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Purpose: Dive-induced cardiac and hemodynamic changes are caused by various mechanisms, and they are aggravated by cold water. Therefore, aging divers with pre-existing cardiovascular conditions may be at risk of acute myocardial infarction, heart failure, or arrhythmias while diving. The aim of this study was to assess the effect of a single decompression CCR dive in arctic cold water on cardiac function in Finnish technical divers. Methods: Thirty-nine divers performed one identical 45 mfw CCR dive in 2–4 °C water. Hydration and cardiac functions were assessed before and after the dive. Detection of venous gas embolization was performed within 120 min after the dive. Results: The divers were affected by both cold-water-induced hemodynamic changes and immersion-related fluid loss. Both systolic and diastolic functions were impaired after the dive although the changes in cardiac functions were subtle. Venous inert gas bubbles were detected in all divers except for one. Venous gas embolism did not affect systolic or diastolic function. Conclusion: A single trimix CCR dive in arctic cold water seemed to debilitate both systolic and diastolic function. Although the changes were subtle, they appeared parallel over several parameters. This indicates a real post-dive deterioration in cardiac function instead of only volume-dependent changes. These changes are without a clinical significance in healthy divers. However, in a population with pre-existing or underlying heart problems, such changes may provoke symptomatic problems during or after the dive. [ABSTRACT FROM AUTHOR]

IntroductionFaults or errors during use of closed-circuit rebreathers (CCRs) can cause hypoxia. Military aviators face a similar risk of hypoxia and undergo awareness training to determine their 'hypoxia signature', a personalised, reproducible set of symptoms. We aimed to establish a hypoxia signature among divers, and to investigate their ability to detect hypoxia and self-rescue while cognitively overloaded.MethodsEight CCR divers and 12 scuba divers underwent an initial unblinded hypoxia exposure followed by three trials; a second hypoxic trial and two normoxic trials in randomised order. Hypoxia was induced by breathing on a CCR with no oxygen supply. Subjects pedalled on a cycle ergometer while playing a neurocognitive computer game to simulate real world task loading. Subjects identified hypoxia symptoms by pointing to a board listing common hypoxia symptoms, and were instructed to perform a 'bailout' procedure to mimic self-rescue if they perceived hypoxia. Divers were prompted to bailout if peripheral oxygen saturation fell to 75%, or after six minutes during normoxic trials. Subsequently we interviewed subjects to determine their ability to distinguish hypoxia from normoxia.ResultsNinety-five percent of subjects (19/20) showed agreement between unblinded and blinded hypoxia symptoms. Subjects correctly identified the gas mixture in 85% of the trials. During unblinded hypoxia, only 25% (5/20) of subjects performed unprompted bailout. Fifty-five percent of subjects (11/20) correctly performed the bailout but only when prompted, while 15% (3/20) were unable to bailout despite prompting. During blinded hypoxia 45% of subjects (9/20) performed the bailout unprompted while 15% (3/20) remained unable to bailout despite prompting.ConclusionsAlthough our data support a normobaric hypoxia signature among both CCR and scuba divers under experimental conditions, most subjects were unable to recognise hypoxia in real time and perform a self-rescue unprompted, although this improved in the second hypoxia trial. These results do not support hypoxia exposure training for CCR divers.

Bounce diving with rapid descents to very deep depths may provoke the high-pressure neurological syndrome (HPNS). The strategy of including small fractions of nitrogen in the respired gas to produce an anti-HPNS narcotic effect increases the gas density which may exceed recommended guidelines. In 2020 the 'Wetmules' dive team explored the Pearse Resurgence cave (New Zealand) to 245 m breathing trimix (approximately 4% oxygen, 91% helium and 5% nitrogen). Despite the presence of nitrogen, one diver experienced HPNS tremors beyond 200 m. The use of hydrogen (a light yet slightly narcotic gas) has been suggested as a solution to this problem but there are concerns, including the potential for ignition and explosion of hydrogen-containing gases, and accelerated heat loss. In February 2023 a single dive to 230 m was conducted in the Pearse Resurgence to experience hydrogen as a breathing gas in a deep bounce dive. Using an electronic closedcircuit rebreather, helihydrox (approximately 3% oxygen, 59% helium and 38% hydrogen) was breathed between 200 and 230 m. This was associated with amelioration of HPNS symptoms in the vulnerable diver and no obvious adverse effects. The use of hydrogen is a potential means of progressing deeper with effective HPNS amelioration while maintaining respired gas density within advised guidelines. [ABSTRACT FROM AUTHOR]

Nowhere is redundancy more indispensable than extended range cave diving. Training and practice in this discipline ensure divers are equipped with backup regulators, gauges, lights, and adequate breathing gas for a safe exit, emergencies, and decompression. Depending on penetration distances and depth, open circuit cave diving may require carrying more gas cylinders than can be logistically managed by the diver themselves while maintaining safe gas supply margins. Consequently, divers are forced to either stage cylinders in the cave prior to the dive or rely on resupply from support divers. Both scenarios have significant drawbacks. Due to the improved efficiency of breathing gas utilisation and other advantages, closed circuit rebreathers (CCR) have enabled extended range cave diving. With increasing depths, penetration distances, and bottom times, these divers must also plan for an increasing amount of open circuit bail-out gas in the event of CCR failure. Staged cylinders have traditionally been utilised, but this strategy has limitations due to the advanced dives needed to place them and equipment degradation due to prolonged water immersion, which can often result in cylinder and regulator corrosion with consequent leakage of contents over time. Consequently, a growing number of CCR divers are foregoing open-circuit bailout altogether by carrying an additional CCR system for bailout. Although these bailout rebreathers may facilitate further exploration and have certain advantages, the risks of diving with two complex machines remain to be clearly defined.

