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INTRODUCTION: Because a significant association between training to perform emergency free ascent (EFA) and the occurrence of pulmonary barotrauma (PBT) was demonstrated in 2006, the Belgian Underwater Federation (BUF) decided to discontinue this procedure. An evaluation was needed 10 yr after the implementation of this change. METHODS: All medical records with a diagnosis of PBT that occurred in Belgium from November 2006 to September 2016 were prospectively collected. Data on the proportion of in-water skills training dives were obtained from BUF. RESULTS: A total of 5 cases of PBT were identified, significantly down from 34 cases in the previous 10-yr period. Of those cases, four occurred during training dives (two during ascent training). Analysis of the case files furthermore showed that two should have been medically disqualified from diving. Compared with the retrospective cohort (1995-2005), incidences are significantly reduced from 0.83 to 0.078/10,000 training dives and from 3.33 to 0.11/10,000 ascent-training dives; concomitantly, the incidence of PBT in nontraining dives also was reduced (from 0.0042 to 0.0014X10-4 4/10,000 dives), possibly because less divers undertake the EFA procedure in case of a technical incident and have learned to solve the problem differently. DISCUSSION: Discontinuation of emergency free ascent training was associated with a reduction in the incidence of PBT in the 10-yr follow-up period. We observed a significant decrease of PBT during training dives, confirming the hypothesis that EFA training in its previous form did not contribute significantly to diving safety. [ABSTRACT FROM AUTHOR]

Guidelines for the pre-hospital management of decompression illness (DCI) had not been formally revised since the 2004 Divers Alert Network/Undersea and Hyperbaric Medical Society workshop held in Sydney, entitled "Management of mild or marginal decompression illness in remote locations." A contemporary review was initiated by the Divers Alert Network and undertaken by a multinational committee with members from Australasia, the USA and Europe. The process began with literature reviews by designated committee members on: the diagnosis of DCI; first aid strategies for DCI; remote triage of possible DCI victims by diving medicine experts; evacuation of DCI victims; effect of delay to recompression in DCI; pitfalls in management when DCI victims present at hospitals without diving medicine expertise and in-water recompression. This was followed by presentation of those reviews at a dedicated workshop at the 2017 UHMS Annual Scientific Meeting, discussion by registrants at that workshop and, finally, several committee meetings to formulate statements addressing points considered of prime importance to the management of DCI in the field. The committee placed particular emphasis on resolving controversies around the definition of "mild DCI" arising over 12 years of practical application of the 2004 workshop's findings, and on the controversial issue of in-water recompression. The guideline statements are promulgated in this paper. The full workshop proceedings are in preparation for publication. [ABSTRACT FROM AUTHOR]

The purpose of this study was to suggest modifications of autopsy techniques in order to improve post-mortem diagnosis of arterial gas embolism (AGE) based on multidisciplinary investigation of SCUBA diving fatalities. Five adult human cadavers from the voluntary donation program of the Human Anatomy Laboratory, and eight judicial autopsied bodies of SCUBA divers from the Forensic Pathology Service were assessed. Before performing any autopsies, we accessed the diving plan and the divers' profiles for each case. We then introduced a new dissection procedure that included identification, isolation, and manipulation of carotid, vertebral and thoracic arterial systems. The dissected vascular structures that allowed optimall isolation of the systemic arterial circulation were identified and ligated. In three of the eight judicial cases, we had a strongly suggestive history of arterial gas embolism following pulmonary barotrauma (PBt/AGE). In these cases, the additional arterial dissection allowed us to clearly diagnose AGE in one of them. The autopsy of the rest of the cases showed other causes of death such as asphyxia by drowning and heart attack. In all cases we were able to reject decompression sickness, and in some of them we showed the presence of artefacts secondary to decomposition and resuscitation maneuvers. These results allow us to suggest a specific autopsy technique divided into four steps, aimed at confirming or excluding some evidence of dysbaric disorders according to a re-enactment of the incident. We have demonstrated the presence of large volumes of intravascular air, which is typical of PBt/AGE. [ABSTRACT FROM AUTHOR]

Guidelines for the pre-hospital management of decompression illness (DCI) had not been formally revised since the 2004 Divers Alert Network/Undersea and Hyperbaric Medical Society workshop held in Sydney, entitled "Management of mild or marginal decompression illness in remote locations". A contemporary review was initiated by the Diver's Alert Network and undertaken by a multinational committee with members from Australasia, the USA and Europe. The process began with literature reviews by designated committee members on: the diagnosis of DCI; first aid strategies for DCI; remote triage of possible DCI victims by diving medicine experts; evacuation of DCI victims; effect of delay to recompression in DCI; pitfalls in management when DCI victims present at hospitals without diving medicine expertise and in-water recompression. This was followed by presentation of those reviews at a dedicated workshop at the 2017 UHMS Annual Meeting, discussion by registrants at that workshop and finally several committee meetings to formulate statements addressing points considered of prime importance to the management of DCI in the field. The committee placed particular emphasis on resolving controversies around the definition of "mild DCI" arising over 12 years of practical application of the 2004 workshop's findings, and on the controversial issue of in-water recompression. The guideline statements are promulgated in this paper. The full workshop proceedings are in preparation for publication. [ABSTRACT FROM AUTHOR]

