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Francesco Coppolino, Simona Brunetti, Leonardo Maria Bottazzo, Gianluigi Cosenza, Pasquale Sansone, Marco Fiore, Maria Beatrice Passavanti, Vincenzo Pota, Maria Caterina Pace Department of Women, Children and General and Specialized Surgery, University of Campania Luigi Vanvitelli, Naples, ItalyCorrespondence: Simona Brunetti, Department of Women, Children and General and Specialized Surgery, University of Campania Luigi Vanvitelli, Piazza Luigi Miraglia N.2, Naples, 80134, Italy, Tel +393492424108, Email simona.brunetti@studenti.unicampania.itPurpose: Thoracic surgery often results in severe chronic postoperative pain. Current evidence favors two locoregional techniques. Thoracic Epidural Anesthesia (TEA), the gold standard, and Thoracic Paravertebral Block (TPVB), which is associated with fewer side effects but is limited by short duration of action of local anesthetics (LA) and potential failure due to improper drug distribution. This study investigates the use of dexmedetomidine (DEX) as adjuvant to prolong the effects of LA in TPVB, with methylene blue used for visual confirmation of accurate injectate spread.Patients and Methods: We observed 6 patients undergoing Video-Assisted Thoracoscopy (VATS) lobectomy who received TPVB with ropivacaine, DEX and methylene blue. The primary endpoint was postoperative pain recorded at 1, 12, 24, 48 hours using Numeric Rating Scale (NRS); the secondary endpoints were cumulative opioid consumption in the first 24 hours in Milligram Morphine Equivalents (MME); adverse events: occurrence of bradycardia, hypotension, Postoperative Nausea and Vomiting (PONV); length of hospital stay. All patients completed the study.Results: Our results showed optimal pain scores, with NRS scores always below 4, decreased need for opioids, and prolonged analgesia. None of the patients had bradycardia nor PONV, but two patients experienced acute and self-limited hypotension following TPVB.Conclusion: Thoracic Paravertebral Block with Dexmedetomidine and methylene blue was effective and safe in controlling postoperative pain. Methylene blue could help improving knowledge on anesthetics distribution to reduce failure rates.Keywords: locoregional anesthesia, paravertebral block, post-operative pain, thoracic surgery

Salvatore Sardo,1 Giustino Varrassi,2 Mario Scartozzi,3 Maria Caterina Pace,4 Vittorio Schweiger,5 Stefano Tamburin,6 Mario Musu,1 Gabriele Finco1 1Department of Medical Sciences and Public Health, University of Cagliari, Monserrato, Italy; 2Paolo Procacci Foundation, Rome, Italy; 3Medical Oncology Unit, University Hospital and University of Cagliari, Monserrato, Italy; 4Department of Anesthesia and Pain Medicine, University of Napoli, Napoli, Italy; 5Department of Anesthesia and Pain Medicine, University of Verona, Verona, Italy; 6Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, ItalyCorrespondence: Salvatore Sardo, Department of Medical Sciences and Public Health, University of Cagliari, Monserrato, Italy, Email salvatore.sardo@unica.itIntroduction: Chemotherapy-induced peripheral neurotoxicity (CIPN) affects nearly 70% of cancer patients after chemotherapy, causing sensory, motor, autonomic dysfunction, and neuropathic pain. The Desirability of Outcome Ranking (DOOR) framework is proposed as a better way to assess preventive or therapeutic interventions for CIPN.Methods: A survey was conducted among Italian healthcare professionals and researchers affiliated to the Italian Chapter of the International Association for the Study of Pain (AISD) to identify the most important outcomes in clinical management and research.Results: Among the 73 respondents, 61 qualified for the survey, with an overall response rate of 1.2%. The vast majority were physicians (77%), most of whom were anesthesiologists (47.5%). The results showed that pain, survival, sensory impairment, motor impairment, and quality of life were consistently ranked as the most important outcomes, but there was significant disagreement in the outcomes relative ranking, making it difficult to develop a DOOR algorithm. The study also revealed that clinicians commonly use structured interviews to evaluate patients with CIPN, and the most prescribed drugs or supplements were palmitoylethanolamide, pregabalin, gabapentin and alpha lipoic acid as preventive agents and pregabalin, palmitoylethanolamide, duloxetine, gabapentin, and amitriptyline as therapeutic agents. However, many of these drugs have not been clinically proven to be effective for CIPN.Discussion: This study suggests that the implementation of a DOOR framework for CIPN using healthcare professionals is more difficult than expected, given the significant disagreement in our respondents’ ranking of outcomes. Our work provides interesting topics for future research in CIPN, but its limitations include a small sample size, a low response rate, and a possible selection bias.Keywords: neuropathic pain, peripheral neuropathy, cancer, taxane, Desirability of Outcome Ranking, survey, chemotherapy induced peripheral neuropathy

