Program & Abstracts

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UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

PROGRAM & ABSTRACTS

"Raising the Quality of Practice One Member at a Time"

2018 UHMS Scientific Meeting

June 28 – June 30

Lake Buena Vista, Florida

Wednesday, June 27:  How to Prepare for Accreditation: Fiesta 4  Differential Diagnosis of Decompression Illness: Yucatan 1-2  Mapping a course through the Reimbursement Quagmire: Yucatan 3  Welcome Reception: 7pm-9pm: Casita Courtyard Thursday, June 28:  Exhibits/Continental Breakfast/Breaks: Fiesta 6  Poster Sessions: Fiesta 7-10  General Session: Fiesta 5  Non-Physician Breakout Session: Yucatan 1-3 Friday, June 29:  Exhibits/Continental Breakfast/Breaks: Fiesta 6  Poster Sessions: Fiesta 7-10  General Session: Fiesta 5 Saturday, June 30:  Exhibits/Continental Breakfast/Breaks: Fiesta 6  Poster Sessions: Fiesta 7-10  General Session: Fiesta 5

UNDERSEA AND HYPERBARIC MEDICAL SOCIETY TABLE OF CONTENTS

Subject Page No.

UHMS Committee Leadership Listing ...... 6 Schedules Pre-Courses ...... 7 Non-Physician Breakout Track ...... 8 General Session...... 9-26 Thursday: (Sessions A/B) ...... 9-13 Friday: (Sessions C/D) ...... 14-21 Saturday: (Sessions E/F) ...... 22-26 Committee Meetings ...... 27 Continuing Education ...... 28-29 Evaluation / MOC Credit Information ...... 29-30 Disclosures...... 31-35 Exhibitors...... 36-38

SESSIONS/ABSTRACTS THURSDAY GENERAL SESSION ...... 39-80 President’s Address ...... 41 Plenary: Hyperbaric Medicine and Cancer ...... 42 Session A: Diving / Decompression Illness: Theory & Mechanisms ...... 43-59 Lambertsen Memorial Lecture ...... 60-61 Session B: HBO2 Therapy Mechanisms ...... 63-79 Plenary: Mechanisms of HBO2 ...... 80 FRIDAY GENERAL SESSION ...... 81-154 Plenary: Research and Registries for Hyperbaric Oxygen Therapy ...... 83-84 Session C: Diving and Decompression Illness ...... 85-117 Kindwall Memorial Lecture ...... 118-120 Session D: Clinical HBO2 Therapy ...... 121-152 Plenary: HBO2 and DFU ...... 153 SATURDAY GENERAL SESSION ...... 155-197 Plenary: Emerging Indications for Hyperbaric Oxygen Therapy ...... 157-159 Session E: HBO2 Operations, Chambers, and Equipment ...... 161-177 Plenary: New Pearls of Wisdom in the Diving and Hyperbaric Medicine Literature ...... 178 Session F: Top Case Reports ...... 179-195 Plenary: Clinical and Metabolic Aspects in Breath-Hold Diving ...... 196-197

Author Index ...... 198-200 2019 Annual Meeting: Save the Date ...... 201 2019 Meetings/Courses: Save the Dates ...... 202-204

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 5 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

Undersea & Hyperbaric Medical Society Committees

Board of Directors Paul J. Sheffield: 1990-1991 Enoch Huang, President – 2018 Paul Cianci: 1991-1992 Gerardo Bosco, Vice President – 2018 Jon T. Mader: 1992-1993 Nicholas Bird, President-Elect – 2018 James M. Clark: 1993-1994 Jim Holm, Immediate Past President – 2018 Richard E. Moon: 1994-1996 John Feldmeier, Past President – 2018 Stephen R. Thom: 1996-1998 Laurie B. Gesell, Treasurer – 2018 Caroline Fife: 1998-2000 Tracy LeGros, Member at large – 2018 Enrico Camporesi: 2000-2002 Sandra K. Wainwright, Member at large – 2019 Neil Hampson: 2002-2004 Peter J. Witucki, Member at large – 2020 Lindell K. Weaver: 2004-2006 R.B. Gustavson, Assoc. Nurse Rep. – 2018 Bret Stolp: 2006-2008 Kaye Moseley, Assoc. Tech. Rep. – 2019 Laurie Gesell: 2008-2010 Bradley Walker, Assoc. Nurse Rep-Elect. – 2020* Brett Hart: 2010-2012 Phil Schell, Assoc. Tech. Rep. – 2021* John Feldmeier: 2012-2014 John Peters – UHMS Executive Director* James Holm: 2014-2016 * (non-voting) Committee Chairpersons 2018 Organizing & Scientific Program Committee Accreditation Council: Brett Hart Enoch Huang ASM Program: Enoch Huang & Heather Murphy-Lavoie Heather Murphy-Lavoie Associates Council: Gus Gustavson & Kaye Moseley John Feldmeier Awards: Gerardo Bosco Laurie Gesell Audit/Finance: Laurie Gesell Bruce Derrick By-Laws: Nick Bird Stephen Thom DCI & Adjunctive Therapy: Richard Moon & Frank Butler Sandra Wainwright Diving: Tony Alleman Nick Bird Education: Heather Murphy-Lavoie Gus Gustavson, Associates Program FUHM: James Holm Kaye Moseley, Associates Program GME: Enoch Huang Heather Murphy-Lavoie, CME Representative Registry: Jay Buckey Lisa Tidd, Meeting Planner QUARC: Caroline Fife/Helen Gelly/Marc Robins Stacy Harmon, CME Coordinator Safety: Jim Bell & Bill Gearhart Hyperbaric Oxygen Therapy: Richard Moon 2018 ASM Staff Material Testing Advisory (Ad Hoc): Richard Barry Renée Duncan Membership-Chapters/Affiliate: Nick Bird Cinda Hart Nominations: Nick Bird Sherrill White-Wolfe Publications: Marvin Heyboer Dawn Salka Research: John Kirby & John Feldmeier Beth Hands Derall Garrett Tom Workman (photographer) Chapter Presidents

