Differences between nociceptive and neuropathic pain.
\\n\\n
More than half of the publishers listed alongside IntechOpen (18 out of 30) are Social Science and Humanities publishers. IntechOpen is an exception to this as a leader in not only Open Access content but Open Access content across all scientific disciplines, including Physical Sciences, Engineering and Technology, Health Sciences, Life Science, and Social Sciences and Humanities.
\\n\\nOur breakdown of titles published demonstrates this with 47% PET, 31% HS, 18% LS, and 4% SSH books published.
\\n\\n“Even though ItechOpen has shown the potential of sci-tech books using an OA approach,” other publishers “have shown little interest in OA books.”
\\n\\nAdditionally, each book published by IntechOpen contains original content and research findings.
\\n\\nWe are honored to be among such prestigious publishers and we hope to continue to spearhead that growth in our quest to promote Open Access as a true pioneer in OA book publishing.
\\n\\n\\n\\n
\\n"}]',published:!0,mainMedia:null},components:[{type:"htmlEditorComponent",content:'
Simba Information has released its Open Access Book Publishing 2020 - 2024 report and has again identified IntechOpen as the world’s largest Open Access book publisher by title count.
\n\nSimba Information is a leading provider for market intelligence and forecasts in the media and publishing industry. The report, published every year, provides an overview and financial outlook for the global professional e-book publishing market.
\n\nIntechOpen, De Gruyter, and Frontiers are the largest OA book publishers by title count, with IntechOpen coming in at first place with 5,101 OA books published, a good 1,782 titles ahead of the nearest competitor.
\n\nSince the first Open Access Book Publishing report published in 2016, IntechOpen has held the top stop each year.
\n\n\n\nMore than half of the publishers listed alongside IntechOpen (18 out of 30) are Social Science and Humanities publishers. IntechOpen is an exception to this as a leader in not only Open Access content but Open Access content across all scientific disciplines, including Physical Sciences, Engineering and Technology, Health Sciences, Life Science, and Social Sciences and Humanities.
\n\nOur breakdown of titles published demonstrates this with 47% PET, 31% HS, 18% LS, and 4% SSH books published.
\n\n“Even though ItechOpen has shown the potential of sci-tech books using an OA approach,” other publishers “have shown little interest in OA books.”
\n\nAdditionally, each book published by IntechOpen contains original content and research findings.
\n\nWe are honored to be among such prestigious publishers and we hope to continue to spearhead that growth in our quest to promote Open Access as a true pioneer in OA book publishing.
\n\n\n\n
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She studied refrigeration engineering in the Odessa State Academy of Refrigeration, Ukraine, and received her diploma in 1990. She received her Ph.D. in 1994 and Professorship in 2001, all in the Ukraine.\nProfessor Morosuk has over twenty years teaching experience in the fields of refrigeration, energy engineering, and applied thermodynamics. She is associated with several scientific organizations as well as many international energy-related conferences and recognized international journals. She serves as an associate editor for the following international journals: “International Journal of Energy and Environmental Engineering” (Springer), “International Journal of Natural Gas Science and Engineering” (Elsevier), “International Journal of Energy Research” (Wiley), “Energies” (MDPI), “Entropy” (MDPI), and “Journal of Energy Resources Technology” (ASME).\nProfessor Morosuk’s areas of scientific activities include the application of energy-based methods to the improvement of the thermodynamic, economic, environmental performance of different power generation systems, refrigeration/cryogenic systems and chemical plants. Particular attention is given to hydrogen economy, systems associated with the liquefaction of natural gas and the regasification of LNG, alternative refrigeration processes for sustainable industrial and commercial applications, and smart energy supply and use in industrial parks, including innovative concepts of liquid air energy storage. 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The poor ecological state of the environment is a serious global problem which arose as a result of the rapid development of industry, agriculture, urbanization, and transport. Significant factors affecting the state of the environment are both natural (hydrometeors, volcanic ash, desert dust, smoke aerosols, etc.) and anthropogenic (industrial, fuel combustion, fires, heating, etc.) atmospheric aerosols or particulate matter (PM) [1]. The aerosols are fine solid or liquid particles, determining largely the climate, temperature, and dynamic structure of the atmosphere, the functioning of ecosystems, the microphysical properties of clouds and various chemical and photochemical processes in air [2]. The concentration of aerosols in the atmosphere determines the air quality, and in turn affects the human health [3] and references therein]. The fine and ultrafine aerosol particles are particularly harmful for human health, as they more easily penetrate and accumulate in the human body and lead to an increase in cardiovascular and respiratory diseases and even to lung cancer [4, 5]. Because of the above facts and considerations, atmospheric aerosols have been the subject of more intensive research in recent decades [6, 7]. Particularly, near-surface atmospheric measurements over densely populated or industrial areas, purposed to help monitor air quality, have attained increasing societal significance.
Laser radars (lidars) are recognized to be a reliable and powerful instrument for investigating atmospheric objects and air parameters [7–9]. As compared to other measurement approaches, the lidar technique exhibits advantages such as possibilities for performing fast, highly sensitive and accurate monitoring of vast atmospheric domains with high spatial and temporal resolution. Lidar systems are mainly used to assess the vertical structure of the aerosol layers and determine the optical and microphysical properties of the vertical profiles of the aerosols. Scanning ground-based and airborne lidars are applied to produce three-dimensional (3D) maps of earth’s surface and man-made features [10], as well as for characterization of tropospheric wind profiles [11, 12] and temperature fields [13]. Along with the above applications, scanning elastic-scattering lidars are used to obtain maps of important atmospheric pollutants, particularly, of near-surface aerosol fields [14–17]. The aerosol lidar mapping represents a fast and effective approach to detect polluting aerosol loads over broad areas, as well as to characterize them in terms of local density, spatial distribution, and temporal dynamics [18–20].
In this chapter, we present experimental results on lidar mapping of near-surface atmospheric aerosol fields over the city of Sofia, its suburbs and surrounding villages, obtained during an extensive 7-month experimental campaign in 2015 [19]. It was carried out in the framework of a common project with Sofia Municipality aimed to help the local authorities to improve the regional air-quality monitoring. Possibilities are also discussed to incorporate lidar mapping technologies synergistically into municipal air-quality monitoring systems. Aerosol lidar maps are considered to become basic components of such monitoring systems. Their advantages result from the high efficiency of the laser light interaction with the atmospheric particles, thus, providing better visualization of atmospheric motions in comparison with other remote sensing techniques, such as the microwave or acoustic probing.
The analysis of the lidar mapping experiments performed was focused on the following issues:
Two-dimensional (2D) aerosol density distribution above the city areas.
Temporal and spatial dynamics of the near-surface aerosol fields.
Estimating effects of the city structure and terrain topography on the aerosol distribution obtained.
The chapter is organized as follows: In Section 2, we describe the experimental instrumentation, data processing/visualization approaches, and the area investigated. Then, in Section 3, series of experimental data on lidar aerosol mapping over the Sofia region are presented. Results are reported and analyzed of horizontal and vertical lidar scanning of the aerosol density distribution, as well as its temporal dynamics. Special attention is paid in Section 4 to the synergistic effects of mutual use of lidar aerosol mapping and in-situ measurement sites of the air pollution. The main results and conclusions are summarized in Section 5.
