2017 March;47(1)

Diving Hyperb Med. 2017 March;47(1):4-8. doi: 10.28920/dhm47.1.4-8. PMID: 28357818.

Otitis externa in military divers: more frequent and less harmful than reported

Thijs T Wingelaar1,2, Pieter-Jan AM van Ooij1, Rob A van Hulst2

1 Diving Medical Center, Royal Netherlands Navy
2 Department of Anesthesiology, Academic Medical Center, University of Amsterdam

Address for correspondence: TT Wingelaar, MD, Royal Netherlands Navy Diving Medical Center, Rijkszee en marinehaven 1780 CA Den Helder, The Netherlands
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Key words

Scuba diving; Ear infection; Treatment

Abstract

(Wingelaar TT, van Ooij PJAM, van Hulst RA. Otitis externa in military divers: more frequent and less harmful than reported. Diving and Hyperbaric Medicine. 2017 March;47(1):4-8. doi: 10.28920/dhm47.1.4-8. PMID: 28357818.)
Introduction: Although otitis externa (OE) is a common disease, data related to (military) divers are limited. This study aimed to determine the incidence of OE in military divers during their initial training. We also wished to consider seasonal influences on incidence and whether early detection increases completion of the diving course.
Methods: From January 2011 to October 2016 the Royal Netherlands Navy Diving School trained 189 divers. Up to December 2015 we used the training records for the analyses. From January 2016 onward all divers were prospectively screened. Pearson’s χ2 and Fisher’s exact tests were used to analyse the data.
Results: In the 162 included divers, 30 cases of OE were identified. The incidence in 2016 was significantly higher than in 2011–2015 (17/35 (49%) versus 13/127 (10%), P < 0.001). Almost all cases developed after three weeks of diving. No influence of season was found (P = 0.354). Early diagnosis and treatment of OE does not seem to affect completion of diving courses (P = 0.280). Only in three cases did a diver have to discontinue the course due to OE.
Discussion: This study suggests that OE is more frequent among military divers than earlier reported, most likely caused by prolonged water exposure. Diving activities can often be continued with standard topical treatment.

Copyright: This article is the copyright of the authors who grant Diving and Hyperbaric Medicine a non-exclusive licence to publish the article in printed and other forms.

Publication Type: Original article


Diving Hyperb Med. 2017 March;47(1):9-16. doi: 10.28920/dhm47.1.9-16. PMID: 28357819.

A comparative evaluation of two decompression procedures for technical diving using inflammatory responses: compartmental versus ratio deco

Enzo Spisni1, Claudio Marabotti2,3, Luigia De Fazio1, Maria Chiara Valerii1, Elena Cavazza1, Stefano Brambilla3, Klarida Hoxha4, Antonio L’Abbate3, Pasquale Longobardi3,4

1 Department of Biological, Geological and Environmental Sciences, University of Bologna, Italy
2 Department of Cardiology, Civic Hospital Cecina, Italy
3 Institute for Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
4 Hyperbaric Center of Ravenna, Via Augusto Torre 3, Ravenna, Italy

Address for correspondence: Enzo Spisni, Department of Biological, Geological and Environmental Sciences Traslational Physiology and Nutrition Unit, University of Bologna Via Selmi 3, 40126 Bologna, Italy
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Key words

Scuba diving; Decompression tables; Inflammation; Chemokines; Bubbles; Echocardiography

