\r\n\tThe protection of biodiversity is a major target of the European Union Marine Strategy Framework Directive, requiring an assessment of the status of biodiversity on the level of species, habitats, and ecosystems including genetic diversity and the role of biodiversity in food web structure and functioning. The restoration of marine ecosystems can support the productivity and reliability of goods and services that the ocean provides to humankind, to maintain ecosystem integrity and stability. Some of the goods produced by the marine ecosystem services are fish harvests, wild plant and animal resources, water, some of the services provided recreation, tourism, breeding and nursery habitats, water transport, carbon sequestration, erosion control, and habitat provision.
",isbn:"978-1-83968-460-9",printIsbn:"978-1-83968-459-3",pdfIsbn:"978-1-83968-544-6",doi:null,price:0,priceEur:0,priceUsd:0,slug:null,numberOfPages:0,isOpenForSubmission:!0,isSalesforceBook:!1,isNomenclature:!1,hash:"727e7eb3d4ba529ec5eb4f150e078523",bookSignature:"Dr. Ana M.M. Marta Gonçalves",publishedDate:null,coverURL:"https://cdn.intechopen.com/books/images_new/10845.jpg",keywords:"Non-indigenous Species, Dynamics, Ecosystem Maturation, Ecological Succession, Water Quality, Recovery, Biodiversity, Environmental Status, Ecosystem Services, Goods Production, Carbohydrates, Carrageenan",numberOfDownloads:null,numberOfWosCitations:0,numberOfCrossrefCitations:null,numberOfDimensionsCitations:null,numberOfTotalCitations:null,isAvailableForWebshopOrdering:!0,dateEndFirstStepPublish:"April 14th 2022",dateEndSecondStepPublish:"June 22nd 2022",dateEndThirdStepPublish:"August 21st 2022",dateEndFourthStepPublish:"November 9th 2022",dateEndFifthStepPublish:"January 8th 2023",dateConfirmationOfParticipation:null,remainingDaysToSecondStep:"12 days",secondStepPassed:!0,areRegistrationsClosed:!1,currentStepOfPublishingProcess:3,editedByType:null,kuFlag:!1,biosketch:"Dr. Ana Marta Gonçalves (h-index 19) holds a Ph.D. in Biology, from the University of Coimbra, Portugal, in collaboration with Ghent University, in 2011. During her research career obtained several grants is highly international competitive calls, including the MARS award for young scientists funded by The Royal Netherlands Institute for Sea Research (NIOZ) and the Foundation for Science and Technology (FCT, Portugal) grants.",coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"320124",title:"Dr.",name:"Ana M.M.",middleName:"Marta",surname:"Gonçalves",slug:"ana-m.m.-goncalves",fullName:"Ana M.M. Gonçalves",profilePictureURL:"https://mts.intechopen.com/storage/users/320124/images/system/320124.jpg",biography:"Ana Marta Gonçalves obtained a Ph.D. in Biology with a specialization in Ecology from the University of Coimbra, Portugal, in collaboration with Ghent University, Belgium, in 2011. Currently, she is an auxiliary researcher at the Marine and Environmental Sciences Center (MARE), Portugal, where she is also a member of the Directive Board. Since 2016, she has been a member of the Scientific Council of the Institute for Interdisciplinary Research, University of Coimbra (IIIUC). Dr. Gonçalves holds various administrative and management positions in international networks, societies (e.g., Society of Environmental Toxicology and Chemistry, AIL), and associations (e.g., PROAQUA). She is an editorial board member and reviewer for several indexed journals. She has published more than 70 journal articles, 50 book chapters, and 165 communications in international scientific events. She participated as a member and/or coordinator in more than twenty-five national and international projects and is currently the coordinator of four research projects. She has supervised more than ninety-five national and international undergraduate and graduate students. She has experience as a teacher of university courses and in accredited training sessions for teachers. Additionally, she has coordinated several ocean literacy and environmental education activities for kindergarten and school students. During her research career, Dr. Gonçalves obtained several grants and a MARS award for young scientists funded by The Royal Netherlands Institute for Sea Research (NIOZ).\n\nShe has expertise in biosafety, biochemical pathways, and impacts of stressors in aquatic species. Her research focus is on the valorization of marine resources and their applications in the industrial sector, such as the food and pharmaceutical industries. Her studies also highlight the application of biomarker tools for monitoring and managing aquatic systems",institutionString:"University of Coimbra",position:null,outsideEditionCount:0,totalCites:0,totalAuthoredChapters:"1",totalChapterViews:"0",totalEditedBooks:"0",institution:{name:"University of Coimbra",institutionURL:null,country:{name:"Portugal"}}}],coeditorOne:null,coeditorTwo:null,coeditorThree:null,coeditorFour:null,coeditorFive:null,topics:[{id:"12",title:"Environmental Sciences",slug:"environmental-sciences"}],chapters:null,productType:{id:"1",title:"Edited Volume",chapterContentType:"chapter",authoredCaption:"Edited by"},personalPublishingAssistant:{id:"278926",firstName:"Ivana",lastName:"Barac",middleName:null,title:"Ms.",imageUrl:"https://mts.intechopen.com/storage/users/278926/images/8058_n.jpg",email:"ivana.b@intechopen.com",biography:"As an Author Service Manager my responsibilities include monitoring and facilitating all publishing activities for authors and editors. From chapter submission and review, to approval and revision, copyediting and design, until final publication, I work closely with authors and editors to ensure a simple and easy publishing process. I maintain constant and effective communication with authors, editors and reviewers, which allows for a level of personal support that enables contributors to fully commit and concentrate on the chapters they are writing, editing, or reviewing. I assist authors in the preparation of their full chapter submissions and track important deadlines and ensure they are met. I help to coordinate internal processes such as linguistic review, and monitor the technical aspects of the process. As an ASM I am also involved in the acquisition of editors. Whether that be identifying an exceptional author and proposing an editorship collaboration, or contacting researchers who would like the opportunity to work with IntechOpen, I establish and help manage author and editor acquisition and contact."}},relatedBooks:[{type:"book",id:"1591",title:"Infrared Spectroscopy",subtitle:"Materials Science, Engineering and Technology",isOpenForSubmission:!1,hash:"99b4b7b71a8caeb693ed762b40b017f4",slug:"infrared-spectroscopy-materials-science-engineering-and-technology",bookSignature:"Theophile Theophanides",coverURL:"https://cdn.intechopen.com/books/images_new/1591.jpg",editedByType:"Edited by",editors:[{id:"37194",title:"Dr.",name:"Theophile",surname:"Theophanides",slug:"theophile-theophanides",fullName:"Theophile Theophanides"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"3161",title:"Frontiers in Guided Wave Optics and Optoelectronics",subtitle:null,isOpenForSubmission:!1,hash:"deb44e9c99f82bbce1083abea743146c",slug:"frontiers-in-guided-wave-optics-and-optoelectronics",bookSignature:"Bishnu Pal",coverURL:"https://cdn.intechopen.com/books/images_new/3161.jpg",editedByType:"Edited by",editors:[{id:"4782",title:"Prof.",name:"Bishnu",surname:"Pal",slug:"bishnu-pal",fullName:"Bishnu Pal"}],productType:{id:"1",chapterContentType:"chapter",authoredCaption:"Edited by"}},{type:"book",id:"371",title:"Abiotic Stress in Plants",subtitle:"Mechanisms and Adaptations",isOpenForSubmission:!1,hash:"588466f487e307619849d72389178a74",slug:"abiotic-stress-in-plants-mechanisms-and-adaptations",bookSignature:"Arun Shanker and B. 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The main idea is to produce a partition of an image such that each category or region is homogeneous with respect to some measures. The processed image can be useful for posterior image processing treatments.
\n\t\t\tSpatial autoregressive moving average (ARMA) processes have been extensively used in several applications in image/signal processing. In particular, these models have been used for image segmentation, edge detection and image filtering. Image restoration algorithms based on robust estimation of a two-dimensional process have been developed (Kashyap & Eom 1988). Also the two-dimensional autoregressive model has been used to perform unsupervised texture segmentation (Cariou & Chehdi, 2008). Generalizations of the previous algorithms using the generalized M estimators to deal with the effect caused by additive contamination was also addressed (Allende et al., 2001). Later on, robust autocovariance (RA) estimators for two dimensional autoregresive (AR-2D) processes were introduced (Ojeda, 2002). Several theoretical contributions have been suggested in the literature, including the asymptotic properties of a nearly unstable sequence of stationary spatial autoregressive processes (Baran et al., 2004). Other contributions and applications of spatial ARMA processes have been considered in many publications (Basu & Reinsel, 1993, Bustos 2009a, Francos & Friendlaner1998, Guyon 1982, Ho 2011, Illig & Truong-Van 2006, Martin1996, Vallejos & Mardesic 2004).
\n\t\t\tA new approach to perform image segmentation based on the estimation of AR-2D processes has been recently suggested (Ojeda 2010). First an image is locally modeled using a spatial autoregressive model for the image intensity. Then the residual autoregressive image is computed. This resulting image possesses interesting texture features. The borders and edges are highlighted, suggesting that the algorithm can be used for border detection. Experimental results with real images clarify how the algorithm works in practice. A robust version of the algorithm was also proposed, to be used when the original image is contaminated with additive outliers. Applications in the context of image inpainting were also offered.
\n\t\t\tAnother concern that has been pointed out in the context of spatial statistics is the development of coefficients to compare two spatial processes. Coefficients that take into account the spatial association between two processes have been proposed in the literature. (Tjostheim, 1978) suggested a nonparametric coefficient to assess the spatial association between two spatial variables. Later on, (Clifford et al. 1989) proposed an hypothesis testing procedure to study the spatial dependence between two spatial sequences. Rukhin & Vallejos (2008) studied asymptotic properties of the codispersion coefficient first introduced by Matheron(1965). The performance and impact of this coefficient to quantify the spatial association between two images is currently under study Ojeda et al. (2012). An adaptation of this coefficient to time series analysis was studied in Vallejos (2008).
\n\t\t\tIn the context of clustering time series Chouakria & Nagabhushan (2007) proposed a distance measure that is a function of the codispersion coefficient. This measure includes the correlation behavior and the proximity of two time series. They proposed to combine these distances in a multiplicative way, introducing a tuning constant controlling the weight of each quantity in the final product. This makes the measure flexible to model sequences with different behaviors, comparing them in terms of both correlation and dissimilarity between the values of the series.
\n\t\t\tThe structure of this chapter consist in two parts. In the first part we review some theoretical aspects of the spatial ARMA processes. Then the algorithm suggested by Ojeda(2010), its limitations and advantages are briefly described. In order to propose a more efficient algorithm new variants of this algorithm are suggested specially to address the problem of determining the most convenient (in terms of the quality of the segmentation) prediction window of unilateral AR-2D processes. The computation of the distance between the filtered images and the original one will be done by using the codispersion coefficient and other image quality measures (Wang and Bovik 2002). Examples with real images will highlight the features of the modified algorithm. In the second part, the codispersion coefficient previously used to measure the closeness between images is utilized in a distance measure to perform cluster analysis of time series. The distance measure introduced in Chouakria & Nagabhushan (2007) is generalized in the sense that considers an arbitrary lag \n\t\t\t\t\t
Spatial ARMA processes have been studied in the context of random fields indexed over\n\t\t\t\t\t\t
A random field \n\t\t\t\t\t\t
where \n\t\t\t\t\t\t
with\n\t\t\t\t\t\t
Applications of spatial ARMA processes have been developed, including analysis of yield trials in the context of incomplete block designs (Cullis & Glesson 1991, Grondona et al. 1996) and the study of spatial unilateral first-order ARMA model (Basu & Reinsel, 1993). Other theoretical extensions of time series and spatial ARMA models can be found in (Baran et al., 2004, Bustos et al., 2009b, Gaetan & Guyon 2010, Choi 2000, Genton & Koul 2008, Guo 1998, Vallejos and Garccía-Donato 2006).