Closed circuit rebreathers have been widely adopted by technical divers as tools for reducing gas consumption and extending depth and duration capabilities. Rebreathers are technologically complex with many failure points, and their use appears associated with a higher accident rate than open circuit scuba. Rebreather Forum Four (RF4) was held in Malta in April 2023 attracting approximately 300 attendees and representatives of multiple manufacturers and training agencies. Over two and a half days a series of lectures was given by influential divers, engineers, researchers and educators on topics of contemporary relevance to rebreather diving safety. Each lecture was followed by a discussion session with audience participation. Potential consensus statements were drafted by the authors (SJM and NWP) during the course of the meeting. These were worded to be confluent with some important messages emerging from the presentations and subsequent discussions. The statements were presented one by one in a half-day plenary session of participants, and discussion was invited on each. After discussion and any necessary revision, the participants voted on whether to adopt the statement as a position of the forum. A clear majority was required for acceptance. Twenty-eight statements embracing thematic areas designated ‘safety’, ‘research’, ‘operational issues’, ‘education and training’, and ‘engineering’ were adopted. Those statements are presented along with contextualising narrative where necessary. The statements may help shape research and teaching initiatives, and research and development strategies over subsequent years. [ABSTRACT FROM AUTHOR]

Background and Objectives: The use of closed-circuit rebreathers (CCRs) in recreational diving is gaining interest. However, data regarding its physiological effects are still scarce. Immersion, cold water, hyperoxia, exercise or the equipment itself could challenge the cardiopulmonary system. The purpose of this study was to examine the impact of CCR diving on lung function and autonomous cardiac activity after a series of CCR dives in cold water. Materials and Methods: Eight CCR divers performed a diving trip (one week) in the Baltic Sea. Spirometry parameters, SpO2, and the lung ultrasonography score (LUS) associated with hydration monitoring by bioelectrical impedance were assessed at the end of the week. Heart rate variability (HRV) was recorded during the dives. Results: No diver declared pulmonary symptoms. The LUS increased after dives combined with a slight non-pathological decrease in SpO2. Spirometry was not altered, and all body water compartments were increased. Global HRV decreased during diving with a predominant increase in sympathetic tone while the parasympathetic tone decreased. All parameters returned to baseline 24 h after the last dive. Conclusions: The lung aeration disorders observed seem to be transient and not associated with functional spirometry alteration. The HRV dynamics highlighted physiological constraints during the dive as well as environmental-stress-related stimulation that may influence pulmonary changes. The impact of these impairments is unknown but should be taken into account, especially when considering long and repetitive CCR dives. [ABSTRACT FROM AUTHOR]

Mesophotic reefs are poorly known worldwide despite their great ecological relevance and management importance for coral reef conservation strategies. To aid in filling this gap, we conducted a pioneering, large-scale survey, covering a total of around 315 miles in length, in the largest Brazilian coastal Marine Protected Area (MPA) Costa dos Corais. From the digital bathymetry model (30 to 50 m depth) generated by a multibeam echo sounder, we selected areas of greater geomorphological diversity for a detailed investigative expedition of mesophotic ecosystems. Various sampling techniques were used: single-beam echo sounders for detailing the relief, a remotely operated underwater vehicle (ROV) for habitat type investigation, baited remote underwater video (BRUV) for collecting images of the fish community, and scuba diving to perform transects describing the benthic and fish community. We analyzed reef environments from 20 to 68 m deep. As a result, we present the mapping and geomorphological characterization of two compartments of mesophotic reefs at 21–45 m depth and an image library of mesophotic ecosystems with the species description and indications of whether it is a new record in the region. Biodiversity data were collected covering eight species of sponges, with greater abundance for Ircinia spp., Aplysina spp., and Xestospongia muta; eight from corals, mainly Siderastrea spp. And Montastrea cavernosa; and 68 species of reef fish, with the Labridae family (including Scarinae—11 species) being the richest. Our results demonstrate the importance of mesophotic reefs for MPA Costa dos Corais reef biodiversity and, with that, the need to protect these areas through the application of local conservation strategies, such as the creation of "no-take zones". [ABSTRACT FROM AUTHOR]

Introduction: Drysuits use flexible neck and wrist seals to maintain water-tight seals. However, if the seals exert too much pressure adverse physiological effects are possible, including dizziness, lightheadedness, syncope, and paresthesias in the hands. We aimed to quantify the seal pressures of neck and wrist seals in non-immersed divers. Methods: We recruited 33 diving volunteers at two dive facilities in High Springs, Florida. After a history and physical exam, we measured vital signs as well as wrist and neck seal pressures using a manometer system. Results: The mean (SD) seal pressure of the right wrist seals was found to be 38.8 (14.9) mmHg, while that of the left wrist seals was 37.6 (14.9) mmHg. The average neck seal pressure was 23.7 (9.4) mmHg. Subgroup analysis of seal material demonstrated higher mean sealing pressure with latex seals compared to silicone; however, this difference was not statistically significant. Conclusions: Drysuit seal pressures are high enough to have vascular implications and even potentially cause peripheral nerve injury at the wrist. Divers should trim their seals appropriately and be vigilant regarding symptoms of excessive seal pressures. Further research may elucidate if seal material influences magnitude of seal pressure. [ABSTRACT FROM AUTHOR]