Abstract
(Spisni E, Marabotti C, De Fazio L, Valerii MC, Cavazza E, Brambilla S, Hoxha K, L’Abbate A, Longobardi P. A comparative evaluation of two decompression procedures for technical using inflammatory responses: compartmental versus ratio deco. Diving and Hyperbaric Medicine. 2017 March;47(1):9-16. doi: 10.28920/dhm47.1.9-16. PMID: 28357819.) 
Introduction: The aim of this study was to compare two decompression procedures commonly adopted by technical divers: the ZH-L16 algorithm modified by 30/85 gradient factors (compartmental decompression model, CDM) versus the ‘ratio decompression strategy’ (RDS). The comparison was based on an analysis of changes in diver circulating inflammatory profiles caused by decompression from a single dive.
Methods: Fifty-one technical divers performed a single trimix dive to 50 metres’ sea water (msw) for 25 minutes followed by enriched air (EAN50) and oxygen decompression. Twenty-three divers decompressed according to a CDM schedule and 28 divers decompressed according to a RDS schedule. Peripheral blood for detection of inflammatory markers was collected before and 90 min after diving. Venous gas emboli were measured 30 min after diving using 2D echocardiography. Matched groups of 23 recreational divers (dive to 30 msw; 25 min) and 25 swimmers were also enrolled as control groups to assess the effects of decompression from a standard air dive or of exercise alone on the inflammatory profile.
Results: Echocardiography at the single 30 min observation post dive showed no significant differences between the two decompression procedures. Divers adopting the RDS showed a worsening of post-dive inflammatory profile compared to the CDM group, with significant increases in circulating chemokines CCL2 (P = 0.001) and CCL5 (P = 0.006) levels. There was no increase in chemokines following the CDM decompression. The air scuba group also showed a statistically significant increase in CCL2 (P < 0.001) and CCL5 (P = 0.003) levels post dive. No cases of decompression sickness occurred.
Conclusion: The ratio deco strategy did not confer any benefit in terms of bubbles but showed the disadvantage of increased decompression-associated secretion of inflammatory chemokines involved in the development of vascular damage.

Copyright: This article is the copyright of the authors who grant Diving and Hyperbaric Medicine a non-exclusive licence to publish the article in printed and other forms.

Publication Type: Original article


Diving Hyperb Med. 2017 March;47(1):17-23. doi: 10.28920/dhm47.1.17-23. PMID: 28357820.

Preventive effect of rosiglitazone on liver injury in a mouse model of decompression sickness

Bin Peng, Miao-Miao Chen, Zheng-Lin Jiang, Xia Li, Guo-Hua Wang, Li-Hua Xu

Department of Neurophysiology and Neuropharmacology, Institute of Nautical Medicine and Co-innovation Center of Neuroregeneration, Nantong University, Jiangsu, China

Address for correspondence: Dr Zheng-Lin Jiang, Department of Neurophysiology and Neuropharmacology, Institute of Nautical Medicine, Nantong University, 9 Seyuan Road, Chongchuan District Nantong, Jiangsu 226019, China
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Key words

Animal model; Diving research; Injuries; Nitric oxide; Pharmacology

Abstract
(Peng B, Chen M-M, Jiang Z-L, Li X, Wang G-H, Xu L-H. Preventive effect of rosiglitazone on liver injury in a mouse model of decompression sickness. Diving and Hyperbaric Medicine. 2017 March;47(1):17-23. doi: 10.28920/dhm47.1.17-23. PMID: 28357820.)
Background and aims: Severe decompression sickness (DCS) is a multi-organ injury. This study investigated the preventive effects of rosiglitazone on liver injury following rapid decompression in mice and examined the underlying mechanisms. 
Methods: Mice were randomly divided into four groups: a control group, vehicle group, and rosiglitazone (5 and 10 mg∙kg-1) groups, the latter three being exposed to a pressure of 911 kPa. Haematoxylin and eosin staining, plasma levels of alanine transaminase (ALT), aspartate transaminase (AST) and lactate dehydrogenase and blood cell counts were used to evaluate liver injury at 30 min after rapid decompression. The expression of endothelial and inducible nitric oxide synthase (iNOS) and its phosphorylation were measured to uncover the underlying molecular mechanisms.
Results: A significant increase in plasma ALT, red blood cells and platelets, and a decrease in neutrophils were observed in the vehicle group. Furthermore, the expression of iNOS, E-selectin and the total level of NO in hepatic tissue, and soluble E-selectin in the plasma were significantly elevated in the vehicle group. Rosiglitazone pre-treatment prevented the increases in ALT (and AST), soluble E-selectin concentration, red blood cells and platelet counts. Moreover, rosiglitazone reduced over-expression of iNOS and the NO level, prevented the fall in neutrophil count and promoted the phosphorylation of iNOS in the liver.
Conclusions: Pre-treatment with rosiglitazone ameliorated liver injury from severe DCS. This preventive effect may be partly mediated by stimulating endothelial NO production, improving endothelial function and limiting inflammatory processes.

