Baptista, Aleksandra Murawska

Abstract Background: Clostridium ramosum ( C. ramosum ) is an anaerobic gram-positive bacillus of the human intestine and a rare cause of bacteremia. This retrospective cohort study evaluated clinical characteristics and outcomes of a multicenter cohort of adults with C. ramosum bacteremia. Methods: This multicenter retrospective cohort included adults (≥ 18 years) with true C. ramosum bacteremia at Mayo Clinic hospitals in Arizona, Florida, Minnesota, and Wisconsin from September 1, 2012, through December 31, 2025. Data were collected through search for C. ramosum in microbiological culture records. Clinical characteristics assessed included immune status, source of bacteremia, presence of sepsis, neutropenic fever, monomicrobial vs. polymicrobial bacteremia, antimicrobial resistance patterns, antimicrobial therapy, length of stay and 30-day all cause mortality. Exploratory odds ratios (ORs) with 95% confidence intervals (CIs) were reported. Results: Among 90 patients with a positive C. ramosum blood culture, 17 were classified as contaminants and 73 comprised the study cohort. Median age was 66.0 years (IQR, 56.0–75.0); 44 (60.3%) were male and 33 (45.2%) were immunocompromised (including 26 with active malignancy, while the remaining 7 were received biologic immunosuppression). The most common infection sources were gastrointestinal (32/73, 43.8%) and central line-related (8/73, 11%). At presentation, 50.7% of patients met criteria for sepsis and 15/73 (20.5%), were in septic shock. Of 73 isolates tested, 31/73 (44.3%) were clindamycin resistant and 9/73 (12.9%) tested intermediate. Anaerobic-active antimicrobial therapy was received by 53/73 (72.6%). Thirty-day mortality was 11/73 (15.1%). Mortality was 30.0% (6/20) with therapy without reliable anaerobic activity and 9.4% (5/53) with anaerobic-active antimicrobial therapy (OR, 4.02; 95% CI, 0.88–19.46; P = 0.060). The median hospital LOS was 8.0 days. Among 30-day survivors, anaerobic active antimicrobial therapy was associated with a shorter median LOS compared to therapy without reliable anaerobic activity (8.5 vs. 12.0 days). Immunocompromised patients had higher odds of monomicrobial C. ramosum bacteremia than immunocompetent patients (OR 3.16, 95% CI 1.19–8.39; p = 0.03). Patients with polymicrobial bacteremia had higher odds of sepsis (OR, 3.89; 95% CI, 1.43–10.55; P = 0.008) and septic shock (OR, 5.66; 95% CI, 1.17–27.36; P = 0.020). Patients with malignancy or neutropenia demonstrated significantly lower odds of presenting in septic shock (p = 0.018; p = 0.029 retrospectively). Microbiological clearance was achieved in 91.3% (42/46) of evaluable cases. Conclusions: This largest reported cohort defines the clinical and microbiological profile of C. ramosum bacteremia. Frequent clindamycin nonsusceptibility is clinically actionable. Several clinical associations found on univariable analysis should be further investigated in larger studies.

Background: Overlap between diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic state (HHS) is associated with significantly higher mortality than either condition alone. While hypertonic (trans locational) hyponatremia is common in hyperglycemic crises, clinically significant hypernatremia in mixed DKA/HHS presents with certain treatment challenges due to rapid osmotic shifts during insulin therapy. Case presentations: A 40-year-old woman with non-significant past medical history presented with vomiting, polyuria, polydipsia, and confusion for two days. Laboratory evaluation revealed serum glucose 1280 mg/dL, arterial pH 7.214, bicarbonate 13.1 mmol/L, anion gap 24, β-hydroxybutyrate 6.0 mmol/L, corrected sodium 152 mmol/L (measured sodium 133 mmol/L), and calculated effective osmolality 337 mOsm/kg. Initial treatment with isotonic saline and intravenous insulin led to improvement in hyperglycemia but worsening corrected hypernatremia to 160 mmol/L after 3 liters of normal saline. Free water deficit was calculated at 6.3 L. Fluid therapy was transitioned to hypotonic solutions with titration to limit sodium correction to ≤10 mmol/L per 24 hours. Sodium levels gradually normalized with resolution of ketoacidosis, and improvement in mental status without significant neurologic complications. Conclusion: In mixed DKA/HHS, early assessment of corrected sodium and effective osmolality is critical. Insulin-mediated intracellular water shifts may unmask or worsen hypernatremia. Prompt reassessment of corrected sodium and individualized fluid management is needed to avoid treatment-related exacerbation of hypertonicity.

Background: Nonpharmacologic interventions have known benefits for managing chronic pain, particularly for conditions such as fibromyalgia, and are included in clinical guidelines. However, eye movement desensitization and reprocessing (EMDR) has not been established as a routine clinical practice for pain management. Objective: To systematically review the efficacy of EMDR for managing chronic pain. Methods: A search was conducted to identify randomized clinical trials (RCTs) and observational studies by using the keywords “EMDR” and “chronic pain.” Information was collected on the study population, EMDR protocol, methods for pain assessment, and outcomes. Risk of bias was evaluated, and intervention effect sizes were determined by calculating Hedges g values for long-term follow-up data in RCTs. Results: A total of nine studies, including seven RCTs, were reviewed. The studies used various diverse pain measurement tools and EMDR protocols. All reported significant improvements in pain symptoms with EMDR. Most of the studies reported statistically significant improvements in associated mental health issues, notably in psychological distress (four out of four studies), anxiety (three out of three studies), and depression (three out of four studies). Effect sizes varied among the studies, with three RCTs reporting large effects, two RCTs reporting moderate effects, and one RCT reporting small or nonsignificant effects. Conclusion: EMDR shows promise for managing chronic pain and addressing associated mental health symptoms. Despite study differences and limitations, the findings of this systematic review support the potential use of EMDR for chronic pain management.

ABSTRACTThis report details a severe complication of phenol neurolysis in a diabetic patient, where phenol induced tissue necrosis can lead to severe cellulitis with ulceration that may prove difficult to treat. It emphasizes the importance of considering comorbidities when selecting phenol neurolysis for treatment of chronic pain.