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Diving and Hyperbaric Medicine Diving and Hyperbaric Medicine The Journal of the South Pacifi c Underwater Medicine Society and the European Underwater and Baromedical Society Volume 46 No. 3 September 2016 Diving with insulin-dependent diabetes Your wetsuit alters pulmonary mechanics Deaths in American caves and in Scandinavian waters Intensive care HBOT – safe transfers to a stand-alone unit General anaesthesia improves Eustachian tube compliance Sudden deafness – does HBOT help? Bubble counts in ischaemia-conditioned rats Print Post Approved PP 100007612 ISSN 1833-3516, ABN 29 299 823 713 Diving and Hyperbaric Medicine Volume 46 No. 3 September 2016 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 scientifi c conference SOUTH PACIFIC UNDERWATER EUROPEAN UNDERWATER AND MEDICINE SOCIETY BAROMEDICAL SOCIETY OFFICE HOLDERS OFFICE HOLDERS President President David Smart <[email protected]> Jacek Kot <[email protected]> Past President Vice President Michael Bennett <[email protected]> Ole Hyldegaard <[email protected]> Secretary Immediate Past President Douglas Falconer <[email protected]> Costantino Balestra <[email protected]> Treasurer Past President Peter Smith <[email protected]> Peter Germonpré <[email protected]> Education Offi cer Honorary Secretary David Wilkinson <[email protected]> Peter Germonpré <[email protected]> Chairman ANZHMG Member-at-Large 2015 John Orton <[email protected]> Karin Hasmiller <[email protected]> Committee Members Member-at-Large 2014 Denise Blake <[email protected]> Robert van Hulst <[email protected]> Simon Mitchell <[email protected]> Member-at-Large 2013 Jen Coleman <[email protected]> Pierre Lafère <[email protected]> Cathy Meehan <[email protected]> Liaison Offi cer Shirley Bowen <[email protected]> Phil Bryson <[email protected]> Webmaster Joel Hissink <[email protected]> ADMINISTRATION ADMINISTRATION Honorary Treasurer and Membership Secretary Membership Patricia Wooding <[email protected]> Steve Goble <[email protected]> 16 Burslem 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 offi cial 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]> Michael Bennett, Australia PO Box 35 Alf Brubakk, Norway Tai Tapu 7645 David Doolette, USA New Zealand Christopher Edge, United Kingdom Phone: +64-(0)3-329-6857 Peter Germonpré, Belgium Jane Heyworth, Australia European (Deputy) Editor: Jacek Kot, Poland Lesley Blogg <[email protected]> Simon Mitchell, New Zealand Editorial Assistant: Claus-Martin Muth, Germany Nicky Telles <[email protected]> Neal Pollock, USA Journal distribution: Monica Rocco, Italy Steve Goble <[email protected]> Martin Sayer, United Kingdom Erika Schagatay, Sweden Journal submissions: David Smart, Australia Submissions should be made at http://www.manuscriptmanager.com/dhm Robert van Hulst, The Netherlands Diving and Hyperbaric Medicine is published jointly by the South Pacifi c Underwater Medicine Society and the European Underwater and Baromedical Society (ISSN 1833-3516, ABN 29 299 823 713) Diving and Hyperbaric Medicine Volume 46 No. 3 September 2016 133 Editorial Poorly designed research does not help clarify the role of hyperbaric oxygen in the treatment of chronic diabetic foot ulcers Diabetic foot ulcers (DFUs) are one of the most common subset of eight of the 24 included patients had non-healing indications for hyperbaric oxygen treatment (HBOT). The wounds and the proportion of those that were associated role of HBOT in DFUs is often debated. Recent evidence- with diabetes mellitus is unknown. Further, the need for based guidelines, while recommending its use, urge further amputation was not among the management decisions studies to identify the patient subgroups most likely to examined. Wirthlin et al concluded “a prospective trial of benefit from HBOT.1 A recent study in Diabetes Care aimed remote wound management …. is needed to further validate to assess the efficacy of HBOT in reducing the need for major this technology.” amputation and improving wound healing in patients with chronic DFUs.2 In this study, patients with Wagner grade The authors of the second supposedly supporting citation 2−4 diabetic foot lesions3 were randomly assigned to have were mainly interested in the assessment of pressure ulcers HBOT (30 sessions/90 min/244 kPa) or sham treatment by digital photography using the Photographic Wound (30 sessions/90 