Copyright: This article is the copyright of the authors who grant Diving and Hyperbaric Medicine a non-exclusive licence to publish the article in printed and other forms.

Publication Type: Original article


Diving Hyperb Med. 2017 March;47(1):24-32. doi: 10.28920/dhm47.1.24-32. PMID: 28357821.

Tenth European Consensus Conference on Hyperbaric Medicine: recommendations for accepted and non-accepted clinical indications and practice of hyperbaric oxygen treatment

Daniel Mathieu1,2, Alessandro Marroni1,3, Jacek Kot1,4

1 European Committee for Hyperbaric Medicine
2 Critical Care Department, Medical University and Hospital of Lille, France
3 DAN Europe Research Division, Roseto degli Abruzzi, Italy
4 National Center for Hyperbaric Medicine, Institute of Maritime and Tropical Medicine, Medical University of Gdansk, Poland

Address for correspondence: Jacek Kot, Head of the National Center for Hyperbaric Medicine, Institute of Maritime and Tropical Medicine, Medical University of Gdansk, Poland
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Key words

Medical conditions and problems; Evidence; Systematic review; Symposium; European Committee for Hyperbaric Medicine

Abstract

(Mathieu D, Marroni A, Kot J. Tenth European Consensus Conference on Hyperbaric Medicine: recommendations for accepted and non-accepted clinical indications and practice of hyperbaric oxygen treatment. Diving and Hyperbaric Medicine. 2017 March;47(1):24-32. doi: 10.28920/dhm47.1.24-32. PMID: 28357821.)
The tenth European Consensus Conference on Hyperbaric Medicine took place in April 2016, attended by a large delegation of experts from Europe and elsewhere. The focus of the meeting was the revision of the European Committee on Hyperbaric Medicine (ECHM) list of accepted indications for hyperbaric oxygen treatment (HBOT), based on a thorough review of the best available research and evidence-based medicine (EBM). For this scope, the modified GRADE system for evidence analysis, together with the DELPHI system for consensus evaluation, were adopted. The indications for HBOT, including those promulgated by the ECHM previously, were analysed by selected experts, based on an extensive review of the literature and of the available EBM studies. The indications were divided as follows: Type 1, where HBOT is strongly indicated as a primary treatment method, as it is supported by sufficiently strong evidence; Type 2, where HBOT is suggested as it is supported by acceptable levels of evidence; Type 3, where HBOT can be considered as a possible/optional measure, but it is not yet supported by sufficiently strong evidence. For each type, three levels of evidence were considered: A, when the number of randomised controlled trials (RCTs) is considered sufficient; B, when there are some RCTs in favour of the indication and there is ample expert consensus; C, when the conditions do not allow for proper RCTs but there is ample and international expert consensus. For the first time, the conference also issued ‘negative’ recommendations for those conditions where there is Type 1 evidence that HBOT is not indicated. The conference also gave consensus-agreed recommendations for the standard of practice of HBOT.

Copyright: This article is the copyright of the authors who grant Diving and Hyperbaric Medicine a non-exclusive licence to publish the article in printed and other forms.

Publication Type: Consensus Conference


Diving Hyperb Med. 2017 March;47(1):33-37. doi: 10.28920/dhm47.1.33-37. PMID: 28357822.

An assessment of the performance of the Baxter elastomeric (LV10) Infusor™ pump under hyperbaric conditions

Stephen Perks1, Denise F Blake2, Derelle A Young1, John Hardman1, Lawrence H Brown3, Iestyn Lewis4, Tilley Pain1,2

1 The Townsville Hospital, Townsville, Queensland, Australia
2 James Cook University, Townsville
3 University of Texas, Austin, Texas, USA and Mount Isa Centre for Rural and Remote Health, Mount Isa, Queensland
4 Royal Hobart Hospital, Hobart, Tasmania, Australia

Address for correspondence: Stephen Perks, IMB 61, Pharmacy Department, 100 Angus Smith Drive, The Townsville Hospital, Douglas, Queensland Australia, 4814
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Key words

Hyperbaric oxygen therapy; Infectious diseases; Drugs; Equipment; Treatment; Flow rate

