Undersea and Hyperbaric Medicine最新文献

Background: Decompression illness (DCI) poses significant risks for divers, particularly in remote locations with limited resources. Few randomized controlled trials (RCTs) exist, necessitating a review to consolidate current evidence and support evidence-based treatment protocols. This review evaluates RCT evidence on the effectiveness of recompression treatment and adjunctive therapies for diving-related DCI.

Methods: This review included RCTs assessing recompression treatment or adjunctive therapies in managing DCI. Exclusions were non-human studies, trials on DCI prevention, non-English publications, incomplete trials, and those involving non-diving DCI. Databases searched from inception to May 15, 2023, included Ovid MEDLINE, CENTRAL, CINAHL, and EMBASE. Citation chasing was performed on June 1, 2023, using Web of Science. Risk-of-bias assessments were guided by considering the Cochrane risk-of- bias tool for randomized trials.

Results: Two RCTs were identified. One trial (n=180) indicated that tenoxicam might reduce the number of required recompressions from three (range 1-8) to two (range 1-6). The other trial (n=41) showed that a shorter initial recompression treatment table could decrease the number of recompressions (median one vs. two) in cases of mild DCI.

Discussion: Limitations included unblinded participants, small participant numbers, non-protocol interventions, participant blinding, and incomplete outcome data. Recommendations for future research include reaching a consensus on a universal scoring system to support the clear definition and selection of participants, subgroup analyses, and inter-trial comparisons.

e initial terminology used to describe 2,642 cases of necrotizing infections as "hospital gangrene" was coined by Dr. Joseph Jones, surgeon of the Confederate Army in 1871 [1]. Later in 1883, Dr. Jean- Alfred Fournier characterized necrotizing infections to the perineum. Necrotizing fasciitis was initially described and named "hemolytic streptococcal gangrene" by Meleney in 1924 [2]. He described an illness characterized by gangrene of subcutaneous tissues, followed by rapid necrosis of the overlying skin from involvement of the blood vessels supplying the skin, which are found in the affected fascial layers. All his patients grew hemolytic streptococci on cultures, and the patients were all seriously ill. Surgical extirpation appeared to be the best therapeutic approach then and remains so. The actual term Necrotizing Fasciitis was credited to Dr. Wilson much later in 1952 [3]. Media often refers to this entity as infection with «Flesh-eating bacteria."The annual incidence of NSTI varies considerably but is often reported at approximately four per 100,000 in developed countries [4]. Mortality rates highlight the severity of disease with a 90-day mortality of 18% reported in a multi-center study including more than 400 patients [5].

Watchman devices are increasingly implanted in patients with atrial fibrillation who cannot be anticoagulated. We report a case of a patient undergoing Watchman device insertion complicated by cerebral arterial gas embolism. The treatment was delayed because the diagnosis was not initially considered. The patient was eventually treated with hyperbaric oxygen but sustained permanent disabilities. Watchman device implantation has a near 1% risk of arterial gas embolism. The possibility of cerebral gas embolism should be considered in patients emerging from anesthesia with neurologic deficits.

Chronic refractory osteomyelitis, according to the Centers for Medicare & Medicaid Services' (CMS) National Coverage Determination (NCD) 20.29, is an identified condition covered for treatment with adjunctive hyperbaric oxygen (HBO₂) therapy. Within the NCD (20.29) chronic refractory osteomyelitis is outlined as being unresponsive to conventional medical and surgical management [1]. From a practical perspective, patients can be appropriately diagnosed with chronic refractory osteomyelitis when they demonstrate no significant improvement or demonstrate worsening of the underlying osteomyelitis despite 30 days of combined conventional surgical and medical treatment that included systemic antimicrobial therapy. To date, no conclusive randomized clinical trials examining the effects of HBO₂ therapy on refractory osteomyelitis exist. Additionally, many of the initial studies that resulted in positive outcomes were conducted in hospital settings safeguarding compliance, and thus, not unexpectedly, the outcomes have not translated exactly to the outpatient clinic setting. Nonetheless, based on a comprehensive review of the scientific literature, the addition of HBO₂ therapy to routine surgical and antibiotic treatment of previously refractory osteomyelitis appears to be both safe and ultimately improves infection resolution rates. In most cases, the best clinical results are obtained when HBO₂ treatment is administered concomitantly with culture-directed antibiotics and initiated soon after clinically indicated surgical debridement. In situations where extensive surgical debridement or removal of fixation hardware is relatively contraindicated (i.e., cranial, spinal, sternal, or pediatric osteomyelitis), a trial of systemic culture-directed antibiotics and HBO₂ therapy prior to undertaking more than limited surgical interventions provides a reasonable prospect for osteomyelitis cure.