While ectopic gas can be a sign of dangerous disease requiring immediate medical or surgical intervention, it can also be an incidental and benign finding. Intravenous gas and spinal vacuum gas are common and almost always benign. Intravascular gas is most often related to instrumentation and, if intraarticular, can cause end-organ ischemia; however, treatment is usually supportive. Pneumocephalus arises from a communication with paranasal sinuses or mastoids more often than from meningeal infection and can usually be managed nonoperatively. In part 3 of this series, the different causes of ectopic gas in the vessels, skull, and spine are reviewed, as are the imaging features that can help to narrow the differential diagnosis. [ABSTRACT FROM AUTHOR]

Introduction: Important developments in the diagnosis of scuba diving fatalities have been made thanks to forensic imaging tool improvements. Multi-detector computed tomography (MDCT) permits reliable interpretation of the overall gaseous distribution in the cadaver. However, due to post-mortem delay, the radiological interpretation is often doubtful because the distinction between gas related to the dive and post-mortem decomposition artifactual gases becomes less obvious. Methods: We present six cases of fatal scuba diving showing gas in the heart and other vasculature. Carbon dioxide (CO2) in cardiac gas measured by gas chromatography coupled to thermal conductivity detection were employed to distinguish decomposition from embolism based on the detection of decomposition gases (hydrogen, hydrogen sulfide and methane) and to confirm arterial gas embolism (AGE) or post-mortem offgasing diagnoses. A Radiological Alteration Index (RAI) was calculated from the scan. Results: Based on the dive history, the intra-cadaveric gas was diagnosed as deriving from decomposition (one case, minimal RAI of 61), post-mortem decompression artifacts (two cases, intermediate RAI between 60 and 85) and barotrauma/AGE (three cases, maximal RAI between 85 and 100), illustrating a large distribution inside the bodies. Conclusion: MDCT scans should be interpreted simultaneously with compositional analysis of intra-cadaveric gases. Intra-cadaveric gas sampling and analysis may become useful tools for understanding and diagnosing scuba diving fatalities. In cases with short post-mortem delays, the CO2 concentration of the cardiac gas provides relevant information about the circumstances and cause of death when this parameter is interpreted in combination with the diving profile. [ABSTRACT FROM AUTHOR]

Arterial gas embolism (AGE) can be clinically devastating, and is most often associated with exposure to changes in ambient pressure, medical procedure or congenital malformation. Here we report a case of AGE in a 78-year-old male without these traditional risk factors. Rather, the patient's history included chronic obstructive pulmonary disease, necrotizing pneumonia, bullous disease and coughing. He was safely treated with hyperbaric oxygen (HBO2) therapy for AGE, with initial clinical improvement, but ultimately died from his underlying condition. Pathophysiology is discussed. This case illustrates the possibility that AGE can occur due to rupture of lung tissue in the absence of traditional risk factors. HBO2 therapy should be considered in the management of such patients. [ABSTRACT FROM AUTHOR]

Diving is a popular activity, largely practiced worldwide. Diving fatalities are not rare events, with drowning being the most common cause of death, followed by cardiac-related natural causes, immersion pulmonary edema and arterial gas embolism. In such cases, positive signs of drowning are not specific, depending also on the time of submersion of corpses. Moreover, drowning can be the terminal event. Over the years, measures to perform appropriate post-mortem examination in cases of diving fatalities were suggested, including the execution of post-mortem CT-scan, the use of a decompression chamber and the adoption of specific autoptic techniques. Although a multidisciplinary approach in forensic investigations concerning diving fatalities is discussed, poor cases focus on how the analysis of diving computer records and equipment can contribute to determining the cause of death. The present study shows how the cooperation between a forensic underwater expert and a forensic pathologist played a crucial role in interpreting radiological findings, guiding the autopsy and confirming/denying circumstantial data emerging from the investigations. Technical analysis of dive computer records and diving equipment is a fundamental step in the definition of the cause of death in diving fatalities. All diving computer data, not only those related to maximum depth and ascent's profile, should be considered in detail, and the immersion graph carefully studied by both the forensic pathologist and the forensic underwater experts. The diving technical data can often play a crucial role in explaining any legal issue related to the circumstances of death, possibly leading the prosecutor to further investigation. • Diving fatalities are not rare events. • In those cases, autoptic diagnosis can be challenging. • PMCT-scan can steer the forensic pathologist to perform a proper examination. • Forensic underwater experts have a pivotal role in diving fatalities. • Technical analysis of dive computer records and equipment are fundamental. [ABSTRACT FROM AUTHOR]