\n\t\t\tIn this section, we describe an image segmentation algorithm that is based on a previous fitting of spatial autoregressive models to an image. This fitted image is constructed by dividing the original image into squared sub-images (e.g.,\n\t\t\t\t\t\t
Let\n\t\t\t\t\t\t
where\n\t\t\t\t\t\t
where \n\t\t\t\t\t\t
Algorithm 1.
\n\t\t\t\tFor each block \n\t\t\t\t\t\t
1. Compute estimators\n\t\t\t\t\t\t
where\n\t\t\t\t\t\t
2. Let \n\t\t\t\t\t\t
where \n\t\t\t\t\t\t
Then the approximated image \n\t\t\t\t\t\t
The image segmentation algorithm we describe below is supported by a widely known notion in regression analysis. If a fitted image very well represents the patterns on the original image, then the residual image (i.e., the fitted image minus the observed image) will not contain useful information about the original patterns because the model already explains the features that are present in the original image. On the contrary, if the model does not well represent the patterns that are present in the original image, then the residual image will contain useful information that has not been explained by the model. Thus, to implement an algorithm based on these notions, we must characterize which patterns are present in the residual image when the fitted image is not a good representation of the original one, and we must develop a technique to produce a fitting that is satisfactory in terms of segmentation but not a very good estimation in that the residual image still contains valuable information. (Ojeda et al. 2010) investigated these concerns and, based on several numerical experiments with images, determined that the residual image associated with a good local fitting is in fact poor in terms of structure (i.e., it is very similar to a white noise). However, when the fitted image is poor in terms of estimation, the residual image is useful for highlighting the boundaries and edges of the original image. Moreover, a bad fitting is related to the size of the block (or window) used in Algorithm 1. The best performance is attained for the maximum block size, which would be the size of the original image. The image segmentation algorithm introduced by (Ojeda et al. 2010) can be summarized as follows.
\n\t\t\t\tAlgorithm 2.
\n\t\t\t\t1. Use Algorithm 1 to generate an approximated image \n\t\t\t\t\t\t
2. Compute the residual autoregressive image given by \n\t\t\t\t\t\t
Example 1. We present examples with real images to illustrate the performance of Algorithms 1 and 2. These images were taken from the database http://sipi.usc.edu/database. Figure 1(a) shows an original image of size\n\t\t\t\t\t\t
In all experiments carried out in (Ojeda et al., 2010) and (Quintana et al., 2011), Algorithm 1 was implemented using the same prediction window for the AR-2D process, which contains only two elements belonging to a strongly causal region on the plane. Here, we consider other prediction windows to observe the effect on the performance of Algorithm 2. A description
\n\t\t\t\tImages generated by Algorithms 1 and 2.
(b)-(c) Images generated by Algorithm 2 with prediction windows of
of the most commonly used prediction windows in statistical image processing is in Bustos et al., (2009a). A brief description of the strongly causal prediction windows is given below.
\n\t\t\t\tFor all \n\t\t\t\t\t\t
For a given \n\t\t\t\t\t\t
In particular, if\n\t\t\t\t\t\t
The set \n\t\t\t\t\t\t
Strongly causal prediction windows.
Visually, the best segmentation for the aerial image is yielded by the prediction window \n\t\t\t\t\t\t
To gain insight on image quality measures, the fitted images produced by Algorithm 1 associated with the images shown in Figure 4(a) -(d) were compared aerially with the original image using three coefficients described in (Ojeda et al., 2012). These coefficients are briefly described below.
\n\t\t\t\tConsider two weakly stationary processes, \n\t\t\t\t\t\t
where \n\t\t\t\t\t\t
For \n\t\t\t\t\t\t
with\n\t\t\t\t\t\t
a)-(d) Images generated by Algorithm 2 with prediction windows
The index \n\t\t\t\t\t\t
where \n\t\t\t\t\t\t
where \n\t\t\t\t\t\t
The correlation coefficient and the coefficients defined in (6), (7) and (8) were computed to compare the fitted images, which were generated with a prediction window with two elements and associated with the images shown in Figure 4(a) -(f), and the original images. The results are shown in Table 1. In all cases, the highest values of the image quality measures are attained for the image fitted using the prediction window \n\t\t\t\t\t\t
Image quality measures between the fitted and original (aerial) images related to the residual images shown in
experiment was carried out for the image shown in Figure 2(a). Table 2 summarizes the values of the image quality coefficients for the fitted images generated by Algorithm 2 with prediction windows \n\t\t\t\t\t\t
Image quality measures between the fitted and original (peppers) images.
generated with prediction window \n\t\t\t\t\t\t
Algorithm 3.
\n\t\t\t\t1. Use Algorithm 1 to generate the approximated images \n\t\t\t\t\t\t
2. Compute an image quality index between \n\t\t\t\t\t\t
3. Compute the residual autoregressive image \n\t\t\t\t\t\t
Let \n\t\t\t\t\t\t
where \n\t\t\t\t\t\t
where
Dynamic time warping (DTW) is a variant of the Fréchet distance that considers mapping length as the sum of the spans of all coupled observations. That is,
\n\t\t\t\t\nDynamic time warping is then defined as
\n\t\t\t\tThe distances defined above are based on the proximity of the values \n\t\t\t\t\t\t
Several distance measures that are functions of the correlation between two sequences (\n\t\t\t\t\t\t
where \n\t\t\t\t\t\t
Consider two weakly stationary processes, \n\t\t\t\t\t\t
where \n\t\t\t\t\t\t
This coefficient involves a distance measure and a correlation-type measure that addresses both the correlation behavior and the proximity of two time series. The dissimilarity index depends on similarity behaviors, which should be specified in advance. The suggested dissimilarity index \n\t\t\t\t\t\t
where \n\t\t\t\t\t\t
where \n\t\t\t\t\t\t
Note that (13) is a generalization of the dissimilarity index introduced in Chouakria & Nagabhushan, (2007). The dissimilarity index (13) can capture high-order serial correlations between the sequences because the distance lag \n\t\t\t\t\t\t
The dependence of (13) on \n\t\t\t\t\t\t
When the variance of the codispersion coefficient is difficult to compute, resampling methods can be use to estimate the variance of the sample codispersion coefficient (Politis & Romano, 1994, Vallejos, 2008).
\n\t\t\t\tIn the next section, we present two simulation examples to illustrate the capabilities of the hierarchical methods using the distance measure (13) under the tuning function given by (14). All else being constant, the clusters produced using traditional distances are usually different from those yielded using the distance measure (13).
\n\t\t\tIn this example, we simulate observations from six first-order autoregressive models to illustrate the clustering produced by hierarchical methods when the sequences exhibit serial correlation. To generate the series, we consider the following models.
\n\t\t\t\t\nwhere \n\t\t\t\t\t\t
with \n\t\t\t\t\t\t
Two hundred observations were generated from each model for \n\t\t\t\t\t\t
a) Time series clustering using the Euclidean distance, (b) Time series clustering using
In Figure 5, we see that the dendrogram obtained using hierarchical methods with the Euclidean distance does not recognize the correlation structure between \n\t\t\t\t\t\t
To obtain better insight into the classification process using the proposed distance measure (13), we carried out a second simulation study that involves clustering measures based on other distances (but using the same setup). Observations from models 1-6 were generated using Gaussian white noise sequences for the errors, thereby preserving the same correlation structure used in the first study. The goal was to explore the ability of the distance measure (13) to group strongly correlated series first. A total of 1000 runs were considered for this
\n\t\t\t\tPercentage of correct clustering of the correlated series 1,2 and 3.
experiment, and 200 observations were generated in each run. We used measure (13) under the tuning function (14) for \n\t\t\t\t\t\t
Percentage of correct clustering of the correlated series (1,2, and 3).
Note from Table 3 that the traditional distance measures failed to group the correlated sequences, with the exception of the Minkowski distance, which correctly grouped the correlated series 99% of the time. The hierarchical algorithm that uses the distance measure (13) has a higher percentage of well-clustered correlated sequences than the same algorithm using the traditional distance measures described in Section 2 (see Table 4). The percentage of correct clusters increased in all cases with the distance measure (13), suggesting that hierarchical algorithms can be improved by including coefficients of association that consider high-order cross-correlation.
\n\t\t\tIn this section, we consider time series from four different locations in Argentina. The data set consists of 15 monthly NDVI series measured during a period of 19 years (i.e., January 1982-December 2000). The observed values correspond to a transformation to the interval \n\t\t\t\t\t\t
Fifteen NDVI series collected from four different regions in South America.
We can observe a variety of different patterns in Figure 6. In particular, the data collected during the period 1994-1995 show irregular behavior. Additionally, the original data lack some information (less than one percent) for all series over the period 1999-2000. An imputation technique based on moving averages, which takes into account past and future values of the series, was used to replace missing values. The series were grouped by geographical region and then plotted (Figure 7). Similar patterns are observed for the series across each group.
\n\t\t\t\t\n\t\t\t\tAn exploratory data analysis was carried out for each of the 15 series. There exists significant autocorrelation of order of at least one in all series. Seasonal components are present in most of partial autocorrelations. Because there is no large departure from the weakly stationary assumptions (i.e., constant means and variances), all series can be modeled using the Box-Jenkins approach. Specifically, seasonal ARIMA models can be fitted to each single series with a small number of parameters (i.e., \n\t\t\t\t\t\t
The fifteen NDVI series grouped by area.
Using the NVDI data set described in Section 3.5, the distance measure \n\t\t\t\t\t\t
Clusters produced by using a hierarchical method with the Minkowski distance and (13).
Clusters produced by using a hierarchical method with the Fréchet distance and (13)
This chapter described two problems. The first problem involved image segmentation, while the second problem involved clustering time series. For the first problem, a new algorithm was proposed that enhances the segmentation yielded by a previous algorithm (Ojeda et al., 2010). Identifying the best prediction window improves segmentation based on the estimation of AR-2D processes and generalizes the previous algorithm to different prediction windows associated with unilateral processes on the plane. An analysis of the association between the original and fitted images relies on the selection of a suitable image quality measure. Using three image quality coefficients that are commonly used in image segmentation, we carried out experiments that support our algorithm. Specifically, a set of images belonging to the image database (http://sipi.usc.edu/database/) were processed and provided satisfactory results (not shown here) in terms of image segmentation.
\n\t\t\tThis chapter also proposed an extension of the dissimilarity measure first introduced in (Chouakria & Nagabhushan,2007). The simulation experiments performed and the data analysis carried out for relevant ecological series show that the distance lag \n\t\t\t\t\t
Now, further research for the topics presented in this chapter is outlined.
\n\t\t\tFollowing the notation used in the Algorithm 3, consider the following residual image.
\n\t\t\tOne interesting open problem involves the characterization of the types of images and distributions associated with the segmentation produced by Algorithms 2 and 3. In addition, the definition and study of linear combinations of residual images produced by distinct prediction windows is also of interests. For example,
\n\t\t\t\nwhere \n\t\t\t\t\t
Regarding the clustering technique problem, the distribution of \n\t\t\t\t\t
The first author was partially supported by Fondecyt grant 1120048, UTFSM under grant 12.12.05, and Proyecto Basal CMM, Universidad de Chile. The second author was supported in part by CIEM-FAMAF, UNC, Argentina.
