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Background: Few have examined the influence of patent foramen ovale (PFO) on the phenotype of decompression illness (DCI) in affected divers., Methodology: A retrospective review of our database was performed for 75 SCUBA divers over a 10-year period., Results: Overall 4,945 bubble studies were performed at our institution during the study period. Divers with DCI were more likely to have positive bubble studies than other indications (p<0.001). Major DCI was observed significantly more commonly in divers with PFO than those without (18/1,000 v.s. 3/1,000, p=0.02). Divers affected by DCI were also more likely to require a longer course of hyperbaric oxygen therapy (HBOT) if PFO was present (p=0.038). If the patient experienced one or more major DCI symptoms, the odds ratio of PFO being present on a transoesophageal echocardiogram was 3.2 (p=0.02) compared to those who reported no major DCI symptoms., Conclusion: PFO is highly prevalent in selected SCUBA divers with DCI, and is associated with a more severe DCI phenotype and longer duration of HBOT. Patients with unexpected DCI with one or more major DCI symptoms should be offered PFO screening if they choose to continue diving, as it may have considerable prognostic and therapeutic implications., (Copyright © 2014 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.)

A 42 year-old man presented for elective percutaneous lead extraction for pacemaker redundancy. The procedure was performed supine under general anaesthesia via the right femoral vein and was complicated by acute inferior ST elevation and hypotension. Urgent transoesophageal echocardiogram showed inferior left ventricular hypokinesis, right ventricular impairment, a patent foramen ovale and air in the left ventricle. Coronary angiography demonstrated normal coronary arteries, the ST changes resolved and the leads were subsequently removed intact. Post-operatively the patient displayed nystagmus, was managed with hyperbaric oxygen therapy, and had complete resolution of his symptoms. An MRI brain confirmed an acute left cerebellar infarction, and a diagnosis of paradoxical air embolus to the coronary and cerebral circulations was made. This case illustrates the risks associated with paradoxical embolism in patients with PFOs undertaking percutaneous lead extractions. It also highlights the need for further consideration into techniques to avoid this complication in all high-risk percutaneous procedures., (Crown Copyright © 2014. Published by Elsevier B.V. All rights reserved.)

Scuba divers' pulmonary oedema (SDPE) is an increasingly recognised disorder in divers. We report three fatal cases of SDPE, demonstrating its potential serious nature even in the absence of underlying cardiac disease demonstrable clinically or at autopsy. This, together with the frequency of recurrences, has implications on assessing fitness for subsequent diving, snorkelling and swimming. The differential diagnosis of this disorder is also considered, as is its possible inducement by salt water aspiration and its relationship to drowning.

Summary Intervals between births to 1934 women from poor areas of Guayaquil, Ecuador, were subjected to analysis to determine what effect on survival chances of their children, if any, was exerted by differences in these intervals. The analysis showed that risks of miscarriage and stillbirth were increased when the interval between last termination of pregnancy and conception was either very short or very long. Post-neo-natal mortality was strongly influenced by the length of the interval, reaching a minimum where the interval was around three years. The influence of interval length diminished as the level of mortality fell (with improving health standards over time). The possibility could not be discarded that for neo-natal mortality and mortality in the second year of life, extremely short intervals (under three months) carried significant additional risks. For both periods, intervals longer than three years increased the risk of infant mortality. Evidence was found that the survival chances of the first child of a pair were seriously impaired during the first year of life where a fresh conception supervened during that period (the earlier this happened the more serious the impairment). An analysis of'double intervals' (not presented here) showed that the effects of short intervals were exaggerated when two such intervals succeeded one another. The principle conclusions remained valid when competing sources of association between short intervals and mortality were excluded, thus lending plausibility to the view that the two are connected by a causal chain. While no great precision can be claimed, it seems likely that if effective measures were taken to prevent the occurrence of pregnancy intervals shorter than 27 months (corresponding to birth intervals of less than three years) spontaneous abortions might be reduced by one-third and infant mortality by one-half in populations similar to that studied here. These results justify a recommendation that the prescription of contraception for a limited period post-partum in areas of moderate or high neo-natal mortality should become a routine of responsible obstetric or maternity and child welfare care.