Introduction: Although very uncommon, severe injury and death can occur during scuba diving. One of the main causes of scuba diving fatalities is pulmonary barotrauma due to significant changes in ambient pressure. Pathology of the lung parenchyma, such as cystic lesions, might increase the risk of pulmonary barotrauma., Areas Covered: Birt-Hogg-Dubé syndrome (BHD), caused by pathogenic variants in the FLCN gene, is characterized by skin fibrofolliculomas, an increased risk of renal cell carcinoma, multiple lung cysts and spontaneous pneumothorax. Given the pulmonary involvement, in some countries patients with BHD are generally recommended to avoid scuba diving, although evidence-based guidelines are lacking. We aim to provide recommendations on scuba diving for patients with BHD, based on a survey of literature on pulmonary cysts and pulmonary barotrauma in scuba diving., Expert Opinion: In our opinion, although the absolute risks are likely to be low, caution is warranted. Given the relative paucity of literature and the potential fatal outcome, patients with BHD with a strong desire for scuba diving should be informed of the potential risks in a personal assessment. If available a diving physician should be consulted, and a low radiation dose chest computed tomography (CT)-scan to assess pulmonary lesions could be considered.

In recent years, hyperbaric oxygen (HBO) has been used in the treatment of a lot of diseases such as decompression sickness, arterial gas embolism, carbon dioxide poisoning, soft tissue infection, refractory osteomyelitis, and problematic wound, but little is known about its application in liver transplantation. Although several studies have been conducted to investigate the protective effects of HBO on liver transplantation and liver preservation, there are still some controversies on this issue, especially its immunomodulatory effect. In this short review, we briefly summarize the findings supporting the application of HBO during liver transplantation (including donors and recipients). [ABSTRACT FROM AUTHOR]

Abstract Introduction Decompression sickness (DCS) is a rare and dangerous complication from a rapid decrease in environmental pressure, commonly seen in patients leaving a compressed-air environment, such as scuba divers, aviators, and deep tunnel workers. Failure to clinically diagnose and adequately treat DCS with hydration and supplemental oxygen before bridging to hyperbaric oxygen (HBO) therapy can result in permanent residual symptoms or, in rare cases, death. Despite the increasing incidence of DCS, there are limited published simulation case studies discussing this perilous environmental exposure. Methods This fictional simulation case is written for emergency medicine residents to diagnose and manage DCS from a live-actor patient presenting with unilateral neurologic symptoms and concealed cyanotic mottling (cutis marmorata). This case ran for four separate iterations at a simulation center, with a resident, fellow, and attending acting as specific confederates for their respective roles. Following each case, the learners were debriefed at bedside, discussed a PowerPoint presentation, and underwent a question-and-answer session. Results Based on postsimulation qualitative assessments, junior and senior residents correctly identified DCS, but junior residents alone were less likely to elicit pertinent social history or to fully physically examine the patient without the presence of senior residents. Both resident groups were able to verbally explain the fundamental DCS pathophysiology to the patient, but junior residents were unable to specifically direct oxygenation, hydration, and HBO protocols for DCS. After case completion and debriefing, all learners demonstrated achievement of primary learning objectives. Discussion Overall, we noted this case worked well for junior EM residents with senior-resident backup. Both learner groups appreciated the concealed elements of case, including scuba diving history and exposed dermatologic findings, and reported that these were invaluable learning moments for all future patient encounters, not just those limited to DCS.