\n\t\tShoulder surgery by arthroscopy or open methods has increased in recent years. The choice of anesthetic technique depends on the patient’s conditions, the preferences of the surgical group, the position the patient is to be placed, and the experience of the anesthesiologist. General anesthesia (GA) has been considered the ideal technique for this type of surgery, but advances in regional anesthesia have gradually changed this statement. The approaches, interscalene (ISBP) block (C5 C6) or the upper trunk (UT) are the most established options; the supraclavicular approach offers optimal coverage, including the proximal arm. Patients with respiratory compromise may not tolerate hemi diaphragmatic paresis (HDP) associated with proximal approaches. Distal approaches are associated with lower rates of HDP, but coverage of the proximal upper extremity may be incomplete. The use of ultrasound guidance (USG) for nerve blocks has increased success and safety and has allowed access to more peripheral brachial plexus blocks to prevent diaphragmatic paralysis. Regional anesthesia is also an excellent supplement to GA to improve postoperative pain management and decrease the need for opioid use.
Clavicle surgery has even more controversy about the choice of the regional block, since the innervation has not been well described. But in recent years, alternative regional block methods to interscalene brachial plexus block have appeared that are suitable as single anesthesia or combined with sedation or GA.
In this chapter, we pretend to describe the innervation of the shoulder and clavicle based on current knowledge and the sonoanatomy of the neck and armpit as a guide for the performance of regional nerve blocks.
Since shoulder surgeries produce severe postoperative pain, regional anesthesia techniques could effectively control pain at rest and in motion, reduce muscle spasm and facilitate early discharge [1].
The BP is formed by the fusion of the ventral ramus of the spinal nerves C5, C6, C7, C8, and T1, with the variable contribution of C4 (15-62% of cases) and T2 (16-73% of cases). The roots emerge in the groove between the anterior scalenus and middle scalenus muscles [2]. Shoulder and proximal arm innervation are provided by branches of the BP: suprascapular nerve (SSN) (from posterior division of UT), axillary and subscapular nerves (from posterior cord), lateral pectoral nerve, and medial brachial cutaneous nerve (MBCN)) (from lateral cord), and the intercostobrachial nerve (ICBN) (originating directly from proximal intercostal nerves). SSN may be spared by an infraclavicular approach (Figure 1) [3, 4].
Brachial plexus. Roots – Start in the spinal cord. Arise from anterior rami C5-T1. Landmark: Pass inferolateral between the anterior and middle scalene muscles. Trunks
The most frequently identified innervation pattern comprises three nerve bridges consisting of articular branches from suprascapular, axillary, and lateral pectoral nerves, connecting trigger points (Figures 2 and 3) [5, 6, 7].
Distribution of shoulder articular branches. Courtesy of MF Rojas.
Shoulder structures and their related innervation.
Articular branches classified in relation to the spinoglenoid notch:
Medial branch (MSAb) originates 1.3 cm proximal to the suprascapular notch, giving branches to the coracoclavicular ligaments and the medial pole of the subacromial bursa, clavicular insertion of the acromioclavicular ligament, and motor branches to the supraspinatus muscle.
Lateral branch (LSAb) originates at the level of the suprascapular notch, giving sensory branches to the lateral subacromial pole and acromial insertion of the acromioclavicular ligament. Two subacromial branches provide medial and lateral sensory innervation (bipolar) to the subacromial bursa.
The posterior glenohumeral branch (PGHb) originates at 3 cm from the suprascapular notch, and posterior to the spinoglenoid ligament, course inferomedial towards the posterior capsule of the shoulder [8].
One or two articular branches of the main trunk travel with the anterior humeral circumflex artery between the tendons of the subscapular and latissimus dorsi muscles branching into medial branch to scapular aspect of the anteroinferior capsule and portions of the axillary recess; lateral branch to humeral portion of the anterior capsule [6]. The posterior division (after leaving the quadrangular space) gives a branch for the teres minor muscle, from which emerge 1 to 4 articular branches, to innervate the posteroinferior capsule. The branch innervating the deltoid muscle gives small multiple articular branches towards the lateral aspect of the humeral head the posterior and lateral supra-lying fascia of the shoulder capsule [6, 9, 10].
The LPN arises from two branches of the anterior divisions of the upper and middle trunks (33.8% of cases), or as a single root of the lateral cord (23.4%). It receives fibers from C5 to C7. Cross the superomedial side of the coracoid process and sends small branches to the coracoclavicular and coracoacromial ligaments, anterior acromioclavicular joint, subacromial bursa and anterosuperior portion of the glenohumeral capsule. It gives branches to the periosteum of the clavicle. Therefore, its blockade produces analgesia for distal clavicle surgery [6, 11]. The muscular branch originates from the articular branch of the LPN and innervates the deltoid muscle and skin over the subacromial region (Figure 4) [7, 11].
Lateral pectoral nerve.
A glenohumeral articular branch anastomosis with branches of the AN to innervate the long head of the biceps tendon (LHBT) and anterior capsule. The superior subscapular nerve gives 1 or 2 articular branches to innervate the anterosuperior quadrant of the glenohumeral joint [12]. Receives fibers for C5-C6.
The
Mechanoreceptors are more concentrated in the medial and lateral insertions of the anterior capsule. Nociceptors are identified primarily in the upper quadrant of the shoulder, including the subacromial bursa (SAB), glenohumeral ligaments (GHL), coracoacromial (CAL), coracoclavicular ligaments (CCL), the proximal portion of the LHBT, and the transverse humeral ligament (THL). The SAB is the area of densest and tripolar nociceptive innervation. These three nociceptive poles may correspond to the location of the lateral/medial subacromial branches of the SSN (i.e., lateral and middle poles) and the articular branch of the lateral pectoral nerve LPN (anterior pole); Thin articular branches of the AN may also participate in the innervation of the lateral pole of SAB [6].
The most painful structures in clavicle surgery include the skin over the incision area and the highly innervated periosteum. The supraclavicular nerve originates as a single trunk from the anterior ramus of cervical nerves C3-C4. It divides into medial (suprasternal), intermediate (supraclavicular), and lateral (supra-acromial) branches. The medial branch supplements the skin over the anterior aspect of the thorax, as far below as the second rib, and the sternoclavicular joint. The intermediate branch pierces the deep cervical fascia just above the clavicle and runs over the pectoralis major and deltoid muscle; supply cutaneous innervation to the skin above these muscles, as far below as the second rib. The lateral branch pierces the deep cervical fascia just above the clavicle, passes over the acromial process, to innervate skin of the upper and posterior shoulder regions (Figure 5) [13, 14].
Nerves involved in clavicular innervation.
Innervation of the clavicle itself is less well described. Different authors attribute contributions from SSN, long thoracic, nerve for the subclavian muscle, and LPN [15].
Situated posterior to the clavicular part of the pectoralis major muscle. It extends from the clavicle, costochondral joints, and coracoid process. It converges in the axilla and acts as a protective structure over the neurovascular package. The clavicular fascia splits to enclose the subclavius muscle before attaching to the clavicle, the posterior layer fuses with the deep cervical fascia which connects the omohyoid muscle to the clavicle. Medially, it is attached to the first rib before coming together with the fascia over the first two intercostal spaces. Laterally, it is attached to the coracoid process before blending with the coracoclavicular ligament. The fascia often thickens to form the costocoracoid ligament, between the first rib and coracoid process. Inferiorly, the fascia becomes thin, splits around pectoralis minor, and descends to blend with the axillary fascia and laterally with the fascia over the short head of the biceps. It is pierced by CALL [cephalic vein, artery (thoracoacromial), lateral pectoral nerve, lymphatics]. The clavipectoral fascia surrounds the clavicle, and the nerve endings of the clavicle penetrate this fascia (Figure 6) [16].
Clavipectoral fascia.
Interscalene or supraclavicular block of the BP are considered the standard technique for anesthesia and analgesia in this type of surgery. The most common adverse effect is HDP due to ipsilateral PN block in 100% of patients and a 27% decrease in forced vital capacity and forced expiratory volume at the first second [17]. At the level of the cricoid cartilage (C6 transverse process (TP)) the PN is 0.18 cm prior to the BP, but it diverges at a rate of 3 mm for each centimeter below the cricoid cartilage.
USG has allowed to decrease the anesthetic minimum volume required in 50% of patients (5-7 mL vs. 30-40 mL) using ropivacaine 0.75% or bupivacaine 0.5%, and a decrease of 50% in the incidence of paralysis of the diaphragm when the injection is performed laterally to the C5-C6 roots. If the concentration of the anesthetic is also diluted to a half or third, the HDP rate is reduced to 20% (it is still a contraindication in patients with decreased lung reserve) but carries the risk of not achieving surgical anesthesia and decreasing the duration of the blockade. According to Renes et al., if the injection is done at the C7 root level, the minimum volume required to block C5-C6 in 50% of patients was 2.9 mL (maximum volume of 6 mL), with no PN block (although there is a substantial risk of vascular lesions from punctures at this level). Renes et al. avoided PN block by administering the anesthetic in the “cornet pocket “ (intersection of the first rib with the subclavian artery and posterolateral aspect of the BP) and a volume less than 20 ml [18]. Aliste et al. compared ISB with supraclavicular block following the Renes technique, finding equal pain control, but with HDP rate of 9% [19]. Cornish found a 1% of HDP rate by advancing a catheter from the supraclavicular level and locating the tip at the infraclavicular level, inferomedial to the coracoid process [20, 21].
A combination that could be effective would be the association of a SSN block with a BP block at infraclavicular level [22] (addresses the axillary, lateral pectoral, subscapular nerves), although Petrar et al. [23] reported a 3% incidence of HDP during infraclavicular BP block (30 mL ropivacaine 0.5%).
The following paragraphs describe different techniques to achieve a selective block of the nerves supplying the shoulder.
It focuses on the anesthetic deposit near the UT, before the take of the SSN. At this level, the phrenic nerve (PN) has diverged from the BP. Compoy et al. [24] found that 5 mL of methylene blue injected around UT stains SSN, lateral pectoral nerve, and roots of C5 and C6, but not of the PN [25]. Kim et al. found analgesic equivalence between UT block and ISB, achieving equivalent surgical anesthesia and HDP incidence of 5% vs. 71% using 15 mL of injectate [26]. Ultrasound (US) examination reveals the plexus in the groove between the anterior and middle scalene muscles, deep to the prevertebral fascia. The sternocleidomastoid muscle (SCM) lies superficially, and the PN can be seen on the anterior surface of the anterior scalene muscle (ASM), crossing it towards the medial side, after the last contribution originating in the C5 root. Sonoanatomy of the transverse processes can be used to identify spinal roots. Serial images reveal the process of confirmation of the UT [27].
The blocking needle is advanced from lateral to medial, under the deep cervical fascia until its tip reaches the UT lateral edge, proximal to the exit of the SSN (it is identified as a rounded hypoechoic structure that separates laterally from the UT and runs deep to the omohyoid muscle). The needle does not pass through the middle scalene muscle (MSM), where the dorsal scapular nerve (DSN) and long thoracic nerve (LTN) are located. The injectate volume is 7 to 12 mL of local anesthetic (LA) (one-half or one-third strength). Here the nerves have a greater amount of perineural tissue, protecting against neurological dysfunction, which has been reported in about 14% of ISBP blocks and can last for up to 10 days (Figure 7).
Upper trunk and supraclavicular nerves blockade. A. C5 and C6 (bifid) roots at interscalene space, near to PN. C7 TP view. B. UT formation (inferior to C7 TP). C. Origin of supraescapular nerve (SSN). D. Back to UT - needle at its posterior surface. Local anesthetic (LA) injection at posterior surface of UT. E. Retreated needle to space between SCM-MSM. LA injected around supraclavicular nerves.
The UT provides anesthesia to nerves from the spinal cord segments C5 and C6 (originating fiber to SSN and AN, inferior subscapular nerve, and partially, to LPN) [25] and decreases the incidence and severity of PN block. HDP was observed in 97.5% in ISB vs. 76.3% of the UT block groups (P = 0.006); paresis was complete in 72.5% vs. 5.3% of the patients, respectively. The decrease in spirometry values from baseline was significantly greater in the ISB block group. UT block provides non inferior analgesia compared to ISBP block [28].