Abstract

(Perks S, Blake DF, Young DA, Hardman J, Brown LH, Lewis I, Pain T. An assessment of the performance of the Baxter Elastomeric (LV10) Infusor ™ pump under hyperbaric conditions. Diving and Hyperbaric Medicine. 2017 March;47(1):33-37. doi: 10.28920/dhm47.1.33-37. PMID: 28357822.)
Introduction: There are limited data on the use of elastomeric infusion pumps during hyperbaric oxygen treatment.
Aim: This study evaluated the flow rate of the Baxter elastomeric LV10 InfusorTM pump under normobaric (101.3 kPa and three hyperbaric conditions of 203 kPa, 243 kPa and 284 kPa.
Methods: Elastomeric pumps were secured to participants in the same manner as for a typical patient, except that a container collected the delivered antibiotic solution. Pumps and tubing were weighed before and after the test period to determine volume delivered and to calculate flow rates at sea level and the three commonly used hyperbaric treatment pressures at two different time periods, 0–2 hours (h) and 19–21 h into the infusion.
Results: The mean flow rates in ml∙hr-1 (SD) were: 9.5 (0.4), 10.3 (0.6), 10.4 (0.6), 10.4 (0.5) at 0−2 h and 10.5 (1.0), 12.2 (0.6), 9.4 (0.5), 10.3 (0.9) at 19–21 h for the normobaric, 203 kPa, 243 kPa and 284 kPa conditions respectively. There was no significant association between flow rate and time period (P = 0.166) but the 203 kPa flow rates were significantly
faster than the other flow rates (P = 0.008). In retrospect, the 203 kPa experiments had all been conducted with the same antibiotic solution (ceftazidime 6 g). Repeating that experimental arm using flucloxacillin 8 g produced flow rates of 10.4 (0.8) ml∙h-1, with no significant associations between flow rate and time period (P = 0.652) or pressure (P = 0.705).
Conclusion: In this study, the flow rate of the Baxter LV10 InfusorTM device was not significantly affected by increases in ambient pressure across the pressure range of 101.3 kPa to 284 kPa, and flow rates were generally within a clinically acceptable range of 9−12 ml∙h-1. However, there was evidence that the specific antibiotic solution might affect flow rates
and this requires further study.

Copyright: This article is the copyright of the authors who grant Diving and Hyperbaric Medicine a non-exclusive licence to publish the article in printed and other forms.

Publication Type: Technical report


Diving Hyperb Med. 2017 March;47(1):38-43. doi: 10.28920/dhm47.1.38-43. PMID: 28357823.

Performance of the BBraun Perfusor Space syringe driver under hyperbaric conditions

Lachlan Frawley, Bridget Devaney, Theo Tsouras, Geoff Frawley

Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, Australia

Address for correspondence: Geoff Frawley, Department Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Commercial Rd Prahran, Victoria, Australia, 3181
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Key words

Equipment; Hyperbaric medicine; Intensive care medicine; Pharmacology

Abstract

(Frawley L, Devaney B, Tsouras T, Frawley G. Performance of the BBraun Perfusor Space syringe driver under hyperbaric conditions. Diving and Hyperbaric Medicine. 2017 March;47(1):38-43. doi: 10.28920/dhm47.1.38-43. PMID: 28357823.)
Background: The BBraun Perfusor Space™ syringe driver is already in use by ambulance services and retrieval teams but has not previously been assessed for hyperbaric chamber use.
Methods: Pump flow accuracy was tested at rates between 1 and 40 ml·h-1 using three different brands of 50 ml syringe. Function of the occlusion alarms was assessed using the same syringes. The hyperbaric profile involved pressurisation to 284 kPa at 30 kPa·h-1, 30 min at 284 kPa and decompression at 30 kPa·h-1. Output was recorded from differences in
weight of collection containers. A single device was tested. 
Results: Performance was highly dependent on the syringe type used, with two of the three 50 ml syringes used demonstrating 'stiction' at both low and high occlusion pressure alarm settings, most marked during pressurisation. On decompression from 284 kPa all syringes alarmed at significantly lower pressures. Because of the stiction problems only the flow measurements for the BBrown Omnifix 50 ml syringes are reported. At a pressure of 284 kPa, the difference between programmed and delivered rates was within the manufacturer's specification of 10%: at 40 ml·h-1 (median variation 1.25%, IQR 0.5−1.7%), 10 ml·h-1 (8.6%, IQR 8−9.2%), 5 ml·h-1 (-8.8%, IQR -1.6−8.8%) and 1 ml·h-1 (-4%, IQR 4−12%). Pressurisation was associated with significantly lower flow rates whilst decompression was associated with significantly increased rates. Limited testing at 405 kPa was also within the manufacturer’s specifications.
Conclusion: A BBraun Infusor Space syringe driver performed within acceptable performance criteria but is highly dependent on syringe type and flow rates. The potential for the device to under deliver on pressurisation and over deliver on depressurisation, however, suggests vigilance and appropriate rate adjustments may be necessary during these phases.