Introduction: Closed-circuit rebreathers (CCRs) are designed to be watertight. Ingressing water may react with carbondioxide absorbent in the CCR, which may produce alkaline soda with a pH of 12–14, popularly referred to by CCR divers as a ‘caustic cocktail’. This study aimed to explore divers’ responses to caustic cocktail events and to investigate if CCR diving experience is associated with experiencing a caustic cocktail. Methods: An online survey instrument was developed and an invitation to participate was extended to certified CCR divers aged ≥ 18 years. Relationships between number of caustic cocktail events and potential risk factors: age; hours of rebreather diving experience; and number of rebreather dives were explored. Results: Of the 413 respondents, 394 (95%) identified as male, mean age was 46 years and median length of CCR certification was six years. Fifty-seven percent (n = 237) of respondents reported having experienced a caustic cocktail. The probability of self-reporting none, one, or more caustic cocktail events increased with experience. Divers reported a variety of first aid treatments for caustic cocktails, with ~80% citing their CCR instructor as a source of information. Conclusions: The more hours or dives a CCR diver accrues, the more likely they will self-report having experienced one or more caustic cocktail events. The majority of CCR divers responded to a caustic cocktail by rinsing the oral cavity with water. A proportion of divers, however, responded by ingesting soda, dairy, juice, or a mildly acidic solution such as a mixture of vinegar and water. The recommendation to immediately flush with water needs reinforcing among rebreather divers. [ABSTRACT FROM AUTHOR]

Introduction: Technical diving is increasing in popularity in Finland, and therefore the number of decompression illness (DCI) cases is also increasing among technical divers. Although hyperbaric oxygen treatment (HBOT) remains the standard of care, there are anecdotal reports of technical divers treating mild DCI symptoms themselves and not seeking a medical evaluation and possible recompression therapy. This study aimed to make an epidemiologic inventory of technical divingrelated DCI symptoms, to establish the incidence of self-treatment and to determine the apparent effectiveness of different treatment methods. Methods: A one-year prospective survey with online questionnaires was conducted. Fifty-five experienced and highly trained Finnish technical divers answered the survey and reported their diving activity, DCI symptoms, symptom treatment, and treatment outcome. Results: Of the reported 2,983 dives, 27 resulted in symptoms of DCI, which yielded an incidence of 91 per 10,000 dives in this study. All of the reported DCI symptoms were mild, and only one diver received HBOT. The most common selftreatments were oral hydration and rest. First aid oxygen (FAO2 ) was used in 21% of cases. Eventually, none of the divers had residual symptoms. Conclusions: The incidence of self-treated DCI cases was 27 times higher than that of HBO-treated DCI cases. There is a need to improve divers’ awareness of the importance of FAO2 and other recommended first aid procedures and to encourage divers to seek medical attention in case of suspected DCI. [ABSTRACT FROM AUTHOR]

Purpose: Data regarding decompression stress after deep closed-circuit rebreather (CCR) dives are scarce. This study aimed to monitor technical divers during a wreck diving expedition and provide an insight in venous gas emboli (VGE) dynamics. Methods: Diving practices of ten technical divers were observed. They performed a series of three consecutive daily dives around 100 m. VGE counts were measured 30 and 60 min after surfacing by both cardiac echography and subclavian Doppler graded according to categorical scores (Eftedal–Brubakk and Spencer scale, respectively) that were converted to simplified bubble grading system (BGS) for the purpose of analysis. Total body weight and fluids shift using bioimpedancemetry were also collected pre- and post-dive. Results: Depth-time profiles of the 30 recorded man-dives were 97.3 ± 26.4 msw [range: 54–136] with a runtime of 160 ± 65 min [range: 59–270]. No clinical decompression sickness (DCS) was detected. The echographic frame-based bubble count par cardiac cycle was 14 ± 13 at 30 min and 13 ± 13 at 60 min. There is no statistical difference neither between dives, nor between time of measurements (P = 0.07). However, regardless of the level of conservatism used, a high incidence of high-grade VGE was detected. Doppler recordings with the O'dive were highly correlated with echographic recordings (Spearman r of 0.81, P = 0.008). Conclusion: Although preliminary, the present observation related to real CCR deep dives questions the precedence of decompression algorithm over individual risk factors and pleads for an individual approach of decompression. [ABSTRACT FROM AUTHOR]

Introduction: Cold water imposes many risks to the diver. These risks include decompression illness, physical and cognitive impairment, and hypothermia. Cognitive impairment can be estimated using a critical flicker fusion frequency (CFFF) test, but this method has only been used in a few studies conducted in an open water environment. We studied the effect of the cold and a helium-containing mixed breathing gas on the cognition of closed circuit rebreather (CCR) divers. Materials and Methods: Twenty-three divers performed an identical dive with controlled trimix gas with a CCR device in an ice-covered quarry. They assessed their thermal comfort at four time points during the dive. In addition, their skin temperature was measured at 5-min intervals throughout the dive. The divers performed the CFFF test before the dive, at target depth, and after the dive. Results: A statistically significant increase of 111.7% in CFFF values was recorded during the dive compared to the pre-dive values (p < 0.0001). The values returned to the baseline after surfacing. There was a significant drop in the divers' skin temperature of 0.48°C every 10 min during the dive (p < 0.001). The divers' subjectively assessed thermal comfort also decreased during the dive (p = 0.01). Conclusion: Our findings showed that neither extreme cold water nor helium-containing mixed breathing gas had any influence on the general CFFF profile described in the previous studies from warmer water and where divers used other breathing gases. We hypothesize that cold-water diving and helium-containing breathing gases do not in these diving conditions cause clinically relevant cerebral impairment. Therefore, we conclude that CCR diving in these conditions is safe from the perspective of alertness and cognitive performance. [ABSTRACT FROM AUTHOR]