Sofia (the capital of Bulgaria) is located at about 550 m above sea level (a.s.l.), in a valley surrounded by hills and mountains, bordering Stara Planina to the northeast and Vitosha to the southwest. This topographic position, and the temperature inversion conditioned by it, is one of the factors determining the regional air quality. In the past years, the air pollution over the city of Sofia has become a serious ecological problem, provoked by the presence of different industrial facilities, a considerable decrease of green zones, as well as the accelerating growth of the population and the number of cars. The analysis of the PM amount and properties over Europe [21] showed that the aerosol concentrations have reached second-highest levels in eastern and southern Europe.
The measurement site (42.65N, 23.38E; 590 m a.s.l.) is located at the Institute of Electronics, Bulgarian Academy of Sciences, in the southeast part of Sofia. Figure 1 shows a topographical map of Sofia area, overlaid by lidar sector scans in north-northwest (north-NW) (to the central parts of Sofia) and southwest (SW) (toward Vitosha Mountain) directions. In the former case, a horizontal lidar scanning (at a step of 1.7°) was performed in two close azimuth sectors of 8.5°(321–329.5° with respect to the north clockwise) and 17°(348–5°). In the latter case, the investigated sector was 50° (188–238°, at a step of 2°), whereas a low elevation angle (6–7°) was used to measure near-surface atmospheric aerosol fields because of the presence of high buildings in the angular sectors of measurements.
Topographical map of Sofia region with outlined azimuth sectors of lidar scanning.
Under the conditions mentioned above, surface areas of about 100 km2 were scanned and mapped over the central city zone, the north industrial zone and the south urban and suburb parts, including the north slopes of Vitosha Mountain. The results of the lidar aerosol mapping over these areas would allow one to detect and analyze the aerosols of different origin (natural, urban, industrial, etc.), as well as to contribute to the establishment of a modern city air-quality monitoring system.
The measurements described in this chapter were conducted by scanning observation zones in horizontal and vertical directions over Sofia using lidar systems developed at the Laser Radars Laboratory of the Institute of Electronics, Bulgarian Academy of Sciences (LRL-IE). The LRL-IE working groups actively participate in the joint lidar research over the European continent in the framework of the European Aerosol Research Lidar Network, performing systematic lidar monitoring of atmospheric processes [18, 22], unusually high concentrations of aerosols in the troposphere [23], transport of mineral dust from Sahara desert [24], volcanic eruptions [25], and formation of smoke layers resulting from forest or industrial fires [26].
The lidar systems used in the experimental campaign considered are shown in Figure 2. The first one is based on a Cu-vapor laser emitting pulses with duration of 10 ns at a repetition rate of 5 kHz and wavelengths of 510.6 and 578.2 nm. Their mean powers are 1.2 and 0.8 W, respectively. The beam divergence is about 2 mrad. The laser beam is directed in parallel to the axis of the receiving telescope, forming a lidar base of ~30 cm between the axes. A Cassegrain-type telescope with 20 cm aperture and 1 m focal length receives the backscattered laser emission from the atmosphere. Narrow-band interference filters are used to separate the lidar signals. Registration in a photon-counting mode is applied. The single electron pulses, produced by the photodetector (a photomultiplier), are accumulated by a photon-counting board in a computer. This board allows registration of the backscattered lidar signal with a spatial resolution of 15 or 30 m in 1024 samples and variable averaging time. In the present experiments, the lidar profiles of the laser emission backscattered in the atmosphere were registered with an accumulation time of 1 min. In addition, averaging was performed by summation of the data of 5–10 profiles; thus, the effective measurement time for each profile amounted to 5–10 min in a single azimuth direction.
Photographs of the Cu-vapor (a) and Nd:YAG (b) laser-based lidars used in the aerosol lidar mapping experiments.
The lidar used to perform lidar mapping experiments in the south-southwest direction is based on a solid-state frequency-doubled Nd:YAG laser (pulse energy of up to 600 mJ at 1064 nm, 80 mJ at 532 nm; fixed repetition rate of 2 Hz, FWHM pulse duration of 15 ns, beam divergence of 2 mrad), acting as a two-wavelength lidar transmitter. The optical part of the lidar receiver consists of a Cassegrain-type telescope (aperture 35 cm; focal distance 200 cm) and a three-channel spectrum analyzer based on narrow-band interference filters (1–3 nm FWHM). The receiver’s electronic part comprises three compact photoelectronic modules, each including a photodetector, a 10 MHz 14-bit analog-to-digital converter (ADC), a high-voltage power supply, and controlling electronics. The signals backscattered in the atmosphere are digitized every 100 ns by the ADC, resulting in a 15 m range resolution. The system provides detection and storage of lidar returns from distances of up to 30 km. The lidar is mounted on a stable metal coaxial construction allowing reliable fixing and precise synchronized mutual motion of both the telescope and the output laser beam in horizontal and vertical direction with an angular resolution of about 1°.
The lidar remote sensing is based on the interaction (absorption and scattering) of the laser light with molecules and aerosols in the atmosphere. The detected backscattered lidar signals contain information concerning the state and composition of the probed atmospheric domain. The so-called lidar equation describes the power of the received backscattered signal as a range-resolved function of the lidar parameters and the atmospheric optical properties (aerosol backscattering and extinction coefficients). For a single-scattering elastic lidar (measuring backscattered light at the same wavelength as the sensing laser wavelength λ) the power P(r), detected at a time t after the instant of pulse emission, is written as [27]:
where P0 is the average power of a single laser pulse, c is the speed of light, r = ct/2 is the distance along the laser beam path, τ is the pulse duration, A is the area of the receiver, ε is the overall system efficiency, γ(r) describes the overlap between the laser beam and the receiver field of view, and
The determination of the aerosol extinction and backscattering coefficients (BSCs) on the basis of Eq. (1) requires the solution of a Bernoulli differential equation. A stable solution has been proposed by Klett [28] and Fernald [29], applying an inverse integration algorithm starting from the far end of the lidar sounding path. In the case of the backscattering coefficient (BSC), it has the following form:
where
In the case of lidar measurements in vertical or quasi-vertical directions, aerosol-free atmospheric domains are usually reached at certain altitudes (as a rule higher than 5–6 km) in the free troposphere, where the total backscatter coefficient
A typical feature of the atmosphere is its vertical stratification, expressed in the formation of a vertical succession of horizontally extended layers of different thickness. Inside these layers, the atmospheric air content and parameters remain practically constant over considerable horizontal distances. The longer the reachable lidar range of horizontal sounding, the higher the probability such homogeneous air volumes to be present along the lidar line of sight, providing favorable conditions for the method to be used. Thus, the slope method appears to be very suitable for determining aerosol characteristics in horizontal lidar measurements or such performed at low-elevation angles. The accuracy of this method increases with increasing the aerosol concentration, favoring its application to the lidar measurements conducted in the near-surface atmospheric layers where the highest aerosol concentrations are usually observed.