Marco Fiore,1,* Marco Cascella,2,* Sabrina Bimonte,2 Alberto Enrico Maraolo,3 Ivan Gentile,3 Vincenzo Schiavone,4 Maria Caterina Pace1 1Department of Anaesthesiological, Surgical and Emergency Sciences, University of Campania “Luigi Vanvitelli”, Naples, Italy; 2Department of Support for Clinical Activities and Critical Area, Division of Anesthesia and Pain Medicine, Istituto Nazionale Tumori – IRCCS “Fondazione G. Pascale”, Via Mariano Semmola, Naples, Italy; 3Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, Naples, Italy; 4Division of Anesthesia and Intensive Care, Hospital “Pineta Grande”, Castel Volturno, Italy *These authors contributed equally to this work Abstract: Fungal infections of the liver, most commonly caused by Candida spp., often occur in patients with hematologic malignancies treated with chemotherapy. Colonization of the gastrointestinal tract is thought to be the main origin of dissemination of Candida; mucositis and neutropenia facilitate the spread of Candida from the gastrointestinal tract to the liver. Hepatic involvement due to other fungi is a less common infectious complication in this setting. Fungal infections represent a less common cause of hepatic abscesses in non-oncohematologic population and the trend appears to be decreasing in recent years. Understanding of the etiology and epidemiology of fungal infections of the liver is indicated for an appropriate antimicrobial therapy and an overall optimal management of fungal liver infections. Keywords: fungal liver infections, antifungal agents, hepatosplenic candidiasis, acute disseminated candidiasis, life-threatening infections

Marco Fiore,1 Alberto Enrico Maraolo,2 Sebastiano Leone,3 Ivan Gentile,2 Arturo Cuomo,4 Vincenzo Schiavone,5 Sabrina Bimonte,4 Maria Caterina Pace,1 Marco Cascella4 1Department of Anaesthesiological, Surgical and Emergency Sciences, University of Campania “Luigi Vanvitelli”, Naples, Italy; 2Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, Naples, Italy; 3Division of Infectious Diseases, “San Giuseppe Moscati” Hospital, Avellino, Italy; 4Division of Anesthesia, Department of Anesthesia and Pain Medicine, Istituto Nazionale Tumori – IRCCS – Fondazione G. Pascale, Naples, Italy; 5Division of Anesthesia and Intensive Care, Hospital “Pineta Grande”, Castel Volturno, Italy Abstract: Spontaneous peritonitis (SP) is the most common infection among decompensated end-stage liver disease patients. SP is the infection of ascitic fluid (neutrophil ascitic count ≥250/mL) without an alternative focus of abdominal infection. According to the causative agent, clinicians can make the diagnosis of spontaneous bacterial peritonitis or spontaneous fungal peritonitis. The mortality rate is very high, ranging from one-fifth of the patients with spontaneous bacterial peritonitis to four-fifths of the patients with spontaneous fungal peritonitis. An immediate and accurate diagnosis can improve the outcome in end-stage liver disease patients. The aim of this work is to provide physicians with a practical diagnostic guidance for SP diagnosis according to current evidence, in order to improve the management of cirrhotic patients with infected ascitic fluid. Keywords: cirrhosis, spontaneous bacterial peritonitis, spontaneous fungal peritonitis, bacteriascites, fungal ascites