Introduction: Cold water imposes many risks to the diver. These risks include decompression illness, physical and cognitive impairment, and hypothermia. Cognitive impairment can be estimated using a critical flicker fusion frequency (CFFF) test, but this method has only been used in a few studies conducted in an open water environment. We studied the effect of the cold and a helium-containing mixed breathing gas on the cognition of closed circuit rebreather (CCR) divers.Materials and Methods: Twenty-three divers performed an identical dive with controlled trimix gas with a CCR device in an ice-covered quarry. They assessed their thermal comfort at four time points during the dive. In addition, their skin temperature was measured at 5-min intervals throughout the dive. The divers performed the CFFF test before the dive, at target depth, and after the dive.Results: A statistically significant increase of 111.7% in CFFF values was recorded during the dive compared to the pre-dive values (p < 0.0001). The values returned to the baseline after surfacing. There was a significant drop in the divers’ skin temperature of 0.48°C every 10 min during the dive (p < 0.001). The divers’ subjectively assessed thermal comfort also decreased during the dive (p = 0.01).Conclusion: Our findings showed that neither extreme cold water nor helium-containing mixed breathing gas had any influence on the general CFFF profile described in the previous studies from warmer water and where divers used other breathing gases. We hypothesize that cold-water diving and helium-containing breathing gases do not in these diving conditions cause clinically relevant cerebral impairment. Therefore, we conclude that CCR diving in these conditions is safe from the perspective of alertness and cognitive performance.

Mesophotic reefs are poorly known worldwide despite their great ecological relevance and management importance for coral reef conservation strategies. To aid in filling this gap, we conducted a pioneering, large-scale survey, covering a total of around 315 miles in length, in the largest Brazilian coastal Marine Protected Area (MPA) Costa dos Corais. From the digital bathymetry model (30 to 50 m depth) generated by a multibeam echo sounder, we selected areas of greater geomorphological diversity for a detailed investigative expedition of mesophotic ecosystems. Various sampling techniques were used: single-beam echo sounders for detailing the relief, a remotely operated underwater vehicle (ROV) for habitat type investigation, baited remote underwater video (BRUV) for collecting images of the fish community, and scuba diving to perform transects describing the benthic and fish community. We analyzed reef environments from 20 to 68 m deep. As a result, we present the mapping and geomorphological characterization of two compartments of mesophotic reefs at 21–45 m depth and an image library of mesophotic ecosystems with the species description and indications of whether it is a new record in the region. Biodiversity data were collected covering eight species of sponges, with greater abundance for Ircinia spp., Aplysina spp., and Xestospongia muta; eight from corals, mainly Siderastrea spp. And Montastrea cavernosa; and 68 species of reef fish, with the Labridae family (including Scarinae—11 species) being the richest. Our results demonstrate the importance of mesophotic reefs for MPA Costa dos Corais reef biodiversity and, with that, the need to protect these areas through the application of local conservation strategies, such as the creation of “no-take zones”.

Introduction: Technical diving is very popular in Finland throughout the year despite diving conditions being challenging, especially due to arctic water and poor visibility. Cold water, immersion, submersion, hyperoxia, as well as psychological and physiological stress, all have an effect on the autonomic nervous system (ANS). Materials and methods: To evaluate divers' ANS responses, short-term (5 min) heart rate variability (HRV) during dives in 2–4°C water was measured. HRV resting values were evaluated from separate measurements before and after the dives. Twenty-six experienced closed circuit rebreather (CCR) divers performed an identical 45-meter decompression dive with a non-physical task requiring concentration at the bottom depth. Results: Activity of the ANS branches was evaluated with the parasympathetic (PNS) and sympathetic (SNS) indexes of the Kubios HRV Standard program. Compared to resting values, PNS activity decreased significantly on immersion with face out of water. From immersion, it increased significantly with facial immersion, just before decompression and just before surfacing. Compared to resting values, SNS activity increased significantly on immersion with face out of water. Face in water and submersion measures did not differ from the immersion measure. After these measurements, SNS activity decreased significantly over time. Conclusion: Our study indicates that the trigeminocardiac part of the diving reflex causes the strong initial PNS activation at the beginning of the dive but the reaction seems to decrease quickly. After this initial activation, cold seemed to be the most prominent promoter of PNS activity – not pressure. Also, our study showed a concurrent increase in both SNS and PNS branches, which has been associated with an elevated risk for arrhythmia. Therefore, we recommend a short adaptation phase at the beginning of cold-water diving before physical activity. [ABSTRACT FROM AUTHOR]