Applying the slope method to solving the lidar equation, one can obtain the following expressions for the aerosol extinction and backscattering coefficients:
and
Within the mentioned atmospheric parts of homogeneous aerosol parameters,
As an important advantage of the slope method, in comparison to other lidar approaches, determination of the aerosol extinction or backscattering is only or predominantly based on lidar measurement data, without the need of information or suppositions concerning relations between the analyzed quantities. In addition, the method makes use of simple mathematics, provides analytical solutions, and does not require numerical approaches and algorithms.
To implement the lidar mapping described here of the near-surface aerosol density distribution over Sofia region, a combination of the widely adopted and well-elaborated method of Klett-Fernald and the slope method was used. In this combination, the slope method is applied to determining the aerosol extinction and backscattering coefficients in appropriate parts of the lidar beam path by using the technology presented above (Eqs. (3) and (4)). Subsequently, the values of
Generally, the aerosol field could be described as a distribution of the aerosol mass concentration M (μg/m3) defined as the mass of PM per unit volume. From the lidar measurements, the extinction and backscattering coefficients of the aerosol particles are determined that are directly proportional to the aerosol mass concentration:
The mass concentration could be retrieved from the lidar data combining different experimental and numerical approaches [31]. So, obtaining data about the distribution of the aerosol backscattering coefficient could be regarded as representative for the aerosol mass concentration distribution.
Figure 3 shows an example of the stages of formation of an aerosol lidar map using measurements performed on 5 November 2015, in the time interval 20:35–21:28 local time (LT). Aerosol backscattering profiles obtained at different azimuth angles along a fixed elevation angle are presented in Figure 3(a). On the basis of a series of such profiles, 2D color-coded sector maps of the near-surface aerosol density could be created. In Figure 3(b), an aerosol lidar map is displayed in Cartesian coordinates, based on the entire set of BSC profiles in the azimuth sector 190–220°, including the ones in Figure 3(a). Finally, the sector maps so-obtained are superposed on the satellite maps of the corresponding city region.
Range profiles of the aerosol backscattering coefficient at three different azimuth angles (a) and aerosol distribution lidar map based on a series of BCS profiles (b) as measured in the time interval 20:35–21:28 LT on 5 November 2015.
Results of lidar measurements and mapping of the near-surface atmospheric aerosol fields over the city of Sofia, suburbs, and surrounding villages, obtained during the experimental campaign in 2015, are shown and discussed below. Lidar maps are presented from vertical and horizontal scanning of the areas investigated.
In order to acquire detailed information about the vertical structure of the aerosol concentration, lidars perform vertical slice scans. The lidar data shown on Figure 4 represent a two-dimensional color-coded sector map of the aerosol density distribution within the scanned volume of the atmosphere. The map is constructed using lidar profiles (averaged over five individual scans) obtained along a fixed azimuth in NW-direction at different elevation angles (0–10°), with an increment of 1°. The horizontal direction of the lidar scanning, covering distances of about 12 km was close to a thoroughfare with intense traffic. The vertical structure of the aerosol density of the atmosphere is clearly visible on the map. A well-pronounced vertical layer near ground surface was observed at a height in the range of 500–700 m, located above the city away from the lidar station until beyond the city center. At a height of ~1 km above ground, aerosol formations were observed with a density exceeding that of the ambient atmosphere, probably low clouds. Thus, this vertical map demonstrates the capability of such a type of lidar measurements to determine quickly and efficiently the location of the sources of anthropogenic PM emission in the atmosphere. On the other hand, it is clear that the horizontal scanning lidar measurements, made at a low altitude in the range of 500–700 m, provide sufficient information about the air pollution and near-ground surface aerosol fields.
Color-coded sector map of the vertical aerosol density distribution obtained along a fixed azimuth in NW-direction (326° with respect to the north clockwise).
Figure 5 illustrates the range limits of lidar measurements in NW (Figure 5(a)) and SW (Figure 5(b)) directions, performed by lidars with a Cu-vapor laser and a Nd:YAG laser, respectively. In the first case, the operational distance was from 900 m to 25–28 km in nighttime and decreased to about 10–15 km in daytime, due to intensive sky illumination. The maximum distance was limited by the high laser pulse repetition rate, because of an overlap of the laser pulse scattered from far away with the next pulse scattered from a close distance. In SW-direction to the Vitosha Mountain, the assessed maximum distance was longer than 20 km as determined by the surface topology in the observation area.
Colormaps of the near-surface aerosol density distribution demonstrating the maximum achievable operational distances in NW (a) and SW (b) directions, performed by the lidar systems shown in the insets.
Lidar monitoring and mapping of the near-surface aerosols in the atmosphere above the central parts of Sofia were performed by the lidar equipped with a Cu-vapor laser at the wavelength of 510.6 nm.
Figure 6 presents the results of lidar measurements carried out on 27 July 2015, at 21:33–22:10 LT, when relatively strong air pollution was observed. The distance covered by the lidar sounding was 15 km in an azimuth sector of 8.5°. A dust cloud was observed in the atmosphere near ground surface over most of the observation zone. Only the blue-colored areas, at 1.5–2 km away from the two large boulevards, showed a lower concentration of dust particles in the air. The specific movement of air masses, from SW-to-NE-direction, causes a mixing of dust pollutants into the larger part of the area over the city observed by the lidar. The values measured of the aerosol BSC are in the order of 0.5–8 × 10−6 m−1sr−1.
Colormap of the aerosol density distribution as measured on 27 July 2015 in the time interval 21:33–22:10 LT, at distances of up to 15 km.
Figure 7 presents results of lidar mapping in the two main sectors of scanning over the central parts of Sofia, performed in different time periods during the measurement campaign and exhibiting similar features of the aerosol distribution, in particular, the influence of populated areas on the aerosol density. The near-surface aerosol distribution, resulting from lidar measurements performed on 5 August 2015, at 22:10–22:50 LT, is shown in Figure 7(a), covering a distance of 25 km. Due to the heavy city traffic, relatively higher values of the aerosol BSC were observed close to the busy streets and over the entire central parts reaching the city ring road. At distances beyond the ring road, the aerosol pollution concentration dropped rapidly, except for some areas near two local villages. We, therefore, assumed that the aerosol fields observed by the lidar were of anthropogenic origin. The values measured of the aerosol BSC were in order of 0.3–4.3 × 10−6 m−1sr−1. Figure 7(b) presents a map of a lidar scanning conducted on 7 October 2015 within the NW sector, in the time interval 19:35–20:30 LT. The sounding comprised 11 successive scans in an angular sector of 17° by an angle step of 1.7°, covering a distance of 16 km. Well-defined areas of higher aerosol pollution were visible over the city areas, as well as over some residential districts in the far measurement zone. The values calculated of the atmospheric BSC were from 0.5 to 9.8 × 10−6 m−1sr−1.