It can be supplemented with blockade of the supraclavicular nerves to anesthetize the skin over the shoulder. The needle is retracted to the space between prevertebral fascia (over the MSM) and superficial (enveloping) layer of the deep cervical fascia, under the SCM, where the supraclavicular nerves are located. A new injection of 2 to 3 mL of LA blocks nerves supplying skin over collarbone and shoulder cap and their sensitive contribution to the acromioclavicular joint.
The supraclavicular nerve trunk (C3 and C4) emerges at the posterior edge of SCM. The superficial cervical plexus (SCP) is localized by placing a transducer on the posterior edge of the SCM at the level of the upper pole of the thyroid cartilage. It can be difficult to identify the individual nerves. The greater auricular nerve (GAN) is a useful reference reliably identified as a small superficial hypoechoic round structure on SCM (Figure 8) [29].
Supraclavicular nerve trunk and SCP scan process.
The posterior approach in the suprascapular fossa (in the space between the suprascapular notch and the spinoglenoid notch) where the nerve travels through its floor under the supraspinatus muscle fascia, results in adequate flooding of SSN with minimal propagation to the BP [30] but may spare MSAb. This approach is inferior to ISBP block for pain control, at least in the first 4 hours [31, 32, 33]. The UT (C5-C6) is the major contributor to the suprascapular, axillary, and subscapular nerves. Hence, UT blockade can provide adequate control of shoulder pain, but it is still remarkably close to the PN [34, 35].
With ultrasound image, the SSN could be identified as it branches from UT, and runs laterodorsally underneath the omohyoid muscle, in 81% of cases vs. 36% in the supraspinatus fossa, at an average depth of 8 mm vs. 35 mm in the supraspinatus fossa. Peripheral nerve stimulator can help in the identification [35]. Rothe et al. studied twelve healthy volunteers; the SSN was followed into the subclavian triangle under the inferior belly of the omohyoid muscle; injecting 1 mL of lidocaine 2%, 10 blocks were performed, 8 demonstrated a reduced manual muscle-testing scale (MMT) of the supra- and infraspinatus muscles at 15 min and 30 min; increasing the injected volume, produced musculocutaneous and radial nerves blockade due to cephalic diffusion of the anesthetic (Figure 9) [36].
Scan sequence of the SSN at the supraclavicular fossa. A: Locate the transverse process of C6 vertebral vertebra and C6 and C5 roots. B: Scanning downward, locate the C7 TP and C7 root, which can be seen laterally to vertebral vessels. C: Just below the C7 transverse process, C7 root runs towards the interscalene groove. The PN is diverging from the BP, on the anterior surface ASM. Caudally to the C7 transverse process, UT and MT conformation can be imaged. D: In the supraclavicular fossa. From the UT branches the SSN. E: The SSN travels below the omohyoid muscle. F: The SSN separates from the UT, below omohyoid muscle. The nerve goes along suprascapular artery.
In 14 BP of 7 corpses, the separation between the SSN and the PN was found to be 2.5-6.4 cm, and the injection of 10 mL of solution around the SSN produced staining of the UT of the BP and its branches (SSN, anterior and posterior divisions - 14 cases, 100%), the middle trunk (MT) (13 cases, 93%), the PN (3 cases; 21.4%) [37]. In the cadaveric study by Sehmbi, the SSN and omohyoid muscle were easily identified and, with nerve injections of 5 mL, nerve staining with contrast dye was seen in 90% of dissections. The UT, MT, and LT were stained in 90%, 80% in 20% of dissections, respectively. The PN was mildly stained in 20% of the dissections [38]. Figure 9 shows the scan sequence of the SSN at the supraclavicular fossa.
The articular branch or LPN crosses the superomedial side of the coracoid process [6, 11]. The US probe is placed between the inferior border of the clavicle and the superior border of the coracoid process. Below the deltoid muscle, the acromial branch of the thoracoacromial artery and, along with it, the nerve can be found (Figure 10).
USG to locate the articular branch of LPN.
The AN provides motor innervation to subscapular, teres major and minor, and deltoids muscles. The nerve branches before entering the quadrangular space. The anterior division of the AN originates the first articular branch, which ends in the anteroinferior capsule; blocking the nerve by the posterior approach can provide incomplete analgesia.
The sensitive skin supply of the medial aspect of the arm is provided by MBCN, ICBN, and variable branches of the intercostal nerves [39].
The AN run into the inferolateral margin of the subscapular muscle and enters the quadrangular space (QS) (limits: upper, teres minor muscle; inferior, teres major muscle; medial, long head of the triceps muscle; lateral, surgical neck of the humerus; anterior, insertion of the subscapular muscle on the minor tuberosity). The subscapular muscle, the upper edge of the teres major muscle, and the humerus are the sonographic marks that lead to the identification of the AN. The ICBN originates mainly from the second intercostal nerve, with variable contributions from intercostal nerves T1, T3, and T4. It is identified in the axillary subfascial space, along.
with fat, lymph nodes, and other cutaneous branches of the upper intercostal nerves. After crossing the axillary subfascial space, it courses on the surface of the latissimus dorse muscle, covered by the superficial axillaryfascia [40].
With the arm abducted 90o, the BP is identified in the armpit (anterior to the teres major and the tendon of the latissimus dorse muscles, seen in short axis) (Position 1, Figure 11). The probe moves slightly in a proximal direction (position 2, Figure 11) towards the QS, which is identified as soon as the upper edge of the teres major muscle deepens. At this point, the AN appears as an oval honeycomb structure, accompanied by the posterior circumflex artery of the humerus (although it has an inconsistent course and presence). The elevation of the arm from 90 o to 180 o brings the nerve closest to the skin by closing the quadrangular space.
AN US images at axillary fossa. A. Transducer position 1. The US imagen corresponds to D. B. Transducer position 2. The US imagen corresponds to E. C. Anterior view of axilla showing the quadrangular space; AN emerges posterior to brachial plexus and enters the QS divided in anterior and posterior ramus. D. Scanning starts viewing the brachial plexus at the axillary level, observing the fascia of the teres major muscle. E. Moving proximally the transducer (towards the axillary fossa) shows the teres major muscle fascia deepening and the subscapular muscle tendon; the QS is seen. F. with 180° arm extension, the teres major muscle closes the QS. G and H. the axillary nerve is observed above the subscapular muscle as a hyperechoic image next to the circumflex humeral artery.
With the arm positioned parallel to the thoracic wall with internal rotation and forearm pronated on the abdomen, a US probe is placed below and parallel to the clavicula identifying the coracoid process and lesser tubercle and intertubercular (bicipital) groove; then the arm is externally rotated, pushing the subscapular muscle rostrally and identifiable under the deep lamina of the deltoid fascia; the first portion of the AN is present between the deep lamina of the deltoid fascia and the superficial lamina of the subscapular muscle, where needle tip is placed. Interfacial position is confirmed after injection of 2 mL of normal saline, then 10 mL of 0.25% bupivacaine is injected. Rotating caudally the medial side of the probe and abducting the limb permits to directly visualize the AN and posterior circumflex humeral artery.
The injection is distributed on the anterior surface of the subscapular muscle and around the proximal insertion of the coracobrachialis and biceps brachial muscles. The sensory block is detected in AN area and areas supplied by the branches of the musculocutaneous nerve, lateral pectoral nerve, lateral supraclavicular nerve, and intercostobrachial nerve.
A complete AN blockade could provide anesthesia to the anteroinferior and lateral edges, and to part of the posterior aspect. of the shoulder joint capsule. The remaining shoulder joint areas are innervated by the SSN, which must be blocked if complete anesthesia of the shoulder is to be achieved. The LPN, or its articular branches, can be blocked by PECS I block or at the space between the coracoid process and clavicle (Figure 12) [41, 42].
US-guided anterior approach to AN blockade. A. Axillary nerve and its relations to subscapular, deltoid, and pectoralis muscles, axillary and circumflex humeral arteries, coracoid process, and humerus bone. B. Sagittal oblique ultrasound anatomy of the anterior axilla. C. Ultrasound scan: Transducer between coracoid process (medial) and the lesser tubercle of the humerus. Arm adducted and internal rotation. D. Transducer parallel to the inferior border of the clavicle, ultrasound mark is lateral. E and F. arm rotated externally/no abduction; subscapular muscle appears over humeral head. G and H. full external rotation and abduction of the arm. The medial side of the transducer is rotated inferiorly to obtain a sagittal oblique view of the axilla. The subscapular muscle is pushed rostrally and is identifiable under the deep lamina of the deltoid fascia. The cephalic vein is seen in the groove between deltoid and pectoralis major muscles. The axillary artery appears in the image and laterally to it, the axillary nerve is located. The needle shows the injection around the axillary nerve, on the surface of the subscapular muscle.
Clavicle fractures account for 2.6–4% of fractures in adults and 35% of shoulder injuries. The annual incidence is estimated between 29 and 64 per 100,000, and are distributed as follows: diaphysis 69-82%, lateral end 21-28%, and medial end 2-3%. There is often caudal displacement of the lateral fragment under the shoulder weight and elevation of the medial fragment by traction by the SCM. Infrequently, posterior displacement of the medial end can cause compression of the mediastinum and main vessels requiring urgent intervention. Non-displaced fractures are managed without surgery, while surgical management is preferred in cases of displaced fractures in active adults [43].
Innervation of the skin above the second rib is supplied by the supraclavicular nerves of the SCP. Terminal branches of suprascapular, subclavian, lateral pectoral, and long thoracic nerves pass through the plane between the clavipectoral fascia and the clavicle and, theoretically, contribute to collarbone innervation.
Common approaches in anesthesia for clavicle fracture surgery are GA, regional anesthesia techniques such as ISBP block combined with SCP block. The clavipectoral fascial plane (CPB) block (Figure 13) is accomplished by injecting 10 to 15 mL of LA deep to the clavipectoral fascia on the medial and lateral side of the fracture site. A SCP or supraclavicular nerves block should be implemented to provide a sensory block of the skin of the shoulder. This nerve block can potentially involve the PN if the injection is not performed accurately in the proper subcutaneous plane and using low volumes. The block can be used for diaphysis and lateral end interventions, but as isolated block for surgical anesthesia, it only works for diaphysis fractures (Figure 13) [44].
The peri clavicular fascial plane or clavipectoral planes block (CPB). A: Scan throughout all clavicle surface, identifying the fracture site (proximal segment is displaced upward) B: Initiate the US scan in a sagittal paramedian position C: Tilting the ultrasound probe, is positioned on the upper surface of the clavicle D: Identify the anterior and posterior borders of clavicle E: 25 G needle tip positioned between bony surface and periosteum (if seen: By the fractured site, the periosteum is usually detached F: After 1-2 ml injected, the periosteum is further disengaged G: A second hyperechoic line appears, which correspond to clavipectoral fascia H: Needle tip positioned in the gap between periosteum and clavipectoral fascia I: Initial injection under clavipectoral fascia. Track Injectate spread in caudal and cephalic way along the anterior surface of clavicle I: Alternatively, Clavipectoral fascia scanning and needle in plane insertion from caudal to cephalic over clavipectoral fascia between pectoral major and minor muscles; this plane is the target for injection of local anesthetic.
For lateral fractures, including acromioclavicular and coracoacromial ligaments, articular branch of lateral pectoral nerve should be blocked. Likewise, if the surgery involves the acromioclavicular joint, the SSN should be blocked. Yamak Altinpulluk states that in the description of Ince et al., the LA was injected between the periosteum of the clavicle and the surrounding fascia (assumed as the clavipectoral fascia), but cadaveric dissections show that the spread is between the clavicle and fascia of the pectoralis major muscle in the upper and anterior aspect of the clavicle, with anesthetic spread under the deep layer of superficial cervical fascia and the superficial layer of pectoralis major fascia. The naming of this block as CPB is misleading and suggests that this block should be named as peri clavicular block (PB) [45]. The publication of a series of cases by Kukreja et al., shows the injection of the LA between the clavipectoral fascia and the pectoralis major muscle, resolving the previous objections described by Yamak Altinpulluk et al. [46].