Introduction: Dysbaric osteonecrosis (DON) in people working under increased atmospheric pressure is well documented. It is generally less common in military and commercial divers than in caisson workers, except in some high-risk groups, such as in many indigenous diving industries where workers have little or no understanding of decompression principles. With the increasing popularity within the recreational diving community of deep air and mixed-gas decompression diving (‘technical diving’), it is likely that diving physicians may see an increase in the prevalence of DON in this group in the future. Methods: The case report is presented of a technical diving instructor, with a 30-year history of deep diving, who developed bilateral humeral head DON and required a right shoulder hemi-arthroplasty. A focused literature search was also undertaken to identify published cases of DON in recreational divers. Results: The frequency, duration and depth of exposure to pressure, inadequate decompression, the occurrence of DCS and increasing age have been common features associated with DON in both divers and caisson workers. Many of these features were present in this technical diver. Conclusions: Whilst DON is uncommon in recreational air scuba divers, all the above risk factors are present to a greater degree in technical diving. It is suggested that medical review for DON is merited from time to time in this potentially high-risk group of recreational divers. [ABSTRACT FROM AUTHOR]

Introduction: Diving rebreathers use canisters containing soda lime to remove carbon dioxide (CO2) from expired gas. Soda lime has a finite ability to absorb CO2. Temperature sticks monitor the exothermic reaction between CO2 and soda lime to predict remaining absorptive capacity. The accuracy of these predictions was investigated in two rebreathers that utilise temperature sticks. Methods: Inspiration and rEvo rebreathers filled with new soda lime were immersed in water at 19°C and operated on mechanical circuits whose ventilation and CO2-addition parameters simulated dives involving either moderate exercise (6 MET) throughout (mod-ex), or 90 minutes of 6 MET exercise followed by 2 MET exercise (low-ex) until breakthrough (inspired PCO2 [PiCO2] = 1 kPa). Simulated dives were conducted at surface pressure (sea-level) (low-ex: Inspiration, n = 5; rEvo, n = 5; mod-ex: Inspiration, n = 7, rEvo, n = 5) and at 3-6 metres' sea water (msw) depth (mod-ex protocol only: Inspiration, n = 8; rEvo, n = 5). Results: Operated at surface pressure, both rebreathers warned appropriately in four o five low-ex tests but failed to do so in the 12 mod-ex tests. At 3-6 msw depth, warnings preceded breakthrough in 11 of 13 mod-ex tests. The rEvo warned conservatively in all five tests (approximately 60 minutes prior). Inspiration warnings immediately preceded breakthrough in six of eight tests, but were marginally late in one test and 13 minutes late in another. Conclusion: When operated at even shallow depth, temperature sticks provided timely warning of significant CO2 breakthrough in the scenarios examined. They are much less accurate during simulated exercise at surface pressure. [ABSTRACT FROM AUTHOR]

Introduction: Diving rebreathers use "scrubber" canisters containing soda lime to remove carbon dioxide (CO2) from the expired gas. Soda lime has a finite ability to absorb CO2. We undertook an experiment to determine whether the manner of storage of a partly used scrubber affected subsequent CO2 absorption. Methods: An Evolution Plus™ rebreather was mechanically ventilated in a benchtop circuit. Respiratory minute volume was 45 L·min-1 and CO2 was introduced to the expiratory limb at 2 L·min-1. The scrubber canister was packed with 2.64 kg of Sofnolime 797?. Scrubbers were run in this circuit for 90 minutes then removed from the rebreather and stored in packed form under one of three conditions: "open" (unsealed) for 28 days (n = 4); vacuum "sealed" in an airtight plastic bag for 28 days (n = 5); or open overnight (n = 5). Following storage the scrubber canisters were placed back in the rebreather and run as above until the PCO2 in the inspired gas exceeded 1 kPa. The total duration of operation to reach this end-point in each storage condition was compared. Results: The mean run times to reach an inspired CO2 of 1 kPa were 188, 241, and 239 minutes in the open-28-day, the sealed-28-day and the open-overnight storage conditions, respectively. Conclusion: Rebreather divers should consider placing partially used soda lime scrubber canisters in vacuum-sealed plastic bags if storing them for longer periods than overnight. If a partially used scrubber canister is to be used again the next day then the storage modality is unlikely to influence scrubber efficacy. [ABSTRACT FROM AUTHOR]

Divers suspected of suffering decompression illness (DCI) in locations remote from a recompression chamber are sometimes treated with in-water recompression (IWR). There are no data that establish the benefits of IWR compared to conventional first aid with surface oxygen and transport to the nearest chamber. However, the theoretical benefit of IWR is that it can be initiated with a very short delay to recompression after onset of manifestations of DCI. Retrospective analyses of the effect on outcome of increasing delay generally do not capture this very short delay achievable with IWR. However, in military training and experimental diving, delay to recompression is typically less than two hours and more than 90% of cases have complete resolution of manifestations during the first treatment, often within minutes of recompression. A major risk of IWR is that of an oxygen convulsion resulting in drowning. As a result, typical IWR oxygen-breathing protocols use shallower maximum depths (9 metres' sea water (msw), 191 kPa) and are shorter (1-3 hours) than standard recompression protocols for the initial treatment of DCI (e.g., US Navy Treatment Tables 5 and 6). There has been no experimentation with initial treatment of DCI at pressures less than 60 feet' sea water (fsw; 18 msw; 286 kPa; * see footnote) a since the original development of these treatment tables, when no differences in outcomes were seen between maximum pressures of 33 fsw (203 kPa; 10 msw) and 60 fsw or deeper. These data and case series suggest that recompression treatment comprising pressures and durations similar to IWR protocols can be effective. The risk of IWR is not justified for treatment of mild symptoms likely to resolve spontaneously or for divers so functionally compromised that they would not be safe in the water. However, IWR conducted by properly trained and equipped divers may be justified for manifestations that are life or limb threatening where timely recompression is unavailable. [ABSTRACT FROM AUTHOR]

