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The Journal of the South Pacific Underwater Medicine Society and the European Underwater and Baromedical Society Volume 44 No. 1 March 2014 Ultrasound for bubble detection Toward automated bubble counts from 2D echocardiography Ultrasound – the impact of new technology Estimating sample size for ultrasound studies Decompression illness treated in Auckland, New Zealand Biochemical markers of neurological decompression sickness Does vinegar make box jellyfish stings worse? Print Post Approved PP 100007612 ISSN 1833-3516, ABN 29 299 823 713 Diving and Hyperbaric Medicine Volume 44 No. 1 March 2014 PURPOSES OF THE SOCIETIES To promote and facilitate the study of all aspects of underwater and hyperbaric medicine To provide information on underwater and hyperbaric medicine To publish a journal and to convene members of each Society annually at a scientific conference SOUTH PACIFIC UNDERWATER EUROPEAN UNDERWATER AND MEDICINE SOCIETY BAROMEDICAL SOCIETY OFFICE HOLDERS OFFICE HOLDERS President President Mike Bennett <[email protected]> Costantino Balestra <[email protected]> Past President Vice President Chris Acott <[email protected]> Jacek Kot <[email protected]> Secretary Immediate Past President Karen Richardson <[email protected]> Peter Germonpré <[email protected]> Treasurer Past President Shirley Bowen <[email protected]> Alf Brubakk <[email protected]> Education Officer Honorary Secretary David Smart <[email protected]> Joerg Schmutz <[email protected]> Public Officer Member-at-Large 2013 Andrew Fock <[email protected]> Pierre Lafère <[email protected]> Chairman ANZHMG Member-at-Large 2012 Position vacant Lesley Blogg <[email protected]> Committee Members Member-at-Large 2011 Peter Smith <[email protected]> Fiona Sharp <[email protected]> Denise Blake <[email protected]> Liaison Officer Simon Mitchell <[email protected]> Phil Bryson <[email protected]> Webmaster Joel Hissink <[email protected]> ADMINISTRATION ADMINISTRATION Membership Honorary Treasurer & Membership Secretary Steve Goble <[email protected]> Patricia Wooding <[email protected]> 16 Burselm Avenue, Hainault, Ilford MEMBERSHIP Essex, IG6 3EH, United Kingdom For further information on SPUMS and to complete a membership Phone & Fax: +44-(0)20-85001778 application, go to the Society’s website: <www.spums.org.au> The official address for SPUMS is: MEMBERSHIP c/o Australian and New Zealand College of Anaesthetists, For further information on EUBS and to complete a membership 630 St Kilda Road, Melbourne, Victoria 3004, Australia application, go to the Society’s website: <www.eubs.org> SPUMS is incoprorated in Victoria A0020660B DIVING and HYPERBARIC MEDICINE <www.dhmjournal.com> Editor: Editorial Board: Michael Davis <[email protected]> Costantino Balestra, Belgium c/- Hyperbaric Medicine Unit Michael Bennett, Australia Christchurch Hospital, Private Bag 4710 Alf Brubakk, Norway Christchurch, New Zealand David Doolette, USA Phone: +64-(0)3-364-0045 or (0)3-329-6857 Peter Germonpré, Belgium Fax: +64-(0)3-364-0817 or (0)3-329-6810 Jane Heyworth, Australia European Editor: Jacek Kot, Poland Peter Müller <[email protected]> Simon Mitchell, New Zealand Editorial Assistant: Claus-Martin Muth, Germany Nicky McNeish <[email protected]> Neal Pollock, USA Journal distribution: Monica Rocco, Italy Steve Goble <[email protected]> Martin Sayer, United Kingdom Journal submissions: Erika Schagatay, Sweden Submissions should be sent to <[email protected]> David Smart, Australia Robert van Hulst, The Netherlands Diving and Hyperbaric Medicine is published jointly by the South Pacific Underwater Medicine Society and the European Underwater and Baromedical Society (ISSN 1833-3516, ABN 29 299 823 713) Diving and Hyperbaric Medicine Volume 44 No. 1 March 2014 1 Figure 1 Editorials Accelerated peripheral elimination of radioactive tracer during vibration (n = 5); Tc99-labelled albumin was injected The lymphatic pathway for subcutaneously into the first dorsal interosseous space; the gamma camera was positioned over the axilla and the arm vibrated at 30Hz microbubbles using a physiotherapeutic vibrator Costantino Balestra The sites for formation of microbubbles that are routinely detected precordially by Doppler after a decompression are still a matter of debate. Firstly, microbubbles could form on the endothelial wall of capillaries, at specific nanometric sites, but the release mechanism of such small emerging entities remains puzzling. They might also be formed from pre-existing gas nuclei present in the blood when favorable local hydrodynamic/supersaturation conditions generate microcavitation and tribonucleation phenomena. Finally, tissues could represent large pools for microbubble formation