Background: Postpartum haemorrhage (PPH) is an unpredictable obstetric emergency that requires a multidisciplinary approach. Pelvic arterial embolization (PAE) is considered as a second-line treatment, although the published results have not been reviewed systematically since 2007.Objectives: To evaluate success and complication rates of PAE to treat PPH in the study hospital between 2009 and 2015, and to perform a systematic review of the literature on the reported efficacy and safety of PAE for the management of PPH.Search Strategy: A systematic review of articles on PAE in English or Spanish was conducted using Medline and the Cochrane Library.Selection Criteria: All published articles assessing success and complication rates of PAE in cases of PPH. The search was restricted to articles published in English or Spanish between 2000 and 2015, with at least 25 cases.Data Collection and Analysis: Obstetric variables, maternal haemodynamic state, pre-/postembolization management, technique-related variables, post-PAE evolution and complications were recorded in the case series study. Study characteristics, success rates and PAE-related complication rates were recorded in the systematic review.Main Results: The case series included 29 patients. The majority of these patients were primiparous, with singleton term pregnancies and spontaneous labour. Caesarean section was performed in 62.1% of patients undergoing PAE for PPH. PAE was successful in 89.6% [95% confidence interval (CI) 78.3-100] of cases. Twenty studies were included in the systematic review, providing data from 1739 patients. PAE was successful in 89.4% (95% CI 87.9-90.9) of cases. The mortality rate was 0.9%, and other major complications were uncommon (1.8%).Conclusions: PAE was found to be a minimally invasive, highly successful and safe technique for the management of PPH. It should be considered in PPH refractory to initial treatment. [ABSTRACT FROM AUTHOR]

BACKGROUND: Arterial gas embolism (AGE) is a rare condition in the flying community most often only ever seen in flight while operating at high altitude or incidents involving hypobaric chambers. This article describes a severe case of AGE that occurred in a pilot of a fourth generation fighter aircraft at ground level. The environmental control system (ECS) malfunctioned, causing an overpressurized cockpit and a subsequent explosive decompression when the pilot opened the canopy to egress. CASE REPORT: The ECS onboard fourth generation fighter aircraft is composed of many computer-controlled subsystems. When these components fail, the system can potentially overpressurize the cockpit. Combined with opening the canopy without prior venting, this overpressurization can lead to a situation akin to a diver surfacing too quickly. A pilot experienced this scenario and subsequently developed symptoms of arterial gas embolization--one form of decompression illness (DCI). We reviewed the design of the environmental control system and recommend that the cockpit must be slowly depressurized to decrease risk of injury from rapid decompression. DISCUSSION: Literature review showed three similar cases of ground-based overpressurization causing AGE symptoms, although these cases were maintenance personnel intentionally testing aircraft cabin integrity and not associated with aircraft intending flight.7The lessons learned from this case can be used to identify and hopefully prevent severe DCI from ground level cockpit overpressurization and to further general understanding of aircraft ECS. [ABSTRACT FROM AUTHOR]

INTRODUCTION: Supersonic, high altitude aviation places its pilots and aircrew in complex environments, which may lead to injury that is not easily diagnosed or simply treated. Decompression illness (either venous or arterial) and environmental conditions (e.g., abnormal gases and pressure) are the most likely adverse effects aircrew often face. Though symptomatic aircrew personnel may occasionally require hyperbaric oxygen treatment, it is rare to require more than one treatment before returning to baseline function. CASE REPORT: This challenging aviation case details the clinical course and discusses the salient physiological factors of an F/A-18D pilot who presented with neurological symptoms following loss of cabin pressure at altitude. DISCUSSION: Most crucial to this discussion was the requirement for multiple hyperbaric oxygen treatments over several days due to recurrence of symptoms. The likelihood of recurrence during and after future flights cannot be estimated with accuracy. This case illustrates a degree of recurrences for neurological symptoms in aviation (hypobaric exposure to hyperbaric baseline environment) that has not previously been described. [ABSTRACT FROM AUTHOR]

Cerebral arterial gas embolism (CAGE) occurs when gas enters the cerebral arterial vasculature. CAGE can occur during sitting craniotomies, cranial trauma or secondary to gas embolism from the heart. A far less common cause of CAGE is vascular entrainment of gas during endoscopic procedures. We present the case of a 49-year-old male who developed a CAGE following an esophagoduodenoscopy (EGD) biopsy. Due to a delay in diagnosis, the patient was not treated with hyperbaric oxygen (HBO2) therapy until 39 hours after the inciting event. Despite presenting to our institution nonresponsive and with decorticate posturing, the patient was eventually discharged to a rehabilitation facility, with only mild left upper extremity weakness. This delay in HBO2 treatment represents the longest delay in treatment to our knowledge for a patient suffering from CAGE secondary to EGD. In addition to the clinical case report, we discuss the etiology of CAGE and the evidence supporting early HBO2 treatment, as well as the data demonstrating efficacy even after considerable treatment delay. [ABSTRACT FROM AUTHOR]