Color-coded maps of the near-surface aerosol density distribution as measured on 5 August 2015, at 22:10–22:50 LT (a) and on 7 October 2015 in the time interval 19:35–20:30 LT (b).
In Figure 8, results are presented of lidar measurements in the two main sectors of scanning as in Figure 7, performed consecutively in the time intervals 19:22–19:48 and 19:54–20:54 LT on 4 November 2015. The first measurement (shown at the left angular sector of Figure 8) directed northwestward covered the central city zones including and being nearly parallel to one of the main city thoroughfare, reaching distances of up to 12 km. The second lidar sounding (shown at the right angular sector of Figure 8) was directed north-northwestward to distances of 13 km, covering densely populated residential districts in the part of the map near the lidar. Along this second direction, an area of high aerosol concentration was observed, which extended to a distance of 5 km with respect to the lidar. Another area of high concentration of the near-surface aerosols was observed at a distance of 7–8 km, at the end of the urban area. At greater distances, the aerosol air pollution observed was negligible, as shown by the green-blue colors in the figure. The BSC values calculated ranged from 0.5 to 6.2 × 10−6 m−1sr−1.
Color-coded maps of the near-surface aerosol density distribution as measured on 4 November 2015, in the time intervals 19:22–19:48 LT (left angular sector) and 19:54–20:54 LT (right angular sector).
In order to demonstrate the capability of the lidar aerosol mapping technology applied to follow the temporal evolution of the near-surface aerosol density distribution, a series of successive lidar scans over the same areas were carried out. Figure 9 presents four lidar maps resulting from measurements conducted on 18 November 2015, as averaged over 30 min intervals. The start times of each measurement are marked in the upper right corner of the corresponding figure panels. The measurements were implemented in the NW angular sector, reaching distances of up to 9.5 km. These maps illustrate the changes occurring in the near-surface aerosol fields measured over the city area in the observation zones. As can be seen, the areas located near the main city thoroughfare with the most intense traffic are colored in red-brown, indicating strong aerosol pollution, probably due to the car exhaust emissions. Inspecting the four pictures presented in their chronological order, one can perceive a progressive shrinking of the part of the maps polluted by aerosols. This peculiarity can be ascribed to the progressively diminishing traffic intensity in the evening hours, resulting in less car aerosol emissions.
Color-coded maps of the aerosol density distribution as measured on 18 November 2015 in the time intervals 18:2718:52 LT (a), 18:55–19:20 LT (b), 19:22–19:47 LT (c), and 19:49–19:14 LT (d).
Series of both daytime and nighttime lidar measurements of the near-surface aerosol density distribution were carried out in the period 3–9 November 2015. The meteorological conditions during the measurements were as follows: a relatively high temperature for the season (18–20°C); a weak wind; a stable temperature inversion within the atmospheric boundary layer (at altitudes 880–1200 m above ground level); atmospheric pressure: 970–920 hPa. These stable conditions, in combination with the absence of specific aerosol loadings (e.g. fire smoke, desert dust, etc.) in that period, resulted in aerosol distribution pictures generally similar to those obtained from the individual measurements conducted. Still, the lidar data exhibit particular patterns of the aerosol fields above the city, determined by various local horizontal and vertical air circulations in the close-to-the surface atmospheric layer.
Three separate lidar measurements were carried out on 3 November 2015—one in the first half of the day and two successive ones in the evening. During the daytime measurement, the lidar scanning was performed in south-southwest directions within a horizontal angle range of 40° to distances of up to 3 km. The results are shown in Figure 10. The correspondence between the aerosol BCS values and the lidar map colors is given by the color bar in the upper left corner. Inhomogeneous distribution of the aerosol concentration was registered, according to the spotted colormap pattern. In the left-hand upper part of the map, a dark-red colored area can be seen, extending to about 1 km and corresponding to the highest aerosol loading. This observation is reasonable, taking into account the fact that in this part of the city densely populated residential districts are located, with intense daytime street traffic.
Colormap of the near-surface aerosol density distribution, as measured in the time interval 12:00–14:50 LT on 3 November 2015, in an azimuth range of 40° and distances of up to 3 km.
In the evening of 3 November 2015, two successive lidar soundings were performed, the results of which are presented in Figure 11. Juxtaposing data of such successive measurements conducted in the same angular sector allows one to follow temporal variations of the aerosol fields over the areas investigated.
Colormap of the aerosol density distribution as measured on 3 November 2015 in the time interval 19:05–19:41 LT at distances of up to 8 km (a) and in the interval 19:56–20:40 LT at distances up to 12 km (b).
The first measurement was carried out by horizontal lidar scanning in an angular sector of 14°, reaching distances of up to 8 km (Figure 11(a)), whereas the second one, in a sector of 20° to a distance of 12 km (Figure 11(b)). The larger distances reached during the evening measurements are due to the much lower optical background than the daytime one. The comparison of the daytime (Figure 10) and nighttime (Figure 11(a)) lidar soundings showed that the relatively high concentration of aerosols measured at midday over the zone to 3 km near the lidar was preserved until the evening. At longer distances (beyond the ring road), approaching the Vitosha Mountain, the aerosol concentration decreased and remained relatively homogeneous, as indicated by the low-contrast light-bluish coloring of the corresponding map parts.
As an exception, an increased aerosol density could be observed over some remote parts of the scanned region in the distance range 4–6 km (colored in light green-yellow), where residential districts are located in the mountain skirts. This can be ascribed either to the presence of a light fog or to smoke emissions taking into account the started heating season.
Four measurements were conducted on 5 November 2015 – one daytime over distances of up to 4 km and three successive nighttime ones over distances of up to 11 km. The daytime measurement was carried out in an angular sector of 14° and distances of up to 7 km. The highest aerosol loading was observed above the city zone about 4 km away from the lidar station, reaching the ring road, with a relatively homogeneous aerosol density distribution (Figure 12). These results are comparable to the ones presented above obtained during the daytime lidar measurements performed on 3 and 4 November 2015. This is reasonable because of the similar meteorological conditions and the absence of unusual aerosol pollutions.
Colormap of the aerosol density distribution as measured on 5 November 2015 in the time interval 12:26–13:25 LT at distances of up to 7 km.
All three nighttime lidar measurements took place in successive 1 h time intervals, over the same area in an angular sector of 30° and distances up to 12 km. The results are presented as colormaps in Figure 13. The comparison of the three panels shows the disappearance of the dynamic atmospheric processes, resulting in a considerable redistribution of the near-surface aerosol density. This can be clearly seen in the figure panels as expressed by the variable color pattern of the maps, most evident in the zones near the lidar extending to 4–5 km (colored mainly in red and yellow). In addition, the extension observed of the blue-colored remote part of the colormap sectors to the city zone in the course of the measurements could be ascribed to movements of deficient in aerosols air masses from the mountain areas to the city, driven by the evening mountain breeze—characteristic of the Sofia region.
Colormap of the aerosol density distribution as measured on 5 November 2015 in the time intervals 18:37–19:33 LT (a), 19:36–20:29 LT (b) and 20:35–21:28 LT (c), at distances of up to 12 km.