and amplification. Nevertheless, it remains unexplained as to what the potential driving pathways might be.1 Knowing that the permeability of most of the blood capillary network is quite low, an alternative is proposed for such would allow the elimination of a part of intercellular tissue transport. The lymphatic system, which drains the interstitial micronuclei (Figure1).3 fluid to guarantee the fluid balance of tissues, could allow the transfer of micrometric elements, like stabilized In conclusion, the effectiveness of vibration on VGE microbubbles formed in tissues, over long distances. These elimination might be explained by the mechanical action might then be reinjected into the bloodstream via the right of vibration on the endovascular and tissue localization lymphatic and thoracic ducts. The characteristics of this slow of micronuclei. Other preconditioning situations showing transport, activated by the muscular pump, could explain the positive effects on the number of post-dive vascular gas detection of vascular gas emboli (VGE) over long periods. emboli also can be explained by increased lymphatic activity. This hypothesis may give credence to a relatively old References empirical finding of combat and commercial divers: that one should drive the boat fast to the dive site, but not on the 1 Hugon J, Barthelemy L, Rostain JC, Gardette B. The pathway way back, to reduce the risk of decompression sickness. to drive decompression microbubbles from the tissues to the These stories finally interested researchers enough to take a blood and the lymphatic system as a part of this transfer. scientific look at why this happens. It was confirmed that 30 Undersea Hyperb Med. 2009;36:223-36. 2 Germonpré P, Pontier JM, Gempp E, Blatteau JE, Deneweth S, minutes of whole-body vibration before a dive (30 min, 30 2 Lafère P, et al. Pre-dive vibration effect on bubble formation msw) had preventive effects on post-dive bubble formation. after a 30-m dive requiring a decompression stop. Aviat Space As there was no observed change in flow-mediated dilatation Environ Med. 2009;80:1044-8. after vibration, the authors concluded that a nitrogen 3 Leduc A, Lievens P, Dewald J. The influence of multidirectional monoxide-mediated mechanism was not involved; rather, a vibrations on wound healing and on regeneration of blood- and mechanical dislodgement or enhanced lymphatic elimination lymph vessels. Lymphology. 1981;14:179-85. of gas nuclei was hypothesized. Costantino Balestra, PhD There are several possible explanations for this effect. Firstly, President, EUBS the vibrational force transmission to the whole-body should Professor of Integrative Physiology, Haute Ecole Paul Henri- interact with the blood flow as well as the endothelium in Spaak, Brussels order to eliminate the gas nuclei. In addition, vibrations E-mail: <[email protected]> may increase the blood friction forces on the endothelium Key words favoring the detachment of gas micronuclei from the vascular Doppler, bubbles, venous gas embolism, physiology, wall. Vibrations should induce, by force transmission, a editorials modification of endothelial spatial conformation. This modification should be responsible for a higher exposition Front page photo of a rebreather diver at the Cod Hole of gas nuclei to the blood flow drag forces. Finally, the on Ribbon Reef Number 10 at the northern end of the increase of lymphatic circulation, induced by vibration, Great Barrier Reef was taken by Dr Simon Mitchell 2 Diving and Hyperbaric Medicine Volume 44 No. 1 March 2014 Ultrasonic detection of to produce in a robust form. 2D echocardiography, on the other hand, can produce visual representations of bubbles, decompression-induced bubbles potentially more easily assessed with automated counting Neal W Pollock and Ron Y Nishi algorithms. It remains to be seen how such systems can address the confounding introduced by bubbles in the blood Detection of gas emboli (bubbles) using ultrasound is volume either not passing through or repeatedly passing a principle tool for monitoring decompression stress through the imaging plane. short of symptom development. Decompression-induced bubbles were first observed 47 years ago at the Virginia Other major challenges are the estimation of bubble size and Mason Research Center as audible signals from sheep total gas volume when direct measurement is not available being monitored with a Doppler ultrasonic flowmeter.1 for confirmation. While dual frequency ultrasound holds Bubbles were later observed in human divers following potential for future bubble sizing (the first pulse excites decompression.2 Aural detection of decompression- bubbles of a diameter related to the
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