ISBP block targets the roots and trunks of the BP in the interscalene groove between ASM and MSM, and is directed towards C5-C6 nerve roots or UT. With higher volumes, C7 and even C8 nerve roots may be blocked. The block provides analgesia and anesthesia to the shoulder, lateral two-thirds of the clavicle, proximal humerus, and shoulder joint surgeries. Continuous infusion of 0.15% bupivacaine or ropivacaine (vs GA or intravenous anesthesia) provides adequate pain relief, similar side effects, and high patient satisfaction. ISBP block is associated with a high risk of PN blockade and HDP. Persistent PN palsy after ISBP block has recently gained wider recognition (reported incidence of 1:2000). Phrenic nerve palsy could be due to direct needle trauma or intraneural injection during landmark guided ISB but this complication has not been described with USG ISBP block. More peripheral BP nerve blockades are alternatives in scenarios in which avoiding PN palsy is critical, without clinically meaningful analgesic differences compared with ISBP block, except during recovery room stay [47]. Vocal hoarseness and Horner’s syndrome are due to self-limiting temporary blockade of the ipsilateral recurrent laryngeal nerve and stellate ganglion [48]. ISBP block cannot reliably block the C8 and T1 ventral rami [48, 49].
ISBP Blockade relies on the visualization of the relevant anatomy, needle-tip position and LA spread using USG plus peripheral nerve stimulation with or without injection pressure monitoring. USG allows fewer needle passes, lower volumes of LA, and better postoperative analgesia [1].
Figure 14 shows the scan process of interscalene space: At cricoid cartilage level, with transverse scan, identify the carotid artery and move the transducer laterally to locate the sonographic image of C5 and C6 TP; C5-C6 nerve roots are seen between the anterior and posterior tubercles and are traced in the groove between ASM and MSM, deep to the prevertebral fascia. The SCM lies superficially, and the PN runs medially over the ASM, away from the C5 root. Below the C6 TP and nerve root, C7 TP appears and the C7 nerve root can be seen anteriorly as hypoechoic round structure, lateral to vertebral vessels (identified by doppler color scan); meanwhile C5 and C6 nerve trunk are merging to conform to the UT; inferiorly to C7 transverse process, C7 nerve root conforms the MT. The dorsal scapular nerve (DSN) arises from the C5 nerve root and is imaged as a hyperechoic structure traversing the MSM, accompanied by LTN. Both must be avoided not needling through MSM. The block is performed positioning the tip deep to the C6 nerve root or UT and seeking the spread of LA anterior and posterior to the nerves, within the interscalene groove, and then repositioning of the needle superficial to the C5 nerve root or UT to obtain a satisfactory spread of LA. Do not needle between C5 and C6. 10-15 mL of LA (ropivacaine 0.75%) produce surgical anesthesia. Supraclavicular nerves blockade is added aimed to provide complete anesthesia to the shoulder cap.
Interscalene brachial plexus block.
The PN diverges at a rate of 0.3 mm per cm below the cricoid cartilage. Its blockade is reported in as 100% with a traditional landmark-based approach using volumes greater than 20 mL, and between 25 and 50% with lower volumes. Forced expiratory volume in 1 s (FEV1) may be reduced by up to 40%, and patients with comorbidities (obesity and respiratory disease) may develop troublesome dyspnea. ISBP block has been associated with an incidence of temporary neurological dysfunction in up to 14% at 10 days. Hypotension and bradycardic events occur in up to 20% during shoulder surgery, typically in the sitting position, and at around 30 min after the placement of an ISBP block. High circulating catecholamine concentrations and an underfilled, hyper contractile ventricle (induced by venous pooling) stimulates intramyocardial mechanoreceptors resulting in an abrupt reduction in sympathetic tone together with increased vagal tone. Prompt treatment with an antimuscarinic (ideally atropine) with or without sympathomimetic drugs is indicated [1].
Selective trunk block (SeTB) targets injection around individual trunks, with small volumes of LA. Produces anesthesia of the entire upper extremity (C5-T1) except the ICBN innervated area (T2). Is performed as one injection targeting UT and MT at interscalene and another one targeting LT at the corner pocket of the supraclavicular fossa (Up to 25 ml of LA are used). Produces HDP similar to UT approach [49, 50].
Shoulder surgery is accompanied by severe acute postoperative pain that continues to be an unresolved problem. The gold standard for analgesia after this surgery is the ISBP. Unfortunately, this block is associated with a high incidence of ipsilateral phrenic nerve block and the consequent HDP, which restricts its use in patients with pre-existing pulmonary involvement, so it is prudent to consider the practical options to avoid or reduce the incidence of this complication. Nerve block techniques without diaphragmatic involvement such as supraclavicular blocks, upper trunk blocks, anterior suprascapular nerve blocks, costoclavicular blocks, and combined infraclavicular-suprascapular blocks are some of the possible alternatives. It has been suggested that costoclavicular blocks could provide postoperative analgesia similar to ISBP along with a 0% incidence of HDP. It is not clear whether costoclavicular blocks could achieve surgical anesthesia for shoulder surgery. The anterior suprascapular nerve blocks have been shown to provide surgical anesthesia and analgesia similar to ISBP. However, the risk of HDP has not been adequately quantified. Of the remaining nerve blocks that preserve diaphragm function, supraclavicular blocks (with injection of posterolateral local anesthetic to the brachial plexus), upper trunk blocks, and combined anterior and infraclavicular suprascapular blocks achieve analgesia similar to ISBP, along with an incidence of HDP <10% [17, 25, 51].
Orthopedic surgeries are well known to be very painful. General anesthesia or regional anesthesia, or a combination of both, are optimal options for shoulder surgery. Regional nerve blocks are essential for postoperative analgesia and can be used alone or as a complement to GA, therefore the postoperative analgesia could be prolonged for 24 hours or more [49]. Regional anesthesia in the setting of GA has a relative contraindication but, with the use of USG, this statement has been challenged [52].
ISBP blockade is the most common approach and a highly effective technique, but with a high incidence of HDP, that contraindicates it in patients with lung disease or contralateral PN paralysis [25, 51]. Supraclavicular blocks vs. ISBP, result in similar pain control and patient satisfaction, but with an incidence of HDP exceeding 60%, when LA is injected intracluster, vs. 9% depositing LA posterolateral to neural cluster (in this setting, cluster refers to the confluence of trunks and divisions of BP) [25, 28].
UT block targets C5-C6 nerve fibers traveling with SSN and AN, producing analgesia not inferior to ISBP block and a 75% incidence reduction of PN involvement [21, 22, 23, 24]. The HDP occurs with an incidence of 5% [25].
AN block (posterior access) plus SSN block (sub supraspinous muscle access) produces a good analgesic effect in minor surgeries, compared to ISBP block, but spares the AN anterior articular branches, the lateral pectoral nerve articular branch, and subscapular nerve [25, 41, 45] and is inferior in terms of analgesia when compared to ISB in major surgeries. SSN block at sub omohyoid level extends to the UT almost always and occasionally to the middle trunk, with almost no PN block [33, 34, 35, 37]. It provides surgical anesthesia and similar analgesia to ISB [25]. It remains necessary to formally quantify the incidence of HDP. Both blocks should be accompanied by a supraclavicular nerve block at the lateral edge of the SCM to give analgesia to the skin over the shoulder and its contribution to the acromioclavicular joint [29].
AN block may be performed at the axillary fossa, producing anesthesia/analgesia that includes the anterior and posterior branches, with the advantage that intercostobrachial nerve block may be performed with the same puncture [38]. Access to the AN by anterior route is easy to perform and has the possibility of extending to the musculocutaneous nerve, superior subscapular nerve, lateral pectoral nerve and through the clavipectoral fascia, to the lateral supraclavicular nerve [41]. Clavipectoral fascia and peri clavicular block can provide anesthesia and analgesia for fractures of the middle third of the clavicle, without PN paralysis [44, 45, 46].
To date, the strategy that achieves analgesic equivalence with ISB with a 0%-incidence of HDP is the costoclavicular block. In 2019, Aliste et al. [53] compared ISB and costoclavicular block in 44 patients undergoing arthroscopic surgery, finding equivalent analgesia in both groups. Moreover, there is no evidence that this block results in surgical anesthesia [25]. Supraclavicular blocks (with LA injection posterolateral to the BP), UT blocks, and combined infraclavicular-anterior suprascapular blocks have been shown to achieve similar analgesia to ISB [54], coupled with an HDP incidence <10%. Decreasing LA injectate volume could avoid HDP altogether and should also be investigated for the provision of surgical anesthesia [25].
The anesthetic challenge imposed by shoulder surgery is considerable. This chapter reviews current options for regional anesthesia in this type of surgery. A regional technique, GA, or a combination of both can be appropriately used. Performing nerve blocks distally to the ISBP approach, PN paralysis can be reduced considerably, although not eliminated, taking care when performing them in patients with lung disease or contralateral HDP.
We thank MF Rojas for Figure 2. The authors also thank Dr. Victor Whizar-Lugo for his valuable support with this chapter.
The authors declare that they have no conflicts of interest.