Background: People with asthma are an under-represented group amongst scuba divers. Many may avoid or are advised against diving due to the potential risks, including bronchoconstriction, pulmonary barotrauma and arterial gas embolism. The aim of this study was to establish whether divers with asthma were more likely to experience reversible airways obstruction following typical scuba diving than divers without asthma. Method: All divers with a history of asthma attending Operation Wallacea in Honduras were identified and peak expiratory flow rates (PEF) were measured pre and immediately post dive. All dives were boat dives in tropical sea water. Scuba dives were defined as those lasting between 40 and 55 minutes to a depth of between 10 and 18 metres. Of the 356 divers attending, 22 were identified as having asthma, of whom 19 were suitable for testing. They were classified by treatment regimen: five on no treatment, 11 on salbutamol only and three on regular preventative treatment. Twenty-four divers without a history of asthma acted as a control group. Results: Open-water scuba diving caused a small decrease in PEF in all populations (median decrease 4.4%, P < 0.001). Percentage decrease in PEF was significantly more in divers with asthma on regular preventative medication than in the control group (mean 9.3%, median decrease 6% vs. mean 3.1%, median 4.3%; P = 0.039). Conclusion: These findings support the view that asthmatics are more susceptible to airway changes following scuba diving. Differences to previous studies are likely due to environmental conditions, including dive depth. [ABSTRACT FROM AUTHOR]

Coronary chronic total occlusions (CTOs) represent the most technically challenging lesion subset that interventional cardiologists face. CTOs are identified in up to one third of patients referred for coronary angiography and remain seriously undertreated with percutaneous techniques. The complexity of these procedures and the suboptimal success rates over a long period of time, along with the perception that CTOs are lesions with limited scope for recanalization, account for the underutilization of CTO Percutaneous Coronary Intervention (PCI). During the last years, dedicated groups of experts in Japan, Europe and United States fostered the development and standardization of modern CTO recanalization techniques, achieving success rates far beyond 90%, while coping with lesions of increasing complexity. Numerous studies support the rationale of CTO revascularization following documentation of viability and ischemia in the territory distal to the CTO. Successful CTO PCI provide better tolerance in case of future acute coronary syndromes and can significantly improve angina and left ventricular function. Randomized trials are on the way to further explore the prognostic benefit of CTO revascularization. The following review reports on the theory and the most recent advances in the field of CTO recanalization, in an attempt to promote a more balanced approach in patients with chronically occluded coronary arteries. [ABSTRACT FROM AUTHOR]

Background: Implantation of left atrial appendage (LAA) occlusion devices was shown to be a feasible and effective alternative to oral anticoagulation in patients with non-valvular atrial fibrillation. However, only few data about in-hospital and peri-procedural data are currently available. This study aims to report about echocardiographic, procedural and in-hospital data of patients receiving LAA occlusion devices.Methods: This single-center, prospective and observational study includes consecutively patients being eligible for percutaneous implantation of LAA occlusion devices (either Watchman™ or Amplatzer™ Cardiac Plug 2). Data on pre- and peri-procedural transesophageal echocardiography (TEE), implantation and procedure related in-hospital complications were collected. The primary efficacy outcome measure was a successful device implantation without relevant peri-device leaks (i.e., < 5 mm).Results: In total, 37 patients were included, 22 receiving the Watchman™ and 15 ACP 2 device. Baseline characteristics did not differ significantly in both patient groups. The primary efficacy outcome measure was reached in 91.9% of patients (90.9% for the Watchman™, 93.3 % for the ACP 2 group). One device embolization (Watchman™ group) with successful retrieval occurred (2.7% of patients). No thromboembolism or device thrombosis were present. The majority of bleedings was caused by access site bleedings (88.3% of all bleedings), consisting mostly of mild hematomas corresponding to a BARC type 1 bleeding (80.0% of all access-site complications). One patient died due to septic shock (non-procedure related).Conclusions: In daily real-life practice, percutaneous treatment with LAA occlusion devices appears to be an effective and safe. [ABSTRACT FROM AUTHOR]

We propose arterial pCO2 as test to discover vascular access recirculation (VAR) in bicarbonate hemodialysis (HD). We selected 30 HD patients with a ascertained well-functioning arteriovenous fistula (Control). In these patients, we artificially created VAR through the reversion of HD lines (Reversed). Results of the arterial gas analysis were collected at the start of HD (baseline) and after 5 min. At baseline, no differences of pH, pCO2 and HCO3 were found between the 2 groups. At 5 min, pCO2 increased from 38.1 ± 3.3 to 47.2 ± 6.3 mm Hg (p < 0.0001) in Reversed, whereas no increase was found in Control (p = 0.052). Areas under curve of pCO2 -increase was 0.96 (0.91-1.00) and pCO2 at 5 min 0.92 (0.85- 0.98). pCO2 -increase >4.5 mm Hg showed sensitivity 86.7% and specificity 100% with positive predictive value (PPV) 100% and negative predictive value (NPV) 89%. A pCO2 value above 43 mm Hg at 5 min showed sensitivity 80%, specificity 90%, PPV 89%, NPV 82%. pCO2 increase >4.5 mm Hg and/ or pCO2 at 5 min >43 mm Hg may accurately detect VAR. [ABSTRACT FROM AUTHOR]