The invasive macroalgal species Avrainvillea sp. and native species Halimeda kanaloana form expansive meadows that extend to depths of 80 m or more in the waters off of O‘ahu and Maui, respectively. Despite their wide depth distribution, comparatively little is known about the biota associated with these macroalgal species. Our primary goals were to provide baseline information on the fish fauna associated with these deep-water macroalgal meadows and to compare the abundance and diversity of fishes between the meadow interior and sandy perimeters. Because both species form structurally complex three-dimensional canopies, we hypothesized that they would support a greater abundance and diversity of fishes when compared to surrounding sandy areas. We surveyed the fish fauna associated with these meadows using visual surveys and collections made with clove-oil anesthetic. Using these techniques, we recorded a total of 49 species from 25 families for H. kanaloana meadows and surrounding sandy areas, and 28 species from 19 families for Avrainvillea sp. habitats. Percent endemism was 28.6% and 10.7%, respectively. Wrasses (Family Labridae) were the most speciose taxon in both habitats (11 and six species, respectively), followed by gobies for H. kanaloana (six species). The wrasse Oxycheilinus bimaculatus and cardinalfish Apogonichthys perdix were the most frequently-occurring species within the H. kanaloana and Avrainvillea canopies, respectively. Obligate herbivores and food-fish species were rare in both habitats. Surprisingly, the density and abundance of small epibenthic fishes were greater in open sand than in the meadow canopy. In addition, species richness was also higher in open sand for Avrainvillea sp. We hypothesize that the dense holdfasts and rhizoids present within the meadow canopy may impede benthic-dwelling or bioturbator species, which accounted for 86% and 57% of individuals collected in sand adjacent to H. kanaloana and Avrainvillea sp. habitats, respectively. Of the 65 unique species recorded in this study, 16 (25%) were detected in clove oil stations alone, illustrating the utility of clove-oil anesthetic in assessing the diversity and abundance of small-bodied epibenthic fishes.

Mesophotic coral ecosystems (MCEs) extend from 30 to 150 m in depth and support diverse communities of marine organisms. We investigated changes in the structure of mesophotic reef fish assemblages (27-100 m) in the Northwestern Hawaiian Islands (NWHI) along depth and geographical gradients using open- and closed-circuit trimix diving. There were clear changes in the assemblage structure from the southeastern to the northwestern end of the NWHI and from shallow to deep waters. Interactive effects of depth and location were also detected. MCEs in the NWHI can be treated as three regions: southeastern and mid regions primarily separated by the presence and absence, respectively, of the introduced species Lutjanus kasmira, and a northwestern region where fish assemblages are largely composed of endemic species. These spatial patterns may be explained, at least in part, by differences in temperature among the regions. [ABSTRACT FROM AUTHOR]

Aim Oxidative stress is increased in recreational technical diving. In an explorative retrograde study we investigated the hypothesis that, (1) repetitive, multi-day dives with oxygen-enriched breathing gases will have an impact on physiological measures, (2) negative effects can be assessed within one week post-dive. Study Design Exploratory retrospective crossover study. Setting Open-water study. Participants Ten healthy experienced technical divers. Interventions Repetitive dives with oxygen-enriched breathing gases during a 5-days diving trip to the Adriatic Sea (Croatia). Outcome Measures Basic measures of medical examination, electrocardiography, echocardiography, body plethysmography, and spiroergometry. Results The divers (32±8 years; mean±SD) performed 11±4 dives. Static and dynamic pulmonary measures were slightly decreased after the trip. On the bicycle ergometer, arterial oxygen partial pressure (pO2) remained almost unchanged from rest to 300 W before the trip (87.5±7.9 vs 85.4±9.7 mmHg) it decreased after the trip (90.4 ±7.2 vs 81.8±8.2 mmHg; p<0.05). Peak oxygen uptake (at 300 W) was decreased after the trip (45.1±9.9 vs 41.7±9.8 ml/min; p<0.05). In parallel, the aerobic threshold was decreased (234±43 vs 186±39 W; p<0.05). Conclusions Pulmonary injury is not detected at rest but at substantial physical load on the bicycle. Even after maximum one week, pO2 at 300 W was decreased together with the pulmonary O2 uptake, thus decreasing the aerobic threshold. In conclusion: (1) Multi-day, repetitive tech dives seem to induce - at least transient - pulmonary injury. (2) Pauses during a diving trip or more conservative diving are recommended. (3) A major physiological study on open-water divers can be performed by one single medical practice with an adequately equipped laboratory. [ABSTRACT FROM AUTHOR]