Carbon monoxide (CO) is an important source of poisoning in the United States and accounts for over 50,000 emergency department (ED) visits annually. Of these, almost 15,000 cases are reported as intentional, with over 1,000 deaths annually reported in the USA.1 Unintentional deaths from carbon monoxide poisoning are commonly associated with the improper use of generators, heaters, or other sources of combustion, such as malfunctioning home appliances or vehicular exhaust [2,3]. We describe a case of severe intentional CO poisoning that had reversal of CT and MRI findings that were consistent with a globus pallidus injury and a favorable clinical outcome in an adult male treated with Hyperbaric Oxygen Therapy (HBO₂). There are currently conflicting data and guideline recommendations regarding the utility of HBO₂ in the management of CO.4 This case provides additional evidence for HBO₂ treatment in a patient population whose clinical presentation and imaging findings are consistent with severe poisoning.

Introduction: The optimal depth for decompression stops is unclear. We hypothesize that a decompression stop at 1.3 bar, compared with 1.6 bar, decreases post-dive whole-body nitrogen washout volumes and venous gas emboli (VGE).

Methods: In this randomized crossover trial, divers performed wet air dives of 40 minutes at 3.4 bar (340 kPa) with a seven-minute-long decompression stop at either 1.3 bar (Deco 1.3) or 1.6 bar (Deco 1.6) in randomized order. The primary outcome was the difference in post-dive whole body nitrogen washout volume, analyzed using multilevel linear regression. The secondary outcome was the difference in peak VGE detected by cardiac two-dimensional ultrasound, graded using the Eftedal-Brubakk scale, and analyzed with Wilcoxon matched-pairs signed-rank tests.

Results: Sixteen divers completed both Deco 1.3 and Deco 1.6. Post-dive whole body nitrogen washout volumes were measured in eight of the 16 participants and were lower with Deco 1.3 than Deco 1.6 (696 ml [95% confidence interval [CI], 601 to 790] versus 1068 ml [95% CI, 962 to 1174]), mean difference of 373 ml (95% CI, 243 to 502). Deco 1.3 had lower peak bubble grades than Deco 1.6 (interquartile range 2-3 versus 3-4; P=0.005), but the median grade was the same at 3.

Conclusions: Decompression stop at 1.3 bar instead of 1.6 bar decreased post-dive whole body nitrogen washout volume and VGE. These findings may inform the development of future decompression models.

Objectives: Hyperbaric Oxygen (HBO₂) Therapy has been associated with some risks and adverse events. Previous studies examining otologic complications from HBO₂ therapy vary in their reported incidence of adverse events. This study aims to systematically review the otologic complications associated with HBO₂ therapy and investigate contributing risk and protective factors.

Review method: A systematic review was conducted to identify studies reporting otologic adverse effects due to HBO₂ therapy. Utilizing PRISMA 2020 guidelines, titles and abstracts were screened before conducting a full-text analysis. Studies reporting the incidence of otologic complications and studies reporting risk or protective factors for otologic complications were included.

Results: A search for articles on HBO₂ therapy otologic complications yielded 2,027 articles, of which 183 were relevant to the research question. Ultimately, 54 studies met the inclusion criteria. Fifteen percent of the 18,284 patients treated with HBO₂ therapy experienced adverse events. Of the middle ear barotrauma (MEB) that occurred, 42.8% was mild, and 6.4% was severe. The major risk factors were increasing age, female sex, head and neck pathology, sensory neuropathy, and pre-treatment difficulty equalizing ear pressure. The main protective factor was experience with effective equalization techniques.

Conclusions: 15% of patients experienced otologic complications due to HBO₂ therapy. Older age, female sex, and a history of head and neck or neurological conditions may increase the risk for MEB. Increased monitoring of higher-risk patients during initial treatment sessions and proper equalization techniques may help prevent MEB during HBO₂ therapy. This is the most comprehensive systematic review on the topic to date.

Background: The increasing life expectancy presents new challenges in managing elderly patients requiring hyperbaric oxygen (HBO₂) therapy. This retrospective study evaluates the safety and adherence to HBO₂ guidelines in patients aged 75 years and older, focusing on side effects and adverse events.