On 6 November 2015, three (two daytime and one nighttime) mapping lidar measurements were carried out within an angular sector of 26° over the same area. The two daytime measurements covered distances of up to about 4 km, whereas the evening one, to nearly 10 km. The corresponding results are displayed as colormaps on the three panels of Figure 14. The analysis of the two daytime lidar maps (Figure 14(a) and (b)) revealed the highest aerosol densities in the 1 km zone near the lidar station (colored in red-yellow in the map). Examining the map color pattern, one can perceive gradations of coloring from dominating red in the near zone, through yellow-green in the middle part (forming stripe-like structures), to mainly blue approaching the mountain zone. This grading pattern might be explained as resulting from the action of air currents moving from the city to the mountain, capturing and transporting urban/anthropogenic aerosols to the mountain areas. The lidar data obtained during the nighttime mapping scans also support such an explanation. The colormap in this last case (Figure 14(c)) shows a particular aerosol distribution structure dominated by a folded aerosol plume (colored mainly in red and red-yellow) extending from the close-to-the lidar city zone, through the suburbs, up to the mountain skirts, and consisting of two differentiated but connected parts—a dense aerosol field over the urban zones and a similar one at the plane-mountain interface zone. This picture illustrates the complex nature and variability of the near-surface aerosol distribution and spreading, originating from different natural and anthropogenic sources and driven in a complex manner by the local air circulation system.
Colormap of the aerosol density distribution as measured on 6 November 2015 in the time intervals 10:24–11:39 LT (a), 11:48–11:53 LT (b) and 18:23–19:19 LT (c), at distances of up to 4 km (a, b) and 10 km (c).
As shown in the previous sections, the aerosol lidar mapping technique is capable of providing a fast, accurate, and reliable range-time-resolved determination of optical parameters of the near-surface aerosols, such as the extinction and backscattering coefficients (directly proportional to the aerosol mass concentration), covering broad observation areas. In order to achieve complete quantitative aerosol characterization, determination of the aerosol mass concentration itself is also required. On the other hand, the existing set of in-situ air-pollution detectors present at some sites in the city is able to determine the aerosol mass concentration. However, this is possible to be done just for a limited number of detector location points. We consider that, by combining the two mentioned approaches, particularly by using in-situ obtained data to calibrate the aerosol lidar measurements, a synergistic effect could be achieved, allowing direct mapping of the aerosol mass concentration over the whole urban area. Below, we analyze and discuss the possibilities of achieving such a synergy in the characterization of near-surface aerosol pollutions.
As is well known, the typical existing air monitoring city systems contain the following basic structural components: (1) a network of a limited number of in-situ aerosol, gas, and biological sensors; (2) a network of meteorological sensors; (3) a modeling and data-processing system. The use of a low number of sensors by two networks over large urban areas imposes serious limitations on the information capabilities of the air-quality systems. The lidar maps can be considered as being a (virtual) aerosol sensor network of closely distributed very large number of single aerosol sensor cells of dimensions determined by the lidar maps’ spatial resolution. Therefore, the lidar mapping of near-surface aerosol fields appears to be a promising technology for improving the information quality of air-monitoring systems. The combination of the three sensor networks mentioned above incorporated in a joint air-quality monitoring system would provide a synergistic aerosol characterization.
Finally, we have to note that aerosol lidar maps could provide large amounts of additional information about the near-surface atmosphere. They contain data on the near-surface dynamics of air masses, driven by the surface winds but affected by the city structures. This is an important view of a better evaluation of the pollution transport over an urban area. Also, applying multiwavelength lidar mapping, one could contribute to the characterization of the aerosols’ size parameters, as well as to identifying their types and origin.
Summarizing the results of lidar measurements presented here, one can draw the following conclusions:
Lidar mapping of near-surface aerosols, based on (quasi)horizontal and vertical lidar scanning using the two lidar systems of the LRL of IE-BAS, appears to be an effective approach to the accurate and reliable determination of the density, spatial distribution, and temporal dynamics of close-to-ground aerosols, covering broad urban areas in Sofia region.
The analysis of the two-dimensional aerosol lidar maps obtained, as superposed on the topological map of Sofia region, shows a good correlation between the aerosol density distribution and the locations of important sources of aerosol pollutions in the zones of observation, such as city streets with intense traffic, densely populated areas, etc.
Combining the near-surface aerosol lidar mapping technology with the existing set of in-situ air-pollution detectors and related numerical models and computing facilities, is shown to be a promising synergistic approach to the development of more efficient modern city air-quality monitoring systems.
The financial support of the Municipality of Sofia is gratefully acknowledged. The support for EARLINET in the ACTRIS Research Infrastructure Project by the European Union’s Horizon 2020 research and innovation program under grant agreement no. 654169 and previously under grant agreement no. 262254 in the 7th Framework Programme (FP7/2007–2013) is also acknowledged.
It refers to the discomfort that occurs in the groin area of abdominal wall.
The most common causes of groin pain include:
Pulling on a muscle, tendon, or ligament in the leg
Hernia
Hip joint disease or injury
Less common causes include:
Inflammation of the testicle or epididymis and related structures
Torsion of the spermatic cord attached to the testicle (testicular torsion)
Tumor of the testicle
Kidney stones
Inflammation of the large and small intestine
Skin infection
Swelling of the lymph nodes
Urinary infection
This groin pain is perceived, integrated, transmitted and evaluated by neurons and the nervous system, but we have not yet elucidated how this process takes place. Such is the profuse network of nerves that cover the area, that their involvement is a not uncommon phenomenon (Figure 1).
Nervous system in the groin hernia area (3D 4Medical app).
In fact, the most frequent surgical reason is inguinal pain resistant to conservative treatments. Besides, poor preoperative pain control is a key factor in developing acute and chronic postsurgical pain (CPSP; Figure 2).
Predictability of the appearance of CPSP.
Each patient who develops CPSP has a specific genotype, medical history, previous experiences, beliefs and psychosocial conditions related to their pain; but, in general, there are some common risk factors in the development of chronic pain.
Psychosocial factors: Anxiety, depression and catastrophizing that surround the patient during the perioperative period.
Demographic factors: In some surgeries, age is a determining factor (i.e. young women for mastectomies [1]). In others, the male gender is more prone than the female [2, 3].
Genetic factors: Several authors point to the relationship of different clinical pathologies such as fibromyalgia, migraine, irritable bowel, irritable bladder, Raynaud’s syndrome … as markers of chronic postsurgical pain [4, 5].
Preoperative pain: The presence of preoperative pain has been correlated in different studies with the development of CPSP. Of all the types of surgical interventions, the hernia procedure stands out for its high preoperative pain rates [6, 7, 8, 9].
Surgical factors: Some important surgical factors may be related to the development of CPSP such as:
Duration of the operation (more than 3 h),
Surgical technique (laparoscopy vs. open),
Incision (site and type),
Experience of the surgeon,
Center where the intervention is carried out [10].