Copyright: This article is the copyright of the authors who grant Diving and Hyperbaric Medicine a non-exclusive licence to publish the article in printed and other forms.

Publication Type: Technical report


Diving Hyperb Med. 2017 March;47(1):44-54. doi: 10.28920/dhm47.1.44-54. PMID: 28357824.

Identifying and acting on inappropriate metadata: a critique of the Grattan Institute Report on questionable care in Australian hospitals

P David Cooper, David R Smart 

P David Cooper and David R Smart are employed by the Tasmanian State Government as Medical Co-directors of the Department of Diving and Hyperbaric Medicine, Royal Hobart Hospital, Tasmania. DRS is also the current President of the South Pacific Underwater Medicine Society and has previously participated in the Commonwealth's MSAC reviews 1054(2003) and 1054.1(2011). 

Address for correspondence: Dr David Cooper, Department of Diving and Hyperbaric Medicine, Royal Hobart Hospital, GPO Box 1061L, Hobart, Tasmania 7001, Australia
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Key words

Critical appraisal; Data; Economics; Evidence; Health; Hyperbaric oxygen therapy; Policy

Abstract

(Cooper PD, Smart DR. Identifying and acting on inappropriate metadata: a critique of the Grattan Institute Report on questionable care in Australian hospitals. Diving and Hyperbaric Medicine. 2017 March;47(1):44-54. doi: 10.28920/dhm47.1.44-54. PMID: 28357824.)
Introduction: In an era of ever-increasing medical costs, the identification and prohibition of ineffective medical therapies is of considerable economic interest to healthcare funding bodies. Likewise, the avoidance of interventions with an unduly elevated clinical risk/benefit ratio would be similarly advantageous for patients. Regrettably, the identification of such therapies has proven problematic. A recent paper from the Grattan Institute in Australia (identifying five hospital procedures as having the potential for disinvestment on these grounds) serves as a timely illustration of the difficulties inherent in nonclinicians attempting to accurately recognize such interventions using non-clinical, indirect or poorly validated datasets.
Aim: To evaluate the Grattan Institute report and associated publications, and determine the validity of their assertions regarding hyperbaric oxygen treatment (HBOT) utilisation in Australia. 
Methods: Critical analysis of the HBOT metadata included in the Grattan Institute study was undertaken and compared against other publicly available Australian Government and independent data sources. The consistency, accuracy and reproducibility of data definitions and terminology across the various publications were appraised and the authors’ methodology was reviewed. Reference sources were examined for relevance and temporal eligibility.
Results: Review of the Grattan publications demonstrated multiple problems, including (but not limited to): confusing patient-treatments with total patient numbers; incorrect identification of ‘appropriate’ vs. ‘inappropriate’ indications for HBOT; reliance upon a compromised primary dataset; lack of appropriate clinical input, muddled methodology and use of inapplicable references. These errors resulted in a more than seventy-fold over-estimation of the number of patients potentially treated inappropriately with HBOT in Australia that year.
Conclusion: Numerous methodological flaws and factual errors have been identified in this Grattan Institute study. Its conclusions are not valid and a formal retraction is required.

Copyright: This article is the copyright of the authors who grant Diving and Hyperbaric Medicine a non-exclusive licence to publish the article in printed and other forms.

