 18 years old), and 2,067 were in the adult group (≥ 18 years). The prevalence of fungal infection during ECMO varied by age group and timing of infection and ranged from 0.04% to 5%. Fungal infections pre- and on-ECMO conferred a statistically significant higher relative risk of mortality for all age groups and varied by support type and timing of infection. ECMO related complications and component failures were not statistically significantly affected by infection status. Conclusions Fungal infection before or during ECMO increases the odds of mortality and the magnitude of this effect is dependent upon age-group and timing of infection. This increased mortality was not the result of increased patient or mechanical complications during ECMO. For patients with fungal infections pre-ECMO, 82–89% demonstrated presumed clearance during ECMO. Although the risk of mortality increased with fungal infections, it does not appear that fungal infection before or during ECMO is a contraindication to initiation or continuation of support.

Using dexmedetomidine for the treatment of anticholinergic toxidrome has not been previously described in the literature, but there are multiple reports of its use in alcohol withdrawal syndrome. We suggest that adding dexmedetomidine as an adjunctive agent in the therapy of anticholinergic toxidrome may relieve the symptoms of agitation, psychosis, tachycardia, and hypertension, without the attendant risk of respiratory depression associated with high doses of benzodiazepines.

We conclude that the majority of differentiated thyroid cancers (74%) express TP and low levels of TS (63% undetectable). The results support the hypothesis that capecitabine is activated in the majority of differentiated thyroid cancers and that 32% have favorable expression of all three enzymes (TP, TS, and DPD).

Key Clinical MessageCongenital Methemoglobinemia is a rare neurologic condition which can mimic other diseases such as epilepsy syndromes and leukodystrophies. The responsible gene, CYB5R3, is not typically included on commonly order neurologic and epilepsy panels. We recommend that laboratories include this gene on these tests which often precede larger‐scale genetic studies.