Acute postsurgical pain (APSP): Various studies show the importance of optimal APSP control to avoid chronification of postsurgical pain. Among them, surgeries such as groin, breast, hip, knee … are the most identified [11, 12, 13].
However, and despite the fact that there are different studies addressing this issue, the controversy remains dominant. To date, it can only be suggested that they do not play in favor of a better recovery or a lower probability of chronification, in addition to reducing quality of life in the process; but in no case can we establish a universally accepted causal relationship [3, 13, 14, 15, 16].
For the response to a noxious stimulus (be it chemical, thermal, pressure or any other characteristic that can cause pain), there are structures sensitive to those stimuli in the periphery: they are nociceptors [17].
Different classes of afferent nerve fibers are responsible for the communication of nociceptive information and pain:
Type Aβ: with a myelin sheath, are sensitive fibers responsible for touch and pressure.
Type Aδ: with a myelin sheath are responsible for the transmission of localized acute pain, temperature and part of the touch.
C fibers, without myelin sheath are responsible for the transmission of deep diffuse pain, smell, information from some mechanoreceptors, responses of the reflex and postganglionic arcs of the autonomic nervous system.
In a basal state, a noxious stimulus depolarizes a sensory or nociceptor neuron. The stimulation of nociceptors causes the propagation of the nerve stimulus to the dorsal horn of the spinal cord. Control at the spinal level is carried out in the gelatinous substance of Rolando (Rexed plate II) by stimulating inhibitory interneurons (Golgi II type) that cancel or reduce the nociceptive signal towards the lateral spinothalamic tract. In addition, glutamate is released, an excitatory amino acid that binds to a specific receptor, called AMPA and located in a postsynaptic neuron that transmits information to the higher centers of the CNS. Different brain centers are stimulated from the thalamus:
Periaqueductal gray substance (PAGS): Located in the midbrain, it is one of the most important nuclei and its functions are mediated by the opioid system. Its activation allows the inhibition of the painful process. It is connected with brain structures, with the ascending bundles and sends its projections to structures of the pons such as the nuclei of the raphe magnum.
Nuclei of the raphe magno: Located in the protuberance, receives connections from the ascending systems and the PAGS. It sends its axons to the first afferent synapse of the posterior horn and its nature is serotonergic.
Cerulean nucleus: Located on both sides of the fourth ventricle in the bridge. It is noradrenergic in nature.
The prefrontal cortex integrates all the information and the patient feels pain [18]. From these same superior nuclei, descending pathways are set in motion and reach the dorsal horn of the medulla again releasing endogenous inhibitory substances (mainly opioids and GABA). These inhibitory substances act by modulating the transmission of the stimulus: on the one hand, by decreasing the release of glutamate, and on the other, by hyperpolarizing the membrane of the postsynaptic neuron [19]. Inhibitory interneurons also come into play, which by releasing endogenous opioids, mimic and potentiate the inhibitory effect of the descending pathways.
Refers to pain that is associated with actual or threatened damage to non-neural tissue and involves the activation of peripheral nociceptors (IASP Taxonomy, 2015). There are three major forms of nociceptive pain:
Includes all pain originating from non-visceral structures, (i.e. skull, meninges, and teeth) and is the most common cause of consultation for almost all specialties, especially those dedicated to the locomotor system.
Extremely frequent, although in many cases it is not diagnosed as such. It is a neuromuscular dysfunction with a tendency to chronicity. It consists of a regional pain disorder, which affects the muscles and fasciae, so that the muscles involved have trigger points as essential components. In addition, regional and segmental autonomous alterations may coexist.
Dull, diffuse and poorly localized pain, referred to an area of the body surface, being frequently accompanied by an intense motor and autonomic (sympathetic) reflex response. The stimuli that can produce visceral pain are: spasm of the smooth muscle (hollow viscera), distension and ischemia.
Sometimes there is no relationship between the painful stimulus and the response that it originates in the CNS: it is then when a very important amplification of the nociceptive signal occurs, and this phenomenon is known as neuronal sensitization or neuropathy, so that the information transmitted to the brain causes a disproportionate pain reaction. This derangement occurs both at the peripheral and central levels.
Persistent pain becomes a pathological state that includes a series of elements that facilitate its generation and persistence over time. For this reason, any process that injures nerve tissues or causes neuronal dysfunction can produce neuropathic pain (NP). NP is qualitatively characterized by the absence of a causal relationship between injury and pain. Its etiology is very diverse and the relationship between etiology, pathophysiological mechanisms and symptoms is complex. NP differs from nociceptive pain in several aspects (Table 1).
Nociceptive (somatic / visceral) | Neuropathic | |
---|---|---|
Official definition | Pain caused by activation of peripheral / visceral nociceptors | Pain caused by PNS / CNS dysfunction |
Mechanism | Natural physiological transduction (nociceptor) | Ectopic pulse generation |
Symptom location | Local pain + referred | Territory of innervation of the affected nerve pathway |
No neurological topography | ||
Quality of symptoms | Common painful sensations of daily life - easy verbal description (i.e. Head ache, belly ache…) | New, unfamiliar, aberrant sensations: difficult verbal description (i.e. burning, electrical…) |
Normal neurological examination: response and aggression correspond | Hypo / hypersensitivity: response and aggression do not correspond | |
Treatment | Effective: conventional analgesia | Partially effective: antiepileptics, antidepressants |
Differences between nociceptive and neuropathic pain.
Adapted from Serra Catafau, Treatise on neuropathic pain (Adapted from SGADOR Handbook).
The balance between arousal and inhibition of the somatosensory system is dynamic and is influenced by context, behaviors, emotions, expectations, and pathology. In NP this equilibrium is broken and a loss in inhibitory currents has been demonstrated, with dysfunction in the mechanisms of production and release of GABA, a decrease in μ-opioid receptors in the dorsal root ganglia, and less receptivity to opioids in the spinal neurons. In summary, the neuronal pathological process changes in the course of injury and its pathophysiological mechanisms are evolutionary. The mechanisms that trigger NP produce:
Local inflammation
Glia cell activation
Changes in neuronal plasticity of nociceptive pain-transmitting pathways
Acute pain is an experience, usually of sudden onset, of short duration in time and with remission parallel to the cause that produces it. There is a close temporal and causal relationship with tissue injury or nociceptive stimulation caused by disease. Its duration ranges from a few minutes to several weeks. Acute pain has been attributed a “protective” function, its presence acts by preventing the individual from developing behaviors that may increase the injury or leads him to adopt those that minimize or reduce its impact. The fundamental emotional response is anxiety, with less involvement of other psychological components. Its characteristics offer important help in establishing the etiological diagnosis and selecting the most appropriate treatment. Its presence follows a classic treatment scheme such as Pain-Symptom. The most common causes of acute pain are:
Visceral pain
Gastrointestinal
Biliary
Urological
Cardiovascular
Pulmonary
Nervous system
Pancreatic
Gynecological
Muscle Skeletal Pain
Arthropathies
Chest wall pain
Fractures
Costochondritis
Tendinitis
Oral pain
Burn pain
Postoperative pain
Chronic pain extends beyond the tissue injury or organic involvement with which, initially, there was a relationship. It can also be related to the persistence and repetition of episodes of acute pain, with the progression of the disease, with the appearance of complications thereof and with degenerative changes in bone and musculoskeletal structures. Examples of this are cancer, secondary pathological fractures, osteoarthritis, postherpetic neuralgia, etc.