Publication Type: Scientific integrity review


Diving Hyperb Med. 2017 March;47(1):55-58. doi: 10.28920/dhm47.1.55-58. PMID: 28357825.

The prevalence of electrocardiogram abnormalities in professional divers

Ali Erdal Gunes1, Maide Cimsit2

1 Harran University, Faculty of Medicine, Underwater and Hyperbaric Medicine, Sanliurfa, Turkey
2 Istanbul University, Istanbul Faculty of Medicine, Underwater and Hyperbaric Medicine, Istanbul, Turkey

Address for correspondence: Assistant Professor Ali Erdal Gunes, Harran University School of Medicine, Faculty of Medicine, Department of Underwater and Hyperbaric Medicine, Osmanbey Campus, 63300, Sanliurfa, Turkey
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Key words

Diving at work; Electrocardiography; Health status; Fitness to dive; Diving research

Abstract

(Gunes AE, Cimsit M. The prevalence of electrocardiogram abnormalities in professional divers. Diving and Hyperbaric Medicine. 2017 March;47(1):55-58. doi: 10.28920/dhm47.1.55-58. PMID: 28357825.)
Background: The underwater environment presents physiological challenges for the cardiovascular, renal and pulmonary systems. Increases in external hydrostatic pressure reduce the capacity of the venous compartment and cause blood to move toward the lung. The aim of this study was to evaluate retrospectively electrocardiographic (ECG) changes in a cohort of professional divers.
Methods: Between January 2009 and January 2012, 225 randomly selected professional divers, 204 male (91%) and 21 female (9%) attended our clinic for their biannual diving medical assessment. Their ECG records were evaluated retrospectively.
Results: The most common ECG abnormality observed was incomplete right bundle branch block (IRBBB) in 30 divers (13.3%). Eleven divers (4.9%) showed right QRS axis deviation (seven with IRBBB). Six divers had a sinus tachycardia; in four divers there was early repolarization; three divers had ventricular extrasystoles; one diver had ST elevation in lead V3; there was one with sinus arrhythmia and another with T-wave inversion in leads V2, V3 and aVF. These ECG changes were evaluated retrospectively by a cardiologist who made various recommendations for further review including bubblecontrast echocardiography for IRBBB.
Conclusions: No serious ECG abnormalities were identified, but IRBBB should be f urther investigated because of its association with persistent (patent) foramen ovale. Rapid cardiological review of ECGs could be achieved using modern communications technology, such as telecardiography, and further clinical investigations directed by specialist
recommendation arranged promptly if indicated.

Copyright: This article is the copyright of the authors who grant Diving and Hyperbaric Medicine a non-exclusive licence to publish the article in printed and other forms.

Publication Type: Short communication


Diving Hyperb Med. 2017 March;47(1):59-61. doi: 10.28920/dhm47.1.59-61. PMID: 28357826.

Anton’s syndrome as a presentation of decompression illness

Charles P Azzopardi, Lyubisa Matity, Stephen Muscat

Hyperbaric Unit, Mater Dei Hospital, Msida, Malta

Address for correspondence: Dr Charles Paul Azzopardi, Hyperbaric Unit, Mater Dei Hospital, Msida, Malta MSD 2090
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Key words

Decompression sickness; Central nervous system; Anosognosia; Case reports

Abstract

(Azzopardi CP, Matity L, Muscat S. Anton’s syndrome as a presentation of decompression illness. Diving and Hyperbaric Medicine. 2017 March;47(1):59-61. doi: 10.28920/dhm47.1.59-61. PMID: 28357826.)
We present a case of a patient with Anton’s syndrome due to decompression illness (DCI) after recreational scuba diving. Visual anosognosia, or denial of loss of vision, which is associated with lack of awareness regarding visual loss in the setting of cortical blindness, is known as Anton’s syndrome (also termed Anton-Babinski syndrome). Our patient presented with progressive neurological DCI treated with repeated recompression. The anosogosia resolved after 48 h. Subsequent echocardiography revealed a persistent (patent) foramen ovale.

Copyright: This article is the copyright of the authors who grant Diving and Hyperbaric Medicine a non-exclusive licence to publish the article in printed and other forms.

Publication Type: Case report


 

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