axillary nerve anterior scalene muscle brachial plexus clavipectoral plane block dorsal scapular nerve general analgesia great auricular nerve hemi diaphragmatic paresis intercostobrachial nerve interscalene brachial plexus intravenous analgesia Local anesthetic Long head biceps tendon lateral pectoral nerve lateral suprascapular articular branch Levator scapulae muscle lower trunk long thoracic nerve medial brachial cutaneous nerve medial pectoral nerve medial suprascapular articular Branch middle scalene muscle middle trunk peri clavicular block phrenic nerve Quadrangular space sternocleidomastoid muscle superficial cervical plexus suprascapular nerve Selective trunk block transverse process ultrasound ultrasound guidance ultrasound image upper trunk
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The role of ocean and atmosphere in determining the genesis and intensification of TCs is discussed. This chapter reviews the past and current research activities including inter-annual and intra-seasonal changes in TCs, current status of TC research using numerical weather prediction, gaps identified and relevant measures taken by the meteorological and government agencies in this direction, along with future directions in order to improve the understanding and predictability over the NIO region.",book:{id:"5180",slug:"recent-developments-in-tropical-cyclone-dynamics-prediction-and-detection",title:"Tropical Cyclone Dynamics, Prediction, and Detection",fullTitle:"Recent Developments in Tropical Cyclone Dynamics, Prediction, and Detection"},signatures:"Kasturi Singh, Jagabandhu Panda, Krishna K. 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There are 91 (33) TCs and 113 (50) cases with CE identified in the WNP (ATL). Three CE structural change types are classified as follows: a CE with the inner eyewall dissipated in an eyewall replacement cycle (ERC, 51 and 56% in the WNP and ATL), a CE with the outer eyewall dissipated first and the no eyewall replacement cycle (NRC, 27 and 29% in the WNP and ATL), and a CE structure that is maintained for an extended period (CEM, 23 and 15% in the WNP and ATL). The moat size and outer eyewall width in the WNP (ATL) basin are approximately 20–50% (15–25%) larger in the CEM cases than that in the ERC and NRC cases. Our analysis suggests that the ERC cases are more likely dominated by the internal dynamics, whereas the NRC cases are heavily influenced by the environment condition, and both the internal and environmental conditions are important in the CEM cases. A good correlation of the annual CE TC number and the Oceanic Niño index is found (0.77) in WNP basin, with most of the CE TCs occurring in the warm episodes. In contrast, the El Niño/Southern Oscillation (ENSO) may not influence on the CE formation in the ATL basin. After the CE formation, however, the unfavorable environment that is created by ENSO may reduce the TC intensity quickly during warm episode. The variabilities of structural changes in the WNP basin are larger than that in the ATL basin.",book:{id:"5180",slug:"recent-developments-in-tropical-cyclone-dynamics-prediction-and-detection",title:"Tropical Cyclone Dynamics, Prediction, and Detection",fullTitle:"Recent Developments in Tropical Cyclone Dynamics, Prediction, and Detection"},signatures:"Yi-Ting Yang, Hung-Chi Kuo, Eric A. Hendricks and Melinda S. Peng",authors:[{id:"24152",title:"Dr.",name:"Melinda",middleName:null,surname:"Peng",slug:"melinda-peng",fullName:"Melinda Peng"},{id:"24153",title:"Prof.",name:"Hung-Chi",middleName:null,surname:"Kuo",slug:"hung-chi-kuo",fullName:"Hung-Chi Kuo"},{id:"179607",title:"Dr.",name:"Yi-Ting",middleName:null,surname:"Yang",slug:"yi-ting-yang",fullName:"Yi-Ting Yang"},{id:"180632",title:"Prof.",name:"Eric",middleName:null,surname:"Hendricks",slug:"eric-hendricks",fullName:"Eric Hendricks"}]},{id:"60010",title:"Influence of Climate Regime Shift on the Abrupt Change of Tropical Cyclone Activity in Various Genesis Regions",slug:"influence-of-climate-regime-shift-on-the-abrupt-change-of-tropical-cyclone-activity-in-various-genes",totalDownloads:1192,totalCrossrefCites:2,totalDimensionsCites:3,abstract:"In this chapter, we reported the effect of basin-scale climate regime shift (CRS) on the abrupt change of tropical cyclone (TC) activity in various genesis basins, including the Pacific, Atlantic, and Indian Oceans. An analysis of regime shift index reveals that the worldwide TC activity experienced four significant abrupt changes during 1960–2014, including (i) an abrupt increase/decrease in the eastern North Pacific (ENP)/western North Pacific (WNP) in the early 1970s, (ii) an abrupt increase in the ENP and WNP in the early 1980s, (iii) an abrupt increase in the North Atlantic and ENP in the middle 1990s, and (iv) an abrupt decrease in the WNP and western South Pacific in the late 1990s. Three of them are identified concurrent with a significant CRS. The possible influence of a CRS on the abrupt change of TC activity in various genesis regions is addressed. We demonstrate that a CRS induced time mean state shift results in a rapid change in the large-scale dynamic and thermodynamic conditions, which substantially contributes to the abrupt change of TC activity in various genesis regions. In addition the CRS, the effect of interdecadal variability, such as the interdecadal Pacific Oscillation and Atlantic Multidecadal Oscillation, on the abrupt change of TC activity was discussed.",book:{id:"6701",slug:"extreme-weather",title:"Extreme Weather",fullTitle:"Extreme Weather"},signatures:"Chi-Cherng Hong and Yi-Kai Wu",authors:[{id:"236396",title:"Prof.",name:"Chi-Cherng",middleName:null,surname:"Hong",slug:"chi-cherng-hong",fullName:"Chi-Cherng Hong"},{id:"242960",title:"Mr.",name:"Yi-Kai",middleName:null,surname:"Wu",slug:"yi-kai-wu",fullName:"Yi-Kai Wu"}]},{id:"60156",title:"Heat Waves: Health Effects, Observed Trends and Climate Change",slug:"heat-waves-health-effects-observed-trends-and-climate-change",totalDownloads:1254,totalCrossrefCites:2,totalDimensionsCites:2,abstract:"According to climate change scenarios, the average annual temperature will increase by around 4°C if current trends continue. Maximum temperatures, however, have already registered higher values in different regions of the world, increasing the number, duration and intensity of heat waves. With the increase of maximum temperatures and the increase of significance of heat wave events, reports of mortality episodes due to heat effects have been increasing. According to the information from the Centre for Research on Epidemiology of Disasters (CRED), 5 of the 20 deadliest disasters between 1996 and 2015 were heat wave events. This chapter analyzes heat wave events, the criteria for determining dangerous temperature thresholds, as well as trends already observed, and those expected due to climate change. Heat wave events are correlated with observed increases on mortality rates, and recommendations are suggested to prevent their effects on human health.",book:{id:"6701",slug:"extreme-weather",title:"Extreme Weather",fullTitle:"Extreme Weather"},signatures:"Martínez-Austria Polioptro F and Bandala Erick R.",authors:[{id:"238453",title:"Dr.",name:"Polioptro F.",middleName:null,surname:"Martinez-Austria",slug:"polioptro-f.-martinez-austria",fullName:"Polioptro F. Martinez-Austria"},{id:"238454",title:"Dr.",name:"Erick R.",middleName:null,surname:"Bandala",slug:"erick-r.-bandala",fullName:"Erick R. 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The whole process of submitting an article and editing of the submitted article goes extremely smooth and fast, the number of reads and downloads of chapters is high, and the contributions are also frequently cited.",author:{id:"55578",name:"Antonio",surname:"Jurado-Navas",institutionString:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRisIQAS/Profile_Picture_1626166543950",slug:"antonio-jurado-navas",institution:{id:"720",name:"University of Malaga",country:{id:null,name:"Spain"}}}}]},series:{item:{id:"6",title:"Infectious Diseases",doi:"10.5772/intechopen.71852",issn:"2631-6188",scope:"This series will provide a comprehensive overview of recent research trends in various Infectious Diseases (as per the most recent Baltimore classification). Topics will include general overviews of infections, immunopathology, diagnosis, treatment, epidemiology, etiology, and current clinical recommendations for managing infectious diseases. Ongoing issues, recent advances, and future diagnostic approaches and therapeutic strategies will also be discussed. This book series will focus on various aspects and properties of infectious diseases whose deep understanding is essential for safeguarding the human race from losing resources and economies due to pathogens.",coverUrl:"https://cdn.intechopen.com/series/covers/6.jpg",latestPublicationDate:"June 25th, 2022",hasOnlineFirst:!0,numberOfPublishedBooks:13,editor:{id:"131400",title:"Prof.",name:"Alfonso J.",middleName:null,surname:"Rodriguez-Morales",slug:"alfonso-j.-rodriguez-morales",fullName:"Alfonso J. Rodriguez-Morales",profilePictureURL:"https://mts.intechopen.com/storage/users/131400/images/system/131400.png",biography:"Dr. Rodriguez-Morales is an expert in tropical and emerging diseases, particularly zoonotic and vector-borne diseases (especially arboviral diseases). He is the president of the Travel Medicine Committee of the Pan-American Infectious Diseases Association (API), as well as the president of the Colombian Association of Infectious Diseases (ACIN). He is a member of the Committee on Tropical Medicine, Zoonoses, and Travel Medicine of ACIN. He is a vice-president of the Latin American Society for Travel Medicine (SLAMVI) and a Member of the Council of the International Society for Infectious Diseases (ISID). Since 2014, he has been recognized as a Senior Researcher, at the Ministry of Science of Colombia. He is a professor at the Faculty of Medicine of the Fundacion Universitaria Autonoma de las Americas, in Pereira, Risaralda, Colombia. He is an External Professor, Master in Research on Tropical Medicine and International Health, Universitat de Barcelona, Spain. He is also a professor at the Master in Clinical Epidemiology and Biostatistics, Universidad Científica del Sur, Lima, Peru. In 2021 he has been awarded the “Raul Isturiz Award” Medal of the API. Also, in 2021, he was awarded with the “Jose Felix Patiño” Asclepius Staff Medal of the Colombian Medical College, due to his scientific contributions to COVID-19 during the pandemic. He is currently the Editor in Chief of the journal Travel Medicine and Infectious Diseases. His Scopus H index is 47 (Google Scholar H index, 68).",institutionString:"Institución Universitaria Visión de las Américas, Colombia",institution:null},editorTwo:null,editorThree:null},subseries:{paginationCount:4,paginationItems:[{id:"4",title:"Fungal Infectious Diseases",coverUrl:"https://cdn.intechopen.com/series_topics/covers/4.jpg",editor:{id:"174134",title:"Dr.",name:"Yuping",middleName:null,surname:"Ran",slug:"yuping-ran",fullName:"Yuping Ran",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bS9d6QAC/Profile_Picture_1630330675373",biography:"Dr. Yuping Ran, Professor, Department of Dermatology, West China Hospital, Sichuan University, Chengdu, China. Completed the Course Medical Mycology, the Centraalbureau voor Schimmelcultures (CBS), Fungal Biodiversity Centre, Netherlands (2006). International Union of Microbiological Societies (IUMS) Fellow, and International Emerging Infectious Diseases (IEID) Fellow, Centers for Diseases Control and Prevention (CDC), Atlanta, USA. Diploma of Dermatological Scientist, Japanese Society for Investigative Dermatology. Ph.D. of Juntendo University, Japan. Bachelor’s and Master’s degree, Medicine, West China University of Medical Sciences. Chair of Sichuan Medical Association Dermatology Committee. General Secretary of The 19th Annual Meeting of Chinese Society of Dermatology and the Asia Pacific Society for Medical Mycology (2013). In charge of the Annual Medical Mycology Course over 20-years authorized by National Continue Medical Education Committee of China. Member of the board of directors of the Asia-Pacific Society for Medical Mycology (APSMM). Associate editor of Mycopathologia. Vice-chief of the editorial board of Chinses Journal of Mycology, China. Board Member and Chair of Mycology Group of Chinese Society of Dermatology.",institutionString:null,institution:{name:"Sichuan University",institutionURL:null,country:{name:"China"}}},editorTwo:null,editorThree:null,editorialBoard:[{id:"302145",title:"Dr.",name:"Felix",middleName:null,surname:"Bongomin",slug:"felix-bongomin",fullName:"Felix Bongomin",profilePictureURL:"https://mts.intechopen.com/storage/users/302145/images/system/302145.jpg",institutionString:null,institution:{name:"Gulu University",institutionURL:null,country:{name:"Uganda"}}},{id:"45803",title:"Ph.D.",name:"Payam",middleName:null,surname:"Behzadi",slug:"payam-behzadi",fullName:"Payam Behzadi",profilePictureURL:"https://mts.intechopen.com/storage/users/45803/images/system/45803.jpg",institutionString:"Islamic Azad University, Tehran",institution:{name:"Islamic Azad University, Tehran",institutionURL:null,country:{name:"Iran"}}}]},{id:"5",title:"Parasitic Infectious Diseases",coverUrl:"https://cdn.intechopen.com/series_topics/covers/5.jpg",editor:{id:"67907",title:"Dr.",name:"Amidou",middleName:null,surname:"Samie",slug:"amidou-samie",fullName:"Amidou Samie",profilePictureURL:"https://mts.intechopen.com/storage/users/67907/images/system/67907.jpg",biography:"Dr. Amidou Samie is an Associate Professor of Microbiology at the University of Venda, in South Africa, where he