min/air/125 kPa). Six weeks after the Assessment Tool (PWAT) compared to the Pressure Sore completion of treatment (12 weeks after randomization) Status Tool (PSST).6 Of the 81 included lower leg ulcers, neither the fulfillment of major amputation criteria (11/49 it is not clear how many were associated with diabetes vs. 13/54, odds ratio 0.91 [95% CI 0.37, 2.28], P = 0.846) mellitus. Indications for amputation were not considered. nor wound-healing rates (20% vs. 22%, 0.90 [0.35, 2.31], The authors concluded “The PWAT may be valuable when P = 0.823) significantly differed between groups. The a bedside assessment cannot be made. However, the size of authors concluded that HBOT does not offer any additional circular wounds, wound depth, undermining/tunneling, and advantage over comprehensive wound care. odor cannot be assessed using photographs.” Since this paper was published in Diabetes Care, one of In the Fedorko paper, the decision that there was an the most prestigious diabetes journals, it is likely it will indication for amputation was made by the remote vascular have a major impact on the clinical practice of many surgeon by meeting any of the following criteria: “persistent physicians dealing with diabetic foot problems. Although deep infection involving bone and tendons (antibiotics from a methodological standpoint the conduct of the study required, hospitalization required, pathogen involved); (prospective, double-blind, randomized, controlled) seems ongoing risk of severe systemic infection related to the to be close to ideal, several significant flaws render the wound; inability to bear weight on the affected limb; or conclusions weak. pain causing significant disability”.2 We are particularly concerned that the criteria, “persistent deep infection Firstly, there were some problems with the assessment of the involving bone and tendons”, is subjective. Recent studies primary outcome of “meeting the criteria for amputation”. have demonstrated that diabetic foot osteomyelitis may not In their published protocol paper,4 the triallists indicated that necessarily require amputation and some cases may be cured “At the end of the 6-week follow-up phase……, the patient is with antibiotic therapy alone.1 It is interesting to note that sent to the participating vascular surgeon for an amputation despite the high numbers of participants assessed as fitting evaluation”. However, in the published report in Diabetes the requirements for amputation (23% overall), no patient Care, it is evident that patients were not assessed in a face- actually had a major amputation. The amputation outcome to-face consultation, but rather by the remote examination is inappropriately assessed, done at the wrong time, and the of wound photographs and clinical data “Participant clinical study is grossly underpowered to find any difference in the data together with digital photographs of the study wound rate of true major amputation. Finally, whether the surgeon progress were presented to the vascular surgeon”. This performed a baseline assessment of amputation prior to the departure from the original intent undermines the primary randomised intervention is unknown. A comparison between outcome of the study significantly. Fedorko et al claim this the pre- and post-study estimates of amputation rates could method of assessment has been validated, but neither of have contributed to the interpretation of the results. their supporting citations appear to substantiate this claim.5,6 Secondly, the authors fail to provide a clear comparison Wirthlin et al assessed the level of agreement about a of peripheral arterial disease (PAD) between the groups. collection of wounds between surgeons who were present Although patients were randomized and those who were at the bedside and a remote group who assessed the wounds possible candidates for major vessel revascularization using a short clinical account and digital photography.5 were excluded from the study, microvascular status was There was reasonable agreement between onsite and remote, not assessed. No transcutaneous oxygen measurements although the specificity for particular signs ranged from just were made on any of the patients. Given that, firstly, the 27% (erythema) to 100% (ischaemia). Importantly, only a risk of microvascular vessel compromise increases with 134 Diving
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