Re-circulating underwater breathing apparatus (rebreathers) have become increasingly popular amongst sport divers. In comparison to open-circuit scuba, rebreathers are complex life support equipment that incorporates many inherent failure modes and potential for human error. This individually or in combination can lead to an inappropriate breathing gas. Analysis of rebreather diving incidents suggests that inappropriate breathing gas is the most prevalent disabling agent. This can result in spontaneous loss of consciousness (LoC), water aspiration and drowning. Protecting the airway by maintaining the diver/ rebreather oral interface may delay water aspiration following LoC underwater; the possibility of a successful rescue is, thus, increased. One means of protecting the airway following LoC underwater is the use of a full-face mask (FFM). However, such masks are complex and expensive; therefore, they have not been widely adopted by the sport diving community. An alternative to the FFM used extensively throughout the global military diving community is the mouthpiece retaining strap (MRS). A recent study documented 54 LoC events in military rebreather diving with only three consequent drownings; all divers were reported to be using a MRS. Even allowing for the concomitant use of a tethered diving partner system in most cases, the low number of fatalities in this large series is circumstantially supportive of the efficacy of the MRS. Despite drowning featuring as a final common pathway in the vast majority of rebreather fatalities, the MRS has not been widely adopted by the sport rebreather diving community. [ABSTRACT FROM AUTHOR]

Introduction: Cave divers enter an inherently dangerous environment that often includes little visibility, maze-like passageways and a ceiling of rock that prevents a direct ascent to the surface in the event of a problem. Methods: Reports of cave diving fatality cases occurring between 01 July 1985 and 30 June 2015 collected by Divers Alert Network were reviewed. Training status, safety rules violated, relevancy of the violations, and root causes leading to death were determined. Results: A total of 161 divers who died were identified, 67 trained cave divers and 87 untrained. While the annual number of cave diving fatalities has steadily fallen over the last three decades, from eight to less than three, the proportion of trained divers among those fatalities has doubled. Data regarding trained cave divers were divided into two equal 15-year time periods. Trained cave divers who died in the most recent time period were older but little else differed. The most common cause of death was asphyxia due to drowning, preceded by running out of breathing gas, usually after getting lost owing to a loss of visibility caused by suspended silt. An overwhelming majority of the fatalities occurred in the state of Florida where many flooded caves are located. Conclusion: Even with improvements in technology, the greatest hazards faced by cave divers remain unchanged. Efforts to develop preventative interventions to address these hazards should continue. [ABSTRACT FROM AUTHOR]

Fishes inhabiting rhodolith beds and reefs at mesophotic depths on the Abrolhos Shelf, which encompasses the largest and richest coral reef formation in the South Atlantic Ocean, were assessed through technical diving and remotely operated vehicles ( ROVs). A total of 74 fish species were recorded, including at least one new species, one new record for the south-western Atlantic and six new records for the Abrolhos region. Overfishing, mining and port activities are already threatening many endangered and commercially important species recorded on the mesophotic reefs of Abrolhos Shelf, and the establishment of marine protected areas and off-reserve fisheries regulations are urgently needed. [ABSTRACT FROM AUTHOR]

Introduction: Diving rebreathers use canisters containing sodalime preparations to remove carbon dioxide (CO2) from the expired gas. These preparations have a limited absorptive capacity and therefore may limit dive duration. The Inspiration™ rebreather is designed for use with Sofnolime 797™ but some divers use Spherasorb™ as an alternative. There are no published data comparing the CO2-absorbing efficacy of these sodalime preparations in an Inspiration rebreather. Methods: An Inspiration rebreather was operated in a benchtop circuit under conditions simulating work at 6 metabolic equivalents (MET). Ventilation was maintained at 45 L⋅min-1 (tidal volume 1.5 L; respiratory rate 30 min-1) with CO2 introduced to the expiratory limb at 2 L⋅min-1. The PICO2 was continuously monitored in the inspiratory limb. The rebreather canister was packed to full volume with either Sofnolime or Spherasorb and 10 trials were conducted (five using each absorbent), in which the circuit was continuously run until the PICO2 reached 1 kPa ('breakthrough'). Peak inspiratory and expiratory pressures during tidal ventilation of the circuit were also recorded. Results: The mean operating duration to CO2 breakthrough was 138 ± 4 (SD) minutes for 2.38 kg Spherasorb and 202 ± minutes for 2.64 kg Sofnolime (P < 0.0001). The difference between peak inspiratory and expiratory pressures was 10% less during use of Spherasorb, suggesting lower work of breathing. Conclusions: Under conditions simulating work at 6 MET during use of an Inspiration rebreather a canister packed with Spherasorb reached CO2 breakthrough 32% earlier with 10% less mass than Sofnolime packed to similar volume. Divers cannot alternate between these two preparations and expect the same endurance. [ABSTRACT FROM AUTHOR]

This paper describes the use of ternary plots to graphically depict all diving gases comprising oxygen, helium and/or nitrogen such as nitrox, heliox and trimix. After an explanation on the interpretation of these charts, examples of their use for indicating different categories of breathing mixes and blending gases, and for determining the best mix for a particular depth are given. [ABSTRACT FROM AUTHOR]

