Daily Anesthesiology Research Analysis
A global Candida guideline updates diagnosis and treatment recommendations amid rising antifungal resistance and taxonomic changes. A pragmatic RCT in high-dose long-term opioid users found that offering a switch to buprenorphine did not improve pain or reduce opioid dose beyond usual collaborative care. A geospatial analysis shows that 67% of the U.S. population has ground access to ECMO-capable centers, with marked regional and socioeconomic disparities.
Summary
A global Candida guideline updates diagnosis and treatment recommendations amid rising antifungal resistance and taxonomic changes. A pragmatic RCT in high-dose long-term opioid users found that offering a switch to buprenorphine did not improve pain or reduce opioid dose beyond usual collaborative care. A geospatial analysis shows that 67% of the U.S. population has ground access to ECMO-capable centers, with marked regional and socioeconomic disparities.
Research Themes
- Antifungal stewardship and updated Candida management
- Opioid therapy strategies and pain outcomes
- Critical care systems and equitable ECMO access
Selected Articles
1. Global guideline for the diagnosis and management of candidiasis: an initiative of the ECMM in cooperation with ISHAM and ASM.
This multi-society global guideline updates diagnosis and management recommendations for candidiasis, addressing emerging pathogens (e.g., Candida auris) and antifungal resistance amid recent taxonomic revisions. It highlights gaps in prior guidance and provides consolidated, evidence-informed recommendations across invasive and mucocutaneous disease.
Impact: Provides contemporary, globally harmonized recommendations on Candida management at a time of resistance escalation and pathogen reclassification, directly guiding ICU, perioperative, and infectious disease care.
Clinical Implications: Supports antifungal stewardship, diagnostic pathways, and treatment selection for both invasive and mucocutaneous candidiasis, including considerations for Candida auris and fluconazole-resistant C. parapsilosis, informing ICU protocols and perioperative prophylaxis/therapy.
Key Findings
- Highlights rising difficult-to-treat Candida infections driven by new host factors and antifungal resistance.
- Addresses emerging pathogens (Candida auris and fluconazole-resistant Candida parapsilosis) as global threats.
- Notes recent taxonomic revisions that may complicate clinical practice and provides updated recommendations.
Methodological Strengths
- Multi-society, international collaboration (ECMM, ISHAM, ASM).
- Comprehensive scope across invasive and mucocutaneous candidiasis with evidence summaries.
Limitations
- Guideline/Review nature limits causal inference; recommendations depend on underlying evidence quality.
- Details on methodology and grading are not explicit in the abstract.
Future Directions: Implement guideline-concordant care pathways; evaluate outcomes and resistance trends; refine recommendations as new antifungals and diagnostics emerge.
Candida species are the predominant cause of fungal infections in patients treated in hospital, contributing substantially to morbidity and mortality. Candidaemia and other forms of invasive candidiasis primarily affect patients who are immunocompromised or critically ill. In contrast, mucocutaneous forms of candidiasis, such as oral thrush and vulvovaginal candidiasis, can occur in otherwise healthy individuals. Although mucocutaneous candidiasis is generally not life-threatening, it can cause considerable discomfort, recurrent infections, and complications, particularly in patients with underlying conditions such as diabetes or in those taking immunosuppressive therapies. The rise of difficult-to-treat Candida infections is driven by new host factors and antifungal resistance. Pathogens, such as Candida auris (Candidozyma auris) and fluconazole-resistant Candida parapsilosis, pose serious global health risks. Recent taxonomic revisions have reclassified several Candida spp, potentially causing confusion in clinical practice. Current management guidelines are limited in scope, with poor coverage of emerging pathogens and new treatment options. In this Review, we provide updated recommendations for managing Candida infections, with detailed evidence summaries available in the appendix.
2. Buprenorphine, Pain, and Opioid Use in Patients Taking High-Dose Long-Term Opioids: A Randomized Clinical Trial.
In a 12-month pragmatic RCT of 207 patients on high-dose long-term opioids, offering a switch to buprenorphine did not improve pain or reduce opioid dose beyond usual collaborative care. Both arms achieved small pain improvements and substantial opioid dose reductions; only 26% in the option arm switched.
Impact: High-quality pragmatic evidence informs clinicians and health systems about the real-world utility and uptake of switching strategies in chronic opioid therapy.
Clinical Implications: Switching to buprenorphine may not provide additional benefit over collaborative pain care when offered optionally, given low uptake; focus may be placed on multimodal pain care and structured dose reduction irrespective of switching.
Key Findings
- No between-group difference in Brief Pain Inventory total score at 12 months (between-group AMD −0.09; 95% CI, −0.52 to 0.34).
- Both groups had substantial reductions in opioid dose (AMD −61.0 mg/d vs −58.5 mg/d MME within arms), with no between-group difference (AMD −2.5 mg/d; 95% CI, −21.1 to 16.0).
- Only 26% of participants in the buprenorphine option arm switched to buprenorphine.
Methodological Strengths
- Pragmatic, multisite RCT with masked outcome assessment and 12-month follow-up.
- Pre-registered trial with clear primary and secondary outcomes.
Limitations
- Low uptake of switching (26%) likely diluted potential treatment effects.
- Predominantly male VA population may limit generalizability.