graduated for his PhD in May 2008. He joined the Department of Microbiology the same year and has been giving lectures on topics covering parasitology, immunology, molecular biology and industrial microbiology. He is currently a rated researcher by the National Research Foundation of South Africa at category C2. He has published widely in the field of infectious diseases and has overseen several MSc’s and PhDs. His research activities mostly cover topics on infectious diseases from epidemiology to control. His particular interest lies in the study of intestinal protozoan parasites and opportunistic infections among HIV patients as well as the potential impact of childhood diarrhoea on growth and child development. He also conducts research on water-borne diseases and water quality and is involved in the evaluation of point-of-use water treatment technologies using silver and copper nanoparticles in collaboration with the University of Virginia, USA. He also studies the use of medicinal plants for the control of infectious diseases as well as antimicrobial drug resistance.",institutionString:null,institution:{name:"University of Venda",institutionURL:null,country:{name:"South Africa"}}},editorTwo:null,editorThree:null,editorialBoard:[{id:"188881",title:"Dr.",name:"Fernando José",middleName:null,surname:"Andrade-Narváez",slug:"fernando-jose-andrade-narvaez",fullName:"Fernando José Andrade-Narváez",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRIV7QAO/Profile_Picture_1628834308121",institutionString:null,institution:{name:"Autonomous University of Yucatán",institutionURL:null,country:{name:"Mexico"}}},{id:"269120",title:"Dr.",name:"Rajeev",middleName:"K.",surname:"Tyagi",slug:"rajeev-tyagi",fullName:"Rajeev Tyagi",profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRaBqQAK/Profile_Picture_1644331884726",institutionString:"CSIR - Institute of Microbial Technology, India",institution:null},{id:"336849",title:"Prof.",name:"Ricardo",middleName:null,surname:"Izurieta",slug:"ricardo-izurieta",fullName:"Ricardo Izurieta",profilePictureURL:"https://mts.intechopen.com/storage/users/293169/images/system/293169.png",institutionString:null,institution:{name:"University of South Florida",institutionURL:null,country:{name:"United States of America"}}}]},{id:"6",title:"Viral Infectious Diseases",coverUrl:"https://cdn.intechopen.com/series_topics/covers/6.jpg",editor:{id:"158026",title:"Prof.",name:"Shailendra K.",middleName:null,surname:"Saxena",slug:"shailendra-k.-saxena",fullName:"Shailendra K. 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Dr. Saxena is a fellow of various international societies/academies including the Royal College of Pathologists, United Kingdom; Royal Society of Medicine, London; Royal Society of Biology, United Kingdom; Royal Society of Chemistry, London; and Academy of Translational Medicine Professionals, Austria. He was named a Global Leader in Science by The Scientist. 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He also obtained an MSc in Molecular and Genetic Medicine, and a Ph.D. in Clinical Immunology and Human Genetics from the University of Sheffield, UK. He also completed a short-term fellowship in Pediatric Clinical Immunology and Bone Marrow Transplantation at Newcastle General Hospital, England. Dr. Rezaei is a Full Professor of Immunology and Vice Dean of International Affairs and Research, at the School of Medicine, Tehran University of Medical Sciences, and the co-founder and head of the Research Center for Immunodeficiencies. He is also the founding president of the Universal Scientific Education and Research Network (USERN). Dr. Rezaei has directed more than 100 research projects and has designed and participated in several international collaborative projects. He is an editor, editorial assistant, or editorial board member of more than forty international journals. He has edited more than 50 international books, presented more than 500 lectures/posters in congresses/meetings, and published more than 1,100 scientific papers in international journals.",institutionString:"Tehran University of Medical Sciences",institution:{name:"Tehran University of Medical Sciences",country:{name:"Iran"}}},{id:"180733",title:"Dr.",name:"Jean",middleName:null,surname:"Engohang-Ndong",slug:"jean-engohang-ndong",fullName:"Jean Engohang-Ndong",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/180733/images/system/180733.png",biography:"Dr. Jean Engohang-Ndong was born and raised in Gabon. After obtaining his Associate Degree of Science at the University of Science and Technology of Masuku, Gabon, he continued his education in France where he obtained his BS, MS, and Ph.D. in Medical Microbiology. He worked as a post-doctoral fellow at the Public Health Research Institute (PHRI), Newark, NJ for four years before accepting a three-year faculty position at Brigham Young University-Hawaii. Dr. Engohang-Ndong is a tenured faculty member with the academic rank of Full Professor at Kent State University, Ohio, where he teaches a wide range of biological science courses and pursues his research in medical and environmental microbiology. Recently, he expanded his research interest to epidemiology and biostatistics of chronic diseases in Gabon.",institutionString:"Kent State University",institution:{name:"Kent State University",country:{name:"United States of America"}}},{id:"188773",title:"Prof.",name:"Emmanuel",middleName:null,surname:"Drouet",slug:"emmanuel-drouet",fullName:"Emmanuel Drouet",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/188773/images/system/188773.png",biography:"Emmanuel Drouet, PharmD, is a Professor of Virology at the Faculty of Pharmacy, the University Grenoble-Alpes, France. As a head scientist at the Institute of Structural Biology in Grenoble, Dr. Drouet’s research investigates persisting viruses in humans (RNA and DNA viruses) and the balance with our host immune system. He focuses on these viruses’ effects on humans (both their impact on pathology and their symbiotic relationships in humans). He has an excellent track record in the herpesvirus field, and his group is engaged in clinical research in the field of Epstein-Barr virus diseases. He is the editor of the online Encyclopedia of Environment and he coordinates the Universal Health Coverage education program for the BioHealth Computing Schools of the European Institute of Science.",institutionString:null,institution:{name:"Grenoble Alpes University",country:{name:"France"}}},{id:"131400",title:"Prof.",name:"Alfonso J.",middleName:null,surname:"Rodriguez-Morales",slug:"alfonso-j.-rodriguez-morales",fullName:"Alfonso J. Rodriguez-Morales",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/131400/images/system/131400.png",biography:"Dr. Rodriguez-Morales is an expert in tropical and emerging diseases, particularly zoonotic and vector-borne diseases (especially arboviral diseases). He is the president of the Travel Medicine Committee of the Pan-American Infectious Diseases Association (API), as well as the president of the Colombian Association of Infectious Diseases (ACIN). He is a member of the Committee on Tropical Medicine, Zoonoses, and Travel Medicine of ACIN. He is a vice-president of the Latin American Society for Travel Medicine (SLAMVI) and a Member of the Council of the International Society for Infectious Diseases (ISID). Since 2014, he has been recognized as a Senior Researcher, at the Ministry of Science of Colombia. He is a professor at the Faculty of Medicine of the Fundacion Universitaria Autonoma de las Americas, in Pereira, Risaralda, Colombia. He is an External Professor, Master in Research on Tropical Medicine and International Health, Universitat de Barcelona, Spain. He is also a professor at the Master in Clinical Epidemiology and Biostatistics, Universidad Científica del Sur, Lima, Peru. In 2021 he has been awarded the “Raul Isturiz Award” Medal of the API. Also, in 2021, he was awarded with the “Jose Felix Patiño” Asclepius Staff Medal of the Colombian Medical College, due to his scientific contributions to COVID-19 during the pandemic. He is currently the Editor in Chief of the journal Travel Medicine and Infectious Diseases. His Scopus H index is 47 (Google Scholar H index, 68).",institutionString:"Institución Universitaria Visión de las Américas, Colombia",institution:null},{id:"332819",title:"Dr.",name:"Chukwudi Michael",middleName:"Michael",surname:"Egbuche",slug:"chukwudi-michael-egbuche",fullName:"Chukwudi Michael Egbuche",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/332819/images/14624_n.jpg",biography:"I an Dr. Chukwudi Michael Egbuche. I am a Senior Lecturer in the Department of Parasitology and Entomology, Nnamdi Azikiwe University, Awka.",institutionString:null,institution:{name:"Nnamdi Azikiwe University",country:{name:"Nigeria"}}},{id:"284232",title:"Mr.",name:"Nikunj",middleName:"U",surname:"Tandel",slug:"nikunj-tandel",fullName:"Nikunj Tandel",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/284232/images/8275_n.jpg",biography:'Mr. Nikunj Tandel has completed his Master\'s degree in Biotechnology from VIT University, India in the year of 2012. He is having 8 years of research experience especially in the field of malaria epidemiology, immunology, and nanoparticle-based drug delivery system against the infectious diseases, autoimmune disorders and cancer. He has worked for the NIH funded-International Center of Excellence in Malaria Research project "Center for the study of complex malaria in India (CSCMi)" in collaboration with New York University. The preliminary objectives of the study are to understand and develop the evidence-based tools and interventions for the control and prevention of malaria in different sites of the INDIA. Alongside, with the help of next-generation genomics study, the team has studied the antimalarial drug resistance in India. Further, he has extended his research in the development of Humanized mice for the study of liver-stage malaria and identification of molecular marker(s) for the Artemisinin resistance. At present, his research focuses on understanding the role of B cells in the activation of CD8+ T cells in malaria. Received the CSIR-SRF (Senior Research Fellow) award-2018, FIMSA (Federation of Immunological Societies of Asia-Oceania) Travel Bursary award to attend the IUIS-IIS-FIMSA Immunology course-2019',institutionString:"Nirma University",institution:{name:"Nirma University",country:{name:"India"}}},{id:"334383",title:"Ph.D.",name:"Simone",middleName:"Ulrich",surname:"Ulrich Picoli",slug:"simone-ulrich-picoli",fullName:"Simone Ulrich Picoli",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/334383/images/15919_n.jpg",biography:"Graduated in Pharmacy from Universidade Luterana do Brasil (1999), Master in Agricultural and Environmental Microbiology from Federal University of Rio Grande do Sul (2002), Specialization in Clinical Microbiology from Universidade de São Paulo, USP (2007) and PhD in Sciences in Gastroenterology and Hepatology (2012). She is currently an Adjunct Professor at Feevale University in Medicine and Biomedicine courses and a permanent professor of the Academic Master\\'s Degree in Virology. She has experience in the field of Microbiology, with an emphasis on Bacteriology, working mainly on the following topics: bacteriophages, bacterial resistance, clinical microbiology and food microbiology.",institutionString:null,institution:{name:"Universidade Feevale",country:{name:"Brazil"}}},{id:"229220",title:"Dr.",name:"Amjad",middleName:"Islam",surname:"Aqib",slug:"amjad-aqib",fullName:"Amjad Aqib",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/229220/images/system/229220.png",biography:"Dr. Amjad Islam Aqib obtained a DVM and MSc (Hons) from University of Agriculture Faisalabad (UAF), Pakistan, and a PhD from the University of Veterinary and Animal Sciences Lahore, Pakistan. Dr. Aqib joined the Department of Clinical Medicine and Surgery at UAF for one year as an assistant professor where he developed a research laboratory designated for pathogenic bacteria. Since 2018, he has been Assistant Professor/Officer in-charge, Department of Medicine, Manager Research Operations and Development-ORIC, and President One Health Club at Cholistan University of Veterinary and Animal Sciences, Bahawalpur, Pakistan. He has nearly 100 publications to his credit. His research interests include epidemiological patterns and molecular analysis of antimicrobial resistance and modulation and vaccine development against animal pathogens of public health concern.",institutionString:"Cholistan University of Veterinary and Animal Sciences",institution:null},{id:"62900",title:"Prof.",name:"Fethi",middleName:null,surname:"Derbel",slug:"fethi-derbel",fullName:"Fethi Derbel",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/62900/images/system/62900.jpeg",biography:"Professor Fethi Derbel was born in 1960 in Tunisia. He received his medical degree from the Sousse Faculty of Medicine at Sousse, University of Sousse, Tunisia. He completed his surgical residency in General Surgery at the University Hospital Farhat Hached of Sousse and was a member of the Unit of Liver Transplantation in the University of Rennes, France. He then worked in the Department of Surgery at the Sahloul University Hospital in Sousse. Professor Derbel is presently working at the Clinique les Oliviers, Sousse, Tunisia. His hospital activities are mostly concerned with laparoscopic, colorectal, pancreatic, hepatobiliary, and gastric surgery. He is also very interested in hernia surgery and performs ventral hernia repairs and inguinal hernia repairs. He has been a member of the GREPA and Tunisian Hernia Society (THS). During his residency, he managed patients suffering from diabetic foot, and he was very interested in this pathology. For this reason, he decided to coordinate a book project dealing with the diabetic foot. Professor Derbel has published many articles in journals and collaborates intensively with IntechOpen Access Publisher as an editor.",institutionString:"Clinique les Oliviers",institution:null},{id:"300144",title:"Dr.",name:"Meriem",middleName:null,surname:"Braiki",slug:"meriem-braiki",fullName:"Meriem Braiki",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/300144/images/system/300144.jpg",biography:"Dr. Meriem Braiki is a specialist in pediatric surgeon from Tunisia. She was born in 1985. She received her medical degree from the University of Medicine at Sousse, Tunisia. She achieved her surgical residency training periods in Pediatric Surgery departments at University Hospitals in Monastir, Tunis and France.