Chronic pain does not prevent or avoid damage to the body. Both their nature and their intensity show great variability over time, in many cases the complaints are perceived as disproportionate to the underlying disease. The most frequent repercussions in the psychological sphere involve anxiety, anger, fear, frustration or depression, which, in turn, contribute to further increasing pain perception. The socio-family, labor and economic repercussions are multiple and generate important changes in the lives of the people who suffer from it and their families: disability and dependency. The need to use drugs to relieve pain becomes a potential risk factor for use, abuse and self-prescription, not only of analgesics, but also tranquilizers, antidepressants and other drugs.
In its management, in addition to the physical aspects of pain, the other components, emotional, affective, behavioral and social, must be taken into account. The treatment scheme is complicated, we are facing the Pain-Syndrome (Table 2).
Acute Pain | Chronic pain | |
---|---|---|
Purpose | Initial-biological | Initial-destructive |
Duration | Temporary | Persistent |
Generator mechanism | Unifactorial | Multifactorial |
Affected component | Organic+++Psychic+ | Organic+Psychic+++ |
Organic response | Adrenergic: raise in heart rate, arterial hypertension, sweating, pupillary dilation | Vegetative: anorexy, constipation, less lybid, insomnia |
Affective component | Anxiety | Depression |
Physical exhaustion | No | Yes |
Therapeutic goal | Cure | Relief and adaptation |
Differences between acute and chronic pain.
All surgical intervention is associated with acute postsurgical pain (APSP) whose intensity decreases during the first days and weeks, in parallel with the tissue repair process. However, sometimes this pain lasts longer than is reasonable in relation to the surgical procedure. This fact can lead to the appearance of severe and disabling chronic pain syndromes, frequently associated with certain surgical procedures.
The definition of chronic postoperative pain (CPSP) does not find a consensus among the different authors in the literature reviewed. The most commonly used definition continues to be that of McRae [20, 21] based on the following aspects:
pain with a minimum duration of two months after a surgical procedure
after excluding other etiologies of pain
ruled out any pre-existing cause of pain (Figure 3).
Temporal evolution of postsurgical pain (adapted from Woolf and salter, science 2000; 288: 1765 [22]).
CPSP originates from the injury to the nerves and tissues inherent in the surgical process. During the immediate postsurgical period appears the breakthrough pain limited to the surgical site and its vicinity and develops through the direct activation of nociceptors, the inflammatory process and, in some cases, of direct nerve injury [23]. For this reason, the patient will present pain in the area of the surgical scar (primary hyperalgesia) and around it (secondary hyperalgesia). These changes are usually reversible and the normal sensitivity of the nociceptive system will then be restored. This type of pain, APSP, has a known beginning and an end in direct relation to tissue repair. In addition, it responds effectively to non-steroidal anti-inflammatory drugs, paracetamol, and minor or major opioids.
In the event of nerve injury during surgery, the neuropathic component of pain can immediately develop and persist in the absence of any noxious peripheral stimuli or ongoing peripheral inflammation [24]. The prerequisite for the development of CPSP is an injury to the major nerves that run through the surgical site. However, in a small group of patients, an ongoing inflammatory response may help maintain inflammatory pain and lead to a CPSP, such as that occurs after inguinal mesh hernia repair [25]. During progression from APSP to CPSP after inguinal hernia surgery:
7% of patients present severe acute pain the first 24 h;
14% of patients present subacute pain that could last until 8 weeks after surgery;
12% of patients present CPSP that could last until 12 months after surgery (80% of whom present Neuropathic component)
The incidence of chronic pain after inguinal hernia surgery rates from 5–63%, with an estimated incidence of severe chronic pain (VAS > 4) between 2% and 4%.
Inguinal hernia surgery can trigger a post-herniorrhaphy chronic inguinal pain syndrome, which can occur in up to 10% of the interventions performed [21].
The symptoms of postherniorrhaphy neuropathic inguinodynia consist of pain, paresthesias, allodynia (sensation of pain in the presence of non-harmful stimuli such as touch or pressure), pain radiating to the scrotal area, labia majora of the vagina and Scarpa’s triangle. This symptomatology also worsens with walking or hyperextension of the hip and decreases with decubitus and flexion of the thigh. These last aspects of the symptomatology make us see that the affectation of the nervous tract is the main actor of the chronic pain postherniorrhaphy [26].
There are three types of causes for the appearance of this painful syndrome:
Non-neuropathic
Reaction of the periosteum of the pubis
Keloid scar formation
Direct pressure exerted by bent or wrinkled prosthetic material (mesh) [27].
Neuropathic
Fibrosis of the perineurium of the nerves that run along the inguinal path (ilioinguinal nerve and genital branch of the genitofemoral nerve)
Compression of these by suture material, staples or prosthetic material
Direct injury to the nervous tract in a complete or incomplete manner. It can be produced by traction, direct cutting with a scalpel, or excessive thermocoagulation.
Peripheral sensitization involves lowering the discharge threshold from the peripheral terminal of the nociceptor. The molecules released in response to tissue damage and the activation of cells in the environment such as keratinocytes, mast cells, lymphocytes, platelets or the nociceptor itself, are called inflammatory soup (Substance P, calcitonin gene receptor protein [CGRP], quinines, amines, prostaglandins, growth factors, chemokines, cytokines, ATP, protons, etc.). These molecules induce morphological and functional changes in the neuron, which consequently generate an increase in the expression of structures such as the Na2+ channels and transient receptor potential cation channel subfamily V member 1 [TRPV1]; or molecules such as neuropeptides, or brain-derived neurotrophic factor [BDNF]. The interaction of these molecules with the different membrane receptors initiates an activation cascade of intracellular second messengers that modify the firing capacity of the cell, the final consequence being a greater capacity to respond to stimuli. This circumstance translates clinically into the following processes: hyperalgesia, allodynia, and spontaneous pain.
Spontaneous pain can be caused by:
An abnormal response to stimuli that normally do not cause harm (arterial heartbeat, increased temperature)
Ectopic discharges from the damaged nociceptor itself
Those produced by surrounding healthy fibers in response to the release of TNFα by damaged Schwann cells
At present, it is proposed a new state of the nociceptor, called “priming”, in which, a sensitized nociceptor, after a few hours will have a normal response to physiological stimuli, but will have an increased response to stimuli derived from inflammation. This state lasts for weeks and the hyperalgesic response to inflammatory agents is greater, which could be a possible explanation for the maintenance of chronic pain.