Future Directions: Evaluate structured protocols to increase buprenorphine uptake, identify subgroups who benefit from switching, and integrate behavioral and interdisciplinary pain programs.
IMPORTANCE: Guidelines recommend dose reduction or discontinuation of long-term opioid therapy when harm outweighs benefit, but strategies to help patients do so are limited. OBJECTIVE: To test optionally switching to buprenorphine as a strategy for improving pain and reducing opioids among patients prescribed high-dose, full agonist long-term opioid therapy. DESIGN, SETTING, AND PARTICIPANTS: In this pragmatic, multisite, 12-month randomized clinical trial with masked outcome assessment, patients treated at Veterans Affairs primary care clinics were recruited from October 2017 to March 2021, with follow-up completed June 2022. Eligible patients had moderate to severe chronic pain despite high-dose opioid therapy (≥70 mg/d for at least 3 months). Patients were randomized to having the option to switch to buprenorphine or not having the option to switch. INTERVENTIONS: The buprenorphine option was discussed with eligible patients as part of a larger trial of collaborative pain care interventions. Those who switched had structured follow-up to optimize dosing and address adverse effects. MAIN OUTCOMES AND MEASURES: The primary outcome was Brief Pain Inventory total score at 12 months. The main secondary outcome was opioid dose in morphine milligram equivalents at 12 months. RESULTS: Of 207 included participants, 185 (89.4%) were male, and the mean (SD) age was 60.9 (10.2) years. A total of 104 were randomized to the buprenorphine option and 103 to the no buprenorphine option. In the buprenorphine option arm, 27 participants (26.0%) switched. Over 12 months, the mean (SD) Brief Pain Inventory score improved from 6.8 (1.5) to 6.1 (1.9; adjusted mean difference [AMD], -0.59; 95% CI, -0.89 to -0.29) in the buprenorphine option arm and from 6.8 (1.6) to 6.3 (1.7; AMD, -0.50; 95% CI, -0.81 to 0.20) in the no option arm (between-group AMD, -0.09; 95% CI, -0.52 to 0.34). Over 12 months, mean (SD) opioid dosage decreased from 157 (75) mg/d to 94 (98) mg/d in the buprenorphine option arm (AMD, -61.0 mg/d; 95% CI, -74.1 to -47.9) and from 165 (88) mg/d to 107 (89) mg/d (AMD, -58.5 mg/d; 95% CI, -71.6 to -45.4) in the no option arm (between-group AMD, -2.5 mg/d; 95% CI, -21.1 to 16.0). CONCLUSIONS AND RELEVANCE: In this trial, outcomes did not differ between groups; both had small improvements in pain and substantial reductions in opioid dosage, but the proportion of participants who switched to buprenorphine was low. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03026790.
3. Geospatial Access to Extracorporeal Membrane Oxygenation in the United States.
Using U.S. Census and GIS data, 67% of the population had ground access to ECMO-capable centers, but entire regions (Puerto Rico, Wyoming, North Dakota, Alaska) lacked access. Limited access correlated with poverty, older age, and low population density, with racial/ethnic disparities in the Midwest and Northeast.
Impact: Defines national ECMO access gaps and correlates with sociodemographics, guiding health system planning and resource allocation for time-critical cardiopulmonary support.
Clinical Implications: Supports regionalization, hub-and-spoke ECMO planning, and consideration of aeromedical transport to mitigate access inequities, particularly in low-density and high-poverty areas.
Key Findings
- 67% of the U.S. population had ground access to ECMO-capable centers.
- No access identified in Puerto Rico, Wyoming, North Dakota, and Alaska.
- Limited access correlated with poverty, older age, and lower population density; racial/ethnic disparities were significant in the Midwest and Northeast.
Methodological Strengths
- Nationwide geospatial analysis leveraging U.S. Census block group data.
- Integration of demographic variables to quantify disparities.
Limitations
- Cross-sectional design cannot capture temporal changes or outcomes.
- Access defined by ground transport proximity may not reflect real-time availability or capacity.
Future Directions: Model ECMO network scenarios (hub-and-spoke, aeromedical) and evaluate impact on outcomes; incorporate capacity, referral pathways, and real-time transport constraints.
OBJECTIVES: To conduct a Geospatial Information System analysis of extracorporeal membrane oxygenation (ECMO) centers in the United States utilizing data from the U.S. Census Bureau to better understand access to ECMO care and identify potential disparities. DESIGN: A cross-sectional descriptive and statistical analysis of geospatial access to ECMO-capable centers in the United States, accounting for demographic variables. SETTING: The unit of analysis were U.S. Census block groups and demographic variables of interest obtained from the American Community Survey. PATIENTS: Patients accounted for in the U.S. Census data. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Sixty-seven percent of the U.S. population had direct access to ECMO-capable centers. Disparities were present, with Puerto Rico, Wyoming, North Dakota, and Alaska having no access. Poverty, increased age, and lower population density consistently correlated with limited access. We identified significant racial and ethnic disparities in the Midwest and Northeast. CONCLUSIONS: While 67% of the U.S. population had access to ECMO-capable centers by ground transportation, significant disparities in access exist. These findings emphasize the need for thoughtful implementation of ECMO systems of care to ensure equitable access. Future work should focus on developing novel systems of care that increase access utilizing advanced technology, such as aeromedical transport services.