Scuba diving is an increasingly common recreational activity. We describe the physiopathology of barotrauma in two cases where death was caused by pulmonary barotrauma while diving. An inspection and autopsy were carried out in both cases. The autopsy data were supported by post-mortem radiological investigation. Histological and toxicological analyses were also carried out, and dive computer and tank manometer analysis performed. In both cases, the cause of death was attributable to arterial gas embolism, resulting from pulmonary barotrauma subsequent to pulmonary over-distension. The dive computer analysis and the tank manometer allowed us to understand what happened underwater. In our opinion, a multidisciplinary approach is crucial in order to clarify the cause of death. Some pathological conditions and risk factors should be considered before diving. [ABSTRACT FROM AUTHOR]

Arterial gas embolism is a catastrophic event. Bubbles in the arterial circulation may lodge in the brain and cause infarction in the affected area and/or in a coronary vessel causing acute myocardial ischaemia. There is no well-defined window of time beyond which a response to hyperbaric oxygen is not expected. Major improvement may occur if the patient is treated as soon as possible, but is less likely in divers with severe decompression illness who have delayed intervention. We report on a 51-year-old, male rebreather diver who suffered loss of consciousness and cardiovascular collapse within minutes of a 30-metre deep dive at a remote Micronesian dive site. Recompression treatment did not start for six days for reasons to be presented, during which time he remained deeply comatose, cardiovascularly unstable and intubated on ventilator support. Despite this, following aggressive hyperbaric treatment over many days he made a functional recovery. At one year post injury, he is leading a functional life but has not returned to his previous occupation as a diver and suffers from moderately severe tinnitus and impaired right ear hearing and occasional mild speech problems. He is undertaking a number of on-line courses with a view to re-employment. [ABSTRACT FROM AUTHOR]

Background: Arterial gas embolism (AGE) is a major cause of morbidity and mortality in self-contained underwater breathing apparatus (SCUBA) diving and certain medical procedures. There are currently no well-defined criteria to diagnose AGE. Emergency physicians often find themselves facing a decision whether or not a patient with dive-related symptoms has an AGE and needs to be transferred to a hyperbaric facility.Objectives: The objective of this study was to test the accuracy of diagnostic criteria developed by the San Diego Hyperbaric Oxygen Group (SANDHOG) for the diagnosis of AGE.Methods: This was a retrospective review of consultations completed by the Hyperbaric Medicine Department (HBO) at the University of California San Diego where the diagnosis of AGE was considered. HBO staff blinded to the purpose of the study identified potential cases of AGE. The criterion standard was the final diagnosis by a panel of HBO specialists also blinded to the purpose of this study. Descriptive statistics and comparisons evaluating SANDHOG criteria compared to the criterion standard were performed.Results: Twenty-six patients were identified for inclusion. Twenty-three of 26 (88%) were SCUBA divers, 2 had intravascular gas injections, and 1 patient had a military training chamber accident. Nineteen of 26 (73%) patients were diagnosed with AGE. A SANDHOG score of 2 had 94.7% sensitivity (95% confidence interval [CI] 71.9-99.7), 85.7% specificity (95% CI 42.0-99.2), positive likelihood ratio of 6.6 (95% CI 1.1-40.8), and negative likelihood ratio of 0.06 (95% CI 0.01-0.43) for AGE. A SANDHOG score <2 had a negative predictive value of 100% for AGE.Conclusion: The SANDHOG criteria appear to be reliable in diagnosing AGE. AGE is unlikely with SANDHOG scores <2, whereas SANDHOG scores ≥2 resulted in high sensitivity and specificity for AGE. Emergency physicians may find this tool useful in evaluating patients for suspected AGE, and it may assist in determining whether to transfer the patient to a hyperbaric facility. Future studies should be performed to further examine and validate the accuracy and inter-rater reliability of this tool. [ABSTRACT FROM AUTHOR]

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A 26-year-old male U.S. Navy submariner suffered an arterial gas embolism during pressurized submarine escape training. Routine pretraining medical screening revealed no history of asthma, pneumothorax or recent respiratory infection. Pulmonary function testing and posterioranterior/lateral chest X-ray were normal. He forcefully exhaled at the start of his ascent and developed neurological abnormalities including lightheadedness with lower extremity weakness and paresthesias after surfacing. He fully recovered after a U.S. Navy Treatment Table 6. This case represents the first report of an arterial gas embolism since the U.S. Navy resumed pressurized submarine escape training utilizing the Submarine Escape and Immersion Equipment suit. We discuss possible contributing factors and propose that his AGE was caused by pulmonary barotrauma due to a combination of low forced expiratory low rates and an overly forceful exhalation during his ascent. [ABSTRACT FROM AUTHOR]