\r\nShe is currently working at the Pediatric surgery department, Sidi Bouzid Hospital, Tunisia. Her hospital activities are mostly concerned with laparoscopic, parietal, urological and digestive surgery. She has published several articles in diffrent journals.",institutionString:"Sidi Bouzid Regional Hospital",institution:null},{id:"229481",title:"Dr.",name:"Erika M.",middleName:"Martins",surname:"de Carvalho",slug:"erika-m.-de-carvalho",fullName:"Erika M. de Carvalho",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/229481/images/6397_n.jpg",biography:null,institutionString:null,institution:{name:"Oswaldo Cruz Foundation",country:{name:"Brazil"}}},{id:"186537",title:"Prof.",name:"Tonay",middleName:null,surname:"Inceboz",slug:"tonay-inceboz",fullName:"Tonay Inceboz",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/186537/images/system/186537.jfif",biography:"I was graduated from Ege University of Medical Faculty (Turkey) in 1988 and completed his Med. PhD degree in Medical Parasitology at the same university. I became an Associate Professor in 2008 and Professor in 2014. I am currently working as a Professor at the Department of Medical Parasitology at Dokuz Eylul University, Izmir, Turkey.\n\nI have given many lectures, presentations in different academic meetings. I have more than 60 articles in peer-reviewed journals, 18 book chapters, 1 book editorship.\n\nMy research interests are Echinococcus granulosus, Echinococcus multilocularis (diagnosis, life cycle, in vitro and in vivo cultivation), and Trichomonas vaginalis (diagnosis, PCR, and in vitro cultivation).",institutionString:"Dokuz Eylül University",institution:{name:"Dokuz Eylül University",country:{name:"Turkey"}}},{id:"71812",title:"Prof.",name:"Hanem Fathy",middleName:"Fathy",surname:"Khater",slug:"hanem-fathy-khater",fullName:"Hanem Fathy Khater",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/71812/images/1167_n.jpg",biography:"Prof. Khater is a Professor of Parasitology at Benha University, Egypt. She studied for her doctoral degree, at the Department of Entomology, College of Agriculture, Food and Natural Resources, University of Missouri, Columbia, USA. She has completed her Ph.D. degrees in Parasitology in Egypt, from where she got the award for “the best scientific Ph.D. dissertation”. She worked at the School of Biological Sciences, Bristol, England, the UK in controlling insects of medical and veterinary importance as a grant from Newton Mosharafa, the British Council. Her research is focused on searching of pesticides against mosquitoes, house flies, lice, green bottle fly, camel nasal botfly, soft and hard ticks, mites, and the diamondback moth as well as control of several parasites using safe and natural materials to avoid drug resistances and environmental contamination.",institutionString:null,institution:{name:"Banha University",country:{name:"Egypt"}}},{id:"99780",title:"Prof.",name:"Omolade",middleName:"Olayinka",surname:"Okwa",slug:"omolade-okwa",fullName:"Omolade Okwa",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/99780/images/system/99780.jpg",biography:"Omolade Olayinka Okwa is presently a Professor of Parasitology at Lagos State University, Nigeria. She has a PhD in Parasitology (1997), an MSc in Cellular Parasitology (1992), and a BSc (Hons) Zoology (1990) all from the University of Ibadan, Nigeria. She teaches parasitology at the undergraduate and postgraduate levels. She was a recipient of a Commonwealth fellowship supported by British Council tenable at the Centre for Entomology and Parasitology (CAEP), Keele University, United Kingdom between 2004 and 2005. She was awarded an Honorary Visiting Research Fellow at the same university from 2005 to 2007. \nShe has been an external examiner to the Department of Veterinary Microbiology and Parasitology, University of Ibadan, MSc programme between 2010 and 2012. She is a member of the Nigerian Society of Experimental Biology (NISEB), Parasitology and Public Health Society of Nigeria (PPSN), Science Association of Nigeria (SAN), Zoological Society of Nigeria (ZSN), and is Vice Chairperson of the Organisation of Women in Science (OWSG), LASU chapter. She served as Head of Department of Zoology and Environmental Biology, Lagos State University from 2007 to 2010 and 2014 to 2016. She is a reviewer for several local and international journals such as Unilag Journal of Science, Libyan Journal of Medicine, Journal of Medicine and Medical Sciences, and Annual Research and Review in Science. \nShe has authored 45 scientific research publications in local and international journals, 8 scientific reviews, 4 books, and 3 book chapters, which includes the books “Malaria Parasites” and “Malaria” which are IntechOpen access publications.",institutionString:"Lagos State University",institution:{name:"Lagos State University",country:{name:"Nigeria"}}},{id:"273100",title:"Dr.",name:"Vijay",middleName:null,surname:"Gayam",slug:"vijay-gayam",fullName:"Vijay Gayam",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/273100/images/system/273100.jpeg",biography:"Dr. Vijay Bhaskar Reddy Gayam is currently practicing as an internist at Interfaith Medical Center in Brooklyn, New York, USA. He is also a Clinical Assistant Professor at the SUNY Downstate University Hospital and Adjunct Professor of Medicine at the American University of Antigua. He is a holder of an M.B.B.S. degree bestowed to him by Osmania Medical College and received his M.D. at Interfaith Medical Center. His career goals thus far have heavily focused on direct patient care, medical education, and clinical research. He currently serves in two leadership capacities; Assistant Program Director of Medicine at Interfaith Medical Center and as a Councilor for the American\r\nFederation for Medical Research. As a true academician and researcher, he has more than 50 papers indexed in international peer-reviewed journals. He has also presented numerous papers in multiple national and international scientific conferences. His areas of research interest include general internal medicine, gastroenterology and hepatology. He serves as an editor, editorial board member and reviewer for multiple international journals. His research on Hepatitis C has been very successful and has led to multiple research awards, including the 'Equity in Prevention and Treatment Award” from the New York Department of Health Viral Hepatitis Symposium (2018) and the 'Presidential Poster Award” awarded to him by the American College of Gastroenterology (2018). He was also awarded 'Outstanding Clinician in General Medicine” by Venus International Foundation for his extensive research expertise and services, perform over and above the standard expected in the advancement of healthcare, patient safety and quality of care.",institutionString:"Interfaith Medical Center",institution:{name:"Interfaith Medical Center",country:{name:"United States of America"}}},{id:"93517",title:"Dr.",name:"Clement",middleName:"Adebajo",surname:"Meseko",slug:"clement-meseko",fullName:"Clement Meseko",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/93517/images/system/93517.jpg",biography:"Dr. Clement Meseko obtained DVM and PhD degree in Veterinary Medicine and Virology respectively. He has worked for over 20 years in both private and public sectors including the academia, contributing to knowledge and control of infectious disease. Through the application of epidemiological skill, classical and molecular virological skills, he investigates viruses of economic and public health importance for the mitigation of the negative impact on people, animal and the environment in the context of Onehealth. \r\nDr. Meseko’s field experience on animal and zoonotic diseases and pathogen dynamics at the human-animal interface over the years shaped his carrier in research and scientific inquiries. He has been part of the investigation of Highly Pathogenic Avian Influenza incursions in sub Saharan Africa and monitors swine Influenza (Pandemic influenza Virus) agro-ecology and potential for interspecies transmission. He has authored and reviewed a number of journal articles and book chapters.",institutionString:"National Veterinary Research Institute",institution:{name:"National Veterinary Research Institute",country:{name:"Nigeria"}}},{id:"158026",title:"Prof.",name:"Shailendra K.",middleName:null,surname:"Saxena",slug:"shailendra-k.-saxena",fullName:"Shailendra K. Saxena",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRET3QAO/Profile_Picture_2022-05-10T10:10:26.jpeg",biography:"Professor Dr. Shailendra K. Saxena is a vice dean and professor at King George's Medical University, Lucknow, India. His research interests involve understanding the molecular mechanisms of host defense during human viral infections and developing new predictive, preventive, and therapeutic strategies for them using Japanese encephalitis virus (JEV), HIV, and emerging viruses as a model via stem cell and cell culture technologies. His research work has been published in various high-impact factor journals (Science, PNAS, Nature Medicine) with a high number of citations. He has received many awards and honors in India and abroad including various Young Scientist Awards, BBSRC India Partnering Award, and Dr. JC Bose National Award of Department of Biotechnology, Min. of Science and Technology, Govt. of India. Dr. Saxena is a fellow of various international societies/academies including the Royal College of Pathologists, United Kingdom; Royal Society of Medicine, London; Royal Society of Biology, United Kingdom; Royal Society of Chemistry, London; and Academy of Translational Medicine Professionals, Austria. He was named a Global Leader in Science by The Scientist. He is also an international opinion leader/expert in vaccination for Japanese encephalitis by IPIC (UK).",institutionString:"King George's Medical University",institution:{name:"King George's Medical University",country:{name:"India"}}},{id:"94928",title:"Dr.",name:"Takuo",middleName:null,surname:"Mizukami",slug:"takuo-mizukami",fullName:"Takuo Mizukami",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/94928/images/6402_n.jpg",biography:null,institutionString:null,institution:{name:"National Institute of Infectious Diseases",country:{name:"Japan"}}},{id:"233433",title:"Dr.",name:"Yulia",middleName:null,surname:"Desheva",slug:"yulia-desheva",fullName:"Yulia Desheva",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/233433/images/system/233433.png",biography:"Dr. Yulia Desheva is a leading researcher at the Institute of Experimental Medicine, St. Petersburg, Russia. She is a professor in the Stomatology Faculty, St. Petersburg State University. She has expertise in the development and evaluation of a wide range of live mucosal vaccines against influenza and bacterial complications. Her research interests include immunity against influenza and COVID-19 and the development of immunization schemes for high-risk individuals.",institutionString:'Federal State Budgetary Scientific Institution "Institute of Experimental Medicine"',institution:null},{id:"238958",title:"Mr.",name:"Atamjit",middleName:null,surname:"Singh",slug:"atamjit-singh",fullName:"Atamjit Singh",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/238958/images/6575_n.jpg",biography:null,institutionString:null,institution:null},{id:"333753",title:"Dr.",name:"Rais",middleName:null,surname:"Ahmed",slug:"rais-ahmed",fullName:"Rais Ahmed",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/333753/images/20168_n.jpg",biography:null,institutionString:null,institution:null},{id:"252058",title:"M.Sc.",name:"Juan",middleName:null,surname:"Sulca",slug:"juan-sulca",fullName:"Juan Sulca",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/252058/images/12834_n.jpg",biography:null,institutionString:null,institution:null},{id:"191392",title:"Dr.",name:"Marimuthu",middleName:null,surname:"Govindarajan",slug:"marimuthu-govindarajan",fullName:"Marimuthu Govindarajan",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/191392/images/5828_n.jpg",biography:"Dr. M. Govindarajan completed his BSc degree in Zoology at Government Arts College (Autonomous), Kumbakonam, and MSc, MPhil, and PhD degrees at Annamalai University, Annamalai Nagar, Tamil Nadu, India. He is serving as an assistant professor at the Department of Zoology, Annamalai University. His research interests include isolation, identification, and characterization of biologically active molecules from plants and microbes. He has identified more than 20 pure compounds with high mosquitocidal activity and also conducted high-quality research on photochemistry and nanosynthesis. He has published more than 150 studies in journals with impact factor and 2 books in Lambert Academic Publishing, Germany. 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