Introduction: The vast majority of freshwater cave diving in Australia occurs within the limestone caves of the Gambier karst in the south-east of South Australia. The incidence of decompression illness (DCI) in cave divers is presumed to be higher than open-water recreational divers because of the greater depths involved, but has not previously been reported. Our aim was to determine the incidence of DCI in cave divers, the patterns of diving and the outcome of hyperbaric treatment. Methods: This was a retrospective cohort study of cave divers with DCI presenting to the Royal Adelaide Hospital or The Alfred Hospital over a 10-year period between 2002 and 2012. We reviewed case notes of cave divers who were treated for DCI after diving in the Mt Gambier karst. As there are no records of the number of dives performed during the study period we generated a denominator for the incidence of DCI by extrapolating available data and making a number of assumptions about the number of dives per dive permit issued. Results: Sixteen patients were treated for DCI during the study period. The precipitating dive was a single deep decompression dive in seven cases, multiday repetitive dive sequences in eight and a non-decompression dive in one. Three of the 16 cases of DCI involved dives in excess of 90 metres' fresh water (mfw) using trimix. As the total estimated number of dives in the study period was approximately 57,000 the incidence of DCI in Australian cave divers was estimated to be 2.8:10,000 (0.028%). It is possible that the overall incidence of DCI is as high as 0.05%, and even higher when dives to depths greater than 90 mfw are involved. Conclusions: The estimated incidence of DCS in this series is lower than expected but consistent with other series describing DCI in cold-water recreational diving. [ABSTRACT FROM AUTHOR]

Self-contained underwater breathing apparatus ( SCUBA) diving is regularly associated with numerous asymptomatic changes in cardiovascular function. Freshwater SCUBA diving presents unique challenges compared with open sea diving related to differences in water density and the potential for dive locations at altitude. The aim of this study was to evaluate the impact of freshwater trimix diving at altitude on human cardiovascular function. Ten divers performed two dives in consecutive days at 294 m altitude with the surface interval of 24 h. Both dives were at a depth of 45 m with total dive time 29 and 26 min for the first and second dive, respectively. Assessment of venous gas embolization, hydration status, cardiac function and arterial stiffness was performed. Production of venous gas emboli was low, and there were no significant differences between the dives. After the first dive, diastolic blood pressure was significantly reduced, which persisted up to 24 h. Left ventricular stroke volume decreased, and heart rate increased after both dives. Pulse wave velocity was unchanged following the dives. However, the central and peripheral augmentation index became more negative after both dives, indicating reduced wave reflection. Ejection duration and round trip travel time were prolonged 24 h after the first dive, suggesting longer-lasting suppression of cardiac and endothelial function. This study shows that freshwater trimix dives with conservative profiles and low venous gas bubble loads can result in multiple asymptomatic acute cardiovascular changes some of which were present up to 24 h after dive. [ABSTRACT FROM AUTHOR]

Background and Objectives : The use of closed-circuit rebreathers (CCRs) in recreational diving is gaining interest. However, data regarding its physiological effects are still scarce. Immersion, cold water, hyperoxia, exercise or the equipment itself could challenge the cardiopulmonary system. The purpose of this study was to examine the impact of CCR diving on lung function and autonomous cardiac activity after a series of CCR dives in cold water. Materials and Methods : Eight CCR divers performed a diving trip (one week) in the Baltic Sea. Spirometry parameters, SpO 2 , and the lung ultrasonography score (LUS) associated with hydration monitoring by bioelectrical impedance were assessed at the end of the week. Heart rate variability (HRV) was recorded during the dives. Results : No diver declared pulmonary symptoms. The LUS increased after dives combined with a slight non-pathological decrease in SpO 2 . Spirometry was not altered, and all body water compartments were increased. Global HRV decreased during diving with a predominant increase in sympathetic tone while the parasympathetic tone decreased. All parameters returned to baseline 24 h after the last dive. Conclusions : The lung aeration disorders observed seem to be transient and not associated with functional spirometry alteration. The HRV dynamics highlighted physiological constraints during the dive as well as environmental-stress-related stimulation that may influence pulmonary changes. The impact of these impairments is unknown but should be taken into account, especially when considering long and repetitive CCR dives.

Long-term and short-term underwater visual censuses using SCUBA, technical Nitrox, and closed circuit rebreathers (CCR) were carried out in Pohnpei, Micronesia, to define spatial and temporal dynamics within a semi-protected multi-species epinephelid (fish) spawning aggregation (FSA) of brown-marbled grouper, Epinephelus fuscoguttatus, camouflage grouper, Epinephelus polyphekadion, and squaretail coralgrouper, Plectropomus areolatus. Results identified species-specific patterns of habitat use, abundance, residency, and dispersal of FSAs. Fish spawning aggregations formed and dispersed monthly within a 21-160-d period after winter solstice within adjacent yet distinct outer reef habitats. The reproductive season coincided with periods of seasonally low sub-surface seawater temperature. Peaks in density varied among species both within the calendar year and relative to the winter solstice. Significant long-term declines in FSA density were observed for all three species, suggesting population-level fishery-induced impacts, similar to those previously reported for E. polyphekadion. Differences in density estimates were also observed between dive gear, with a threefold difference in densities measured by CCR for E. polyphekadion versus SCUBA that suggest a disturbance effect from exhaled SCUBA bubbles for this species. CCR also allowed surveys to be conducted over a larger area in a single dive, thereby improving the potential to gauge actual abundance and density within FSAs. Based on these findings, a combination of long-term and intensive short-term monitoring strategies is recommended to fully characterize trends in seasonal abundance and habitat use for aggregating species at single or multi-species FSA sites. Inherent variations in the timing and distribution of species within FSA make fine-scale temporal management protocols less effective than blanket protective coverage of these species at (e.g., marine protected areas covering FSAs and adjacent migratory corridors) and away from (i.e., temporal sales and catch restrictions) FSA sites. [ABSTRACT FROM AUTHOR]