Pulmonary barotrauma can cause cerebral arterial gas embolism (CAGE) from pulmonary overdistension of alveoli forcing gas into the pulmonary vasculature. We report a case of CAGE in a man found to have occult pulmonary arteriovenous malformation (PAVM) and undiagnosed obstructive sleep apnea (OSA). A 46-year-old man was admitted to the hospital for an acute seizure and left-sided weakness, with telangiectasias on his lower lip and tongue. Brain-computed tomography (CT) showed gas emboli in the right hemisphere. Chest CT revealed a 1.8-cm PAVM in the posterior right costophrenic sulcus. A transthoracic echocardiogram showed no intracardiac shunt or patent foramen ovale. He was treated with phenytoin, lidocaine and hyperbaric oxygen. The PAVM was occluded with a detachable balloon followed by coil embolization. Polysomnography revealed severe obstructive sleep apnea, which was treated with CPAP. Seven years later, the patient was functioning at his pre-event baseline. We propose the CAGE was caused by high negative intrathoracic pressures while breathing against an obstructed upper airway, with air entrainment into the PAVM and subsequent arterialization. [ABSTRACT FROM AUTHOR]

Purpose: Surgical revascularization for pediatric moyamoya disease improves cerebral blood flow (CBF) and consequently may prevent further ischemic events. However, the timing of the treatment is controversial especially for patients with no ischemic symptom and normal CBF. The purpose of this case report is to inform and infer the surgical treatment timing for pediatric moyamoya disease patients. Case report: A 10-year-old female patient with unilateral moyamoya disease complaining of only headache as a symptom and whose Suzuki stage was II or in transition to III by angiography and CBF was almost normal was admitted to Tokyo Women's Medical University Hospital. We performed superficial temporal artery-middle cerebral artery (STA-MCA) double anastomoses for the patient because we estimated her headache was derived from low perfusion in the brain. STA-MCA bypass surgery was not only effective for relief of her severe headache but also valid for her cerebral perfusion. Her angiography showed much supply from external carotid artery to intracranial arteries via bypass grafts in 7 months. Conclusion: Our case showed early surgical treatment was beneficial for relief of severe headache even for early staged pediatric moyamoya disease patients by improving perfusion pressure and cerebral circulation. [ABSTRACT FROM AUTHOR]

The article discusses research that examined the effects of water sports on the cardiovascular system. Topics covered include the physiologic effects of immersion on the cardiovascular system, the physical effects of increased pressure based on the principles of Boyle's law or direct pressure effects, and the effects of increased pressure on kinetics of gases in tissues and organs based on Henry's law or indirect pressure effects.

Background:Knowledge on factors associated with mortality can help identify patients with COPD that might benefit from close monitoring and intervention. Arterial blood gases (ABGs) are related to mortality, but both arterial tension of oxygen (PaO2) and arterial tension of carbon dioxide (PaCO2) vary over time. The aim of our study was to investigate the association between repeatedly measured ABGs and mortality in men and women with COPD.Methods:A cohort of 419 Norwegian subjects with COPD, GOLD stage II-IV, aged 40–75, was followed up with up to seven ABGs, measured during stable phase for three years. Cox proportional hazard models were used to quantify the relationship between both single and repeatedly measured ABGs and all-cause mortality after five years, adjusting for age, sex, and the updated BODE index.Results:A total of 64 subjects died during follow-up. Mean initial arterial oxygen tension (standard deviation) was significantly higher in survivors compared to deceased, with PaO2(in kPa) 9.4 (1.1) versus 8.8 (1.2), p<0.001. Corresponding numbers for PaCO2were 5.3 (0.5) and 5.5 (0.7),p< 0.001. In analyses adjusting for age, sex, and the updated BODE index hazard ratios – HR(95% confidence intervals) - for all-cause mortality were 0.73 (0.55, 0.97) and 1.58 (0.90, 2.76) for repeated measures of PaO2and PaCO2, respectively.Conclusion:Both arterial oxygen and carbon dioxide tension were related to mortality in this study, and arterial oxygen tension added prognostic information to the updated BODE index in COPD. [ABSTRACT FROM PUBLISHER]