Methods: Data from 69 elderly patients treated between 2019 and 2023 at two Sicilian hyperbaric centres were analyzed. Demographics, indications for HBO₂, comorbidities, treatment protocols, and side effects were collected. Pre-treatment evaluations included ENT checkups, ECG, chest X-rays, and laboratory tests. Patients underwent HBO₂ sessions at 2.4-2.8 ATA, with clinical monitoring pre-and post-treatment.

Results: 1,799 HBO₂ sessions were performed in 69 patients (mean age 78 years; 59.4% male). The most common indications were progressive necrotizing infections (33.3%), sudden sensorineural hearing loss (17.3%), and chronic radiation-induced tissue injuries (14.5%). Side effects occurred in 14 patients (20.3%), primarily middle ear barotrauma (8.7%), sinus barotrauma (4.3%), confinement anxiety (4.3%), hypoglycemia (1.4%), and chest pain (1.4%). Most side effects were resolved with prompt care, and no life-threatening events were recorded. Adherence to guidelines and meticulous pre-treatment evaluations minimized risks.

Conclusions: HBO₂ is a safe therapeutic option for elderly patients when strict pre-treatment evaluations and monitoring protocols are implemented. Despite this population's increased vulnerability, the incidence of side effects was comparable to that in younger cohorts. Future research is warranted to optimize treatment protocols and explore outcomes in larger elderly populations.

Case description: We present a case of a 39-year-old healthy female scientific diver who developed cold urticaria (CU) 8 months prior, when immediately postpartum. She had extensive diving experience but discontinued diving during pregnancy and sought to resume diving. Before our consultation, she had seen a dermatologist and allergist for evaluation for an underlying etiology and management.

Intervention: Initial management included diphenhydramine and cetirizine with topical triamcinolone based on dermatology recommendations. Her allergist later advised discontinuing diphenhydramine and remaining on cetirizine 10mg up to four times daily, given breastfeeding concerns. Epinephrine was prescribed in case of anaphylaxis.

Outcome: The workup revealed no underlying pathology, and she was not cleared for diving until her CU was resolved. Despite antihistamines, she continues to be symptomatic, including in pools heated to 90⁰F. Although drysuit certified, we could not clear her for scientific diving and advised against recreational diving given the risk of anaphylaxis.

Discussion: CU is an uncommon but under-reported and under-recognized condition with potentially fatal consequences for swimmers and divers. Although symptom management focuses on antihistamines, corticosteroids and omalizumab (Xolair®) may prove helpful. Nonetheless, the risk of anaphylaxis remains, so CU should be a disqualifying condition for divers. Associated and causative conditions require specialist evaluation, with many patients reporting spontaneous resolution within several years. Hyperbaric physicians should be aware of CU as a disqualifying condition and an etiology of a post-diving rash that could be mistaken for skin manifestations of decompression sickness.

Background: The COVID-19 pandemic, being an airborne disease, posed a challenge in providing Hyperbaric Oxygen (HBO2) Therapy in multiplace chambers by increasing the risk of cross-infectivity while on air break inside the chamber. The standard regimen consisting of two air breaks was modified, and a new low-dose HBO₂ therapy regimen with no air breaks was introduced to mitigate the risk of cross- infection. This study aimed to evaluate the efficacy of the modified HBO₂ therapy regimen compared to the standard HBO2 therapy regimen for patients with soft tissue radiation injury.

Methods: A retrospective observational study compared the modified low-dose HBO₂ therapy regimen of 2.4 Atmosphere Absolute (ATA) for 60 minutes without air-break vis-a-vis the standard regimen of 2.4 ATA for 100 minutes with two air breaks of five minutes each. Patients with soft tissue radiation injury in the form of radiation cystitis and radiation proctitis were selected for comparison in the study. Data was retrieved from patients who underwent the standard and modified regimen during the COVID-19 pandemic. Late Effects Normal Tissue (LENT)/ Subjective Objective Management Analytic (SOMA) questionnaire-based scoring was compared for 30 sessions of HBO₂ therapy. Standard biostatistical methodology was used to compare the outcomes of both regimens.

Results: The mean LENT SOMA score decreased from the baseline to the end of 30 sessions in the HBO₂ therapy protocols. Overall, mean values decreased more for the patients who were offered the standard regimen of HBO₂ therapy.

Conclusion: A modified low-dose HBO₂ therapy treatment regimen achieved statistically significant therapeutic benefits. However, the results were statistically more promising for the patients who underwent the standard HBO₂ therapy regimen.