In a situation in which nociceptive information continues to be sent from the periphery to the dorsal horn of the spinal cord, the nociceptive neuron itself sends, from its soma (without the need for external stimulation) substance P and peptide related to the calcitonin gene (PRCG). These substances bind to neutrophils, mast cells and basophils, and release pro-inflammatory molecules: cytosines, bradykinins, histamines, cyclooxygenases, prostaglandins, eicosanoids and nerve growth factor (NGF). All this “inflammatory soup” produces changes in pH, release of ATP from injured cells, synthesis and release of nitric oxide (NO), etc., which induces amplification of the signal towards the spinal cord and higher centers and causes what is known as peripheral sensitization, which contributes in a very important manner to the maintenance of chronic pain.
If the nociceptive impulses are of great intensity or are sustained over time, plastic changes occur in the neurons of the posterior horn that facilitate the transmission of the nociceptive impulse. These changes in functionality are called central sensitization and cause specific clinical manifestations. It may represent the anatomical and physiological substrate to the fact of persistence of pain in the absence of peripheral nociceptive impulses in chronic pain, since the state of hyper-reactivity of the system would allow to explain the autonomous activity of the system in the absence of peripheral stimulus. In general terms, the following changes can be considered, which can all occur simultaneously or simply manifest some of them:
Disinhibition of the N-methyl-D-aspartate (NMDA) receptor by release of the Mg2+ ion at the first medullary synapse
Access of peripheral Aβ fibers to the nociceptive system. It is one of the causes of the phenomenon of allodynia
Dysregulation of the GABAergic system of inhibitory interneurons, which finally produces an alteration in the current of the Cl− channel.
Activation of the glia with the release of pro-analgesic substances
Alteration of the regulatory capacity of the downstream system
There is also the release of glutamate, which binds to specific receptors, which are not expressed in situations of acute pain. When activated, they contribute not only to depolarize the postsynaptic neuron, but also to generate a series of intracellular changes, which will increase the nociceptive signal. In response to peripheral sensitization, the primary afferent pathways also release substance P, resulting in an increase in signal. In situations of chronic pain there is also a reorganization of the neuronal structure: axonal collateral branches appear that increase the amount of nociceptive afferent signal.
On the other hand, a loss of efficacy of the inhibition produced by the descending pathways has been described, with a decrease in the release of endogenous opioids, and even cellular degeneration of those descending neurons, which indirectly also increases the nociceptive signal that is send to higher centers.
All these changes greatly amplify and sustain the nociceptive signal produced in the dorsal horn of the spinal cord, producing what is known as central sensitization.
The main clinical manifestations of nervous sensitization are hyperalgesia and allodynia phenomena, with the consequent increase in the extension of the painful area.
The presence of sensitization leads to the appearance of vicious circles in which there is a continuous sending of the afferent signal from the periphery to the brain centers in the absence of stimuli that generate them. This sustained stimulation leads to adaptive changes in the brain, such that the brain remains active even in the absence of noxious peripheral stimulus.
This continuous brain overexcitation conditions the effectiveness of the integrative pain response of the higher centers and the inhibitory descending pathway, in such a way that there is no inhibition proportional to the ascending amplified stimulus and the pain becomes chronic. This “centralizing” effect of the neuronal sensitization of nociceptors is one of the most relevant chronifying factors in the postoperative period of surgeries that present moderate to severe acute pain, that is not adequately controlled.
The type of pain, its location, duration and intensity determine the pharmacological approach (Figure 4).
Drugs that target peripheral sensitization: such as topical capsaicin (i.e. 8% capsaicin patch); topical lidocaine (i.e. 5% lidocaine patch); NSAIDs; paracetamol and local anesthetics.
Drugs that target central sensitization: such as serotonin reuptake inhibitors (SSRIs); tapentadol; tramadol; opioids; calcium channel ligands; adjuvants; tricyclic antidepressants; anticonvulsants and COX-2.
Pharmacological approach to chronic pain.
Blocking the pain signal before it reaches the central nervous system prior to surgery will prevent the development of central sensitization. The times that include the first consultation, the referral to the specialist, the decision of surgical treatment, the pre-anesthetic consultation and the appointment for surgery would favor peripheral and central sensitization if pain is not controlled, making the pain chronic and making it independent of the injury.
Using aggressive perioperative analgesia (antihyperalgesics, regional blocks, and multimodal analgesia) during the peri-surgical period could reduce the incidence of CPSP (Figure 5).
Perioperative analgesia.
Chronic pain is common after hernia surgery. Patients with pain before the operation benefit from surgery, but some patients who have no pain before hernia repair surgery develop significant groin pain later. Watchful waiting has proven to be safe [28] and profitable [29] in patients with asymptomatic inguinal hernia. It is a theme of debate whether surgery is appropriate in asymptomatic hernias and possibly in some other interventions as well.
CPSP is a common entity in interventional procedures today. Progress continues in the standardization of prevention and treatment strategies for this delicate problem in the technical and organizational sphere.
The improvement efforts aim to:
Early identification of patients with preoperative pain who need intervention.
Avoid delaying this intervention as far as possible, and if there is a delay, provide adequate pain management until the time of surgery.
At the time of the intervention, determine the least invasive and most appropriate surgical technique for the pathology.
Implement the most appropriate perioperative anesthetic and analgesic techniques for the patient.
Once intervened, individualize postoperative analgesia so that APSP is as low as possible, thus avoiding, as far as possible, chronic pain.
Thanks to Merche and Eduardo, for giving me the opportunity to study without worrying about anything else. To Monica, for her patience in preparing this chapter and to Alaitz and Inhar, for their fun distractions.
I declare that I have no conflict of interests.
IntechOpen implements a robust policy to minimize and deal with instances of fraud or misconduct. As part of our general commitment to transparency and openness, and in order to maintain high scientific standards, we have a well-defined editorial policy regarding Retractions and Corrections.
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\\n\\n4. FINAL REMARKS
\\n\\nIntechOpen wishes to emphasize that the final decision on whether a Retraction, Statement of Concern, or a Correction will be issued rests with the Academic Editor. The publisher is obliged to act upon any reports of scientific misconduct in its publications and to make a reasonable effort to facilitate any subsequent investigation of such claims.
\\n\\nIn the case of Retraction or removal of the Work, the publisher will be under no obligation to refund the APC.
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\n\nPublishing of a Retraction Notice will adhere to the following guidelines:
\n\n1.2. REMOVALS AND CANCELLATIONS
\n\n2. STATEMENTS OF CONCERN
\n\nA Statement of Concern detailing alleged misconduct will be issued by the Academic Editor or publisher following a 3rd party report of scientific misconduct when:
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\n\n3. CORRECTIONS
\n\nA Correction will be issued by the Academic Editor when:
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\n\n4. FINAL REMARKS
\n\nIntechOpen wishes to emphasize that the final decision on whether a Retraction, Statement of Concern, or a Correction will be issued rests with the Academic Editor. The publisher is obliged to act upon any reports of scientific misconduct in its publications and to make a reasonable effort to facilitate any subsequent investigation of such claims.
\n\nIn the case of Retraction or removal of the Work, the publisher will be under no obligation to refund the APC.
\n\nThe general principles set out above apply to Retractions and Corrections issued in all IntechOpen publications.
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