A persistent foramen ovale (PFO) and other types of right-to-left shunts are associated with neurological, cutaneous and cardiovascular decompression illness (DCI). A right-to-left shunt is particularly likely to be implicated in causation when these types of DCI occur after dives that are not provocative. It is believed that venous nitrogen bubbles that form after decompression pass through the shunt to circumvent the lung filter and invade systemic tissues supersaturated with nitrogen (or other inert gas) and as a result there is peripheral amplification of bubble emboli in those tissues. Approximately a quarter of the population have a PFO, but only a small proportion of the population with the largest right-to-left shunts are at high risk of shunt-mediated DCI. The increased risk of DCI in people with migraine with aura is because migraine with aura is also associated with right-to-left shunts and this increased risk of DCI appears to be confined to those with a large PFO or other large shunt. Various ultrasound techniques can be used to detect and assess the size of right-to-left shunts by imaging the appearance of bubble contrast in the systemic circulation after intravenous injection. In divers with a history of shunt-mediated DCI, methods to reduce the risk of recurrence include cessation of diving, modification of future dives to prevent venous bubble liberation and transcatheter closure of a PFO. [ABSTRACT FROM AUTHOR]

Free-swimming ascent is taught to military divers and submariners as a self-rescue technique in the event of an emergency or a planned covert surfacing technique. Although this technique is infrequently used, it is considered a high-risk training event due to the risk and subsequent high morbidity and mortality of pulmonary barotrauma from pulmonary over-inflation injury. This case study will illustrate an example of a pulmonary overinflation injury and arterial gas embolism in an Army Special Forces Combat Diver who had no violation of technique while conducting a 50 foot free-swimming ascent to training standards and under the supervision of experienced Dive Supervisors. Additionally, the issue of allowing such individuals to return to diving is discussed. [ABSTRACT FROM AUTHOR]

Background: Embolization of the left gastric artery (LGA) reduces circulating levels of ghrelin, but might prevent from further obesity surgery, particularly sleeve gastrectomy (SG), since the gastroesophageal junction (GEJ), depending on LGA, would be devascularized. Our aim was to evaluate, in an experimental animal study, an endovascular approach targeting arteries of the gastroepiploic arcade aiming to modulate ghrelin levels and to generate an increased vascular supply of the GEJ to reduce the risks of staple-line leaks after SG. Methods: Seven pigs underwent embolization of both left and right gastroepiploic arteries (LGEA and RGEA) using 500-700-μ microspheres (embolization of arterial gastric supply in obesity (EMBARGO)-alpha). A SG was performed in six pigs 3 weeks after EMBARGO-alpha and on eight controls. Capillary lactates were measured at the cardia and pylorus. Five pigs underwent coiling of RGEA and embolization of LGEA using both coils and 100-300-μ microspheres (EMBARGO-beta). Ghrelin levels were assessed before and once per week after both EMBARGOs. Control celiac trunk angiography was performed at 3 weeks (alpha) and 4 weeks (beta). Results: No significant ghrelin reduction was obtained with EMBARGO-alpha at 3 weeks when compared to baseline. Significant ghrelin reduction was found 3 weeks ( p = 0.0363) and 4 weeks ( p = 0.025) after EMBARGO-beta. Post-EMBARGO-alpha animals presented a significantly lower increase in cardia lactates when compared to controls after SG. Control angiography showed a significantly increased fundic vascular network in 5/6 animals after EMBARGO-alpha and in 5/5 after EMBARGO-beta. Conclusions: EMBARGO is effective to decrease ghrelin production and can enhance the vascular supply of the GEJ, preparing the vascular background for a SG. [ABSTRACT FROM AUTHOR]

Introduction: This study aimed to determine the characteristics of decompression illness patients and their treatment outcomes, at the Center of Hyperbaric Medicine, Somdech Phra Pinklao Hospital, one of the largest centres in Thailand., Methods: Past medical records of patients with decompression illness from 2015 to 2021 were retrieved and analysed., Results: Ninety-eight records of diving-related illness from 97 divers were reviewed. Most of the divers were male (n = 50), Thai (n = 86), and were certified at least open water or equivalent (n = 88). On-site first aid oxygen inhalation was provided to 17 divers. Decompression sickness (DCS) cases were characterised according to organ systems involved. The most prominent organ system involved was neurological (57%), followed by mixed organs (28%), musculoskeletal (13%), and pulmonary (2%). There were three cases of arterial gas embolism (AGE). Median presentation delay was three days. Ninety patients were treated with US Navy Treatment Table 6. At the end of their hyperbaric oxygen treatment, most divers (65%) recovered completely., Conclusions: Despite oxygen first aid being given infrequently and long delays before definitive treatment, treatment outcome was satisfactory. Basic knowledge and awareness of diving-related illnesses should be promoted among divers and related personnel in Thailand along with further studies., (Copyright: This article is the copyright of the authors who grant Diving and Hyperbaric Medicine a non-exclusive licence to publish the article in electronic and other forms.)