Gulf Coast: Kevin “Kip” Posey Past Presidents Mid-West: vacant Christian J. Lambertsen: 1967-1968 Northeast: Dawn Salka Robert D. Workman: 1968-1969 Pacific: Davut Savaser Edward L. Beckman: 1969-1970 Heinz R. Schreiner: 1970-1971 Earl H. Ninow: 1971-1972 Affiliates David H. Elliott: 1972-1973 Canadian Undersea and Hyperbaric Medical Association (CUHMA) Johannes A. Kylstra: 1973-1974 European Underwater and Baromedical Society (EUBS) Dennis N. Walder, 1974-1975 Sociedade Brasileira de Medicina Hiperbárica (SBMH) Peter B. Bennett: 1975-1976 Società Italiana di Medicina Subacquea ed Iperbarica (SIMSI) Arthur J. Bachrach: 1976-1977 South Pacific Underwater Medicine Society (SPUMS) James Vorosmarti, Jr.: 1977-1978 Herbert A. Saltzman: 1978-1979 Jefferson C. Davis: 1979-1980 Paul Webb: 1980-1981 Eric P. Kindwall: 1981-1982

John Hallenbeck: 1982-1983

Alfred A. Bove: 1983-1984

Paul G. Linaweaver: 1984-1985 Mark E. Bradley: 1985-1986 Joseph C. Farmer: 1986-1987 George B. Hart: 1987-1988 Richard D. Heimbach: 1988-1989 Tom S. Neuman: 1989-1990

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 6 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY SCHEDULES

PRE-COURSES: WEDNESDAY, JUNE 27

DIFFERENTIAL DIAGNOSIS OF MAPPING A COURSE THROUGH THE HOW TO PREPARE FOR ACCREDITATION DECOMPRESSION ILLNESS REIMBURSEMENT QUAGMIRE FIESTA 4 Yucatan 1-2 Yucatan 3

8:00-8:15 Welcome and Introductions 8:00-8:10 Welcome & Introductions 8:00-8:15 Welcome/Introductions Petar Denoble, MD Caroline Fife, MD Derall Garrett, CHT 8:15-9:00 Propaedeutic of DCI 8:10-9:00 Reimbursement 101 8:15-10:15 Why accredit clinical hyperbaric facilities? Richard Moon, MD Michael Crouch, CHT Derall Garrett, CHT 9:00-9:45 Neurological exam of injured divers 9:00-9:45 MACRA update – MIPS performance: Where 10:15-10:45 Break Wayne Massey we are now 10:45-11:45 Hyperbaric Facility Accreditation Program 9:45-10:30 Decompression illness and coincidental Caroline Fife, MD Design I & II acute post-dive conditions in 9:45-10:00 Break Derall Garrett, CHT recreational and commercial divers 10:00-10:30 Transition from MIPS to APM Matias Nochetto, MD 11:45-12:45 Lunch Marc Robins, DO 10:30-10:45 BREAK 12:45-1:30 Physician point of view 10:30-11:00 HBO2 under pressure Hank Schwartz, MD 10:45-11:30 Diagnostic algorithms for DCI Marc Robins, DO 1:30-2:15 Nurse point of view Ian Grover, MD 11:00-12:00 Audit proofing: Part I: HBO2 documentation Janet Bello, RN 11:30-12:15 French approach to differential for reimbursement 2:15-3:00 Technologist point of view diagnosis of DCI Helen Gelly, MD Jeff Mize. CHT Jean Eric Blatteau, MD 12:00-1:00 Lunch 3:00-3:15 Break 12:15-13:15 LUNCH 1:00-2:00 Audit proofing: Part 2: Understanding 3:15-:3:45 Organizational Planning 1:15-2:00 Cardiorespiratory post dive conditions PA/PPR/TP&E Tom Workman, CHT Bruce Derrick, MD Helen Gelly, MD 2:00-2:45 Abdominal post-dive issues UCSD 2:00-2:45 The UCLA audit experience 3:45-4:00 Discussion/Questions fellow Walter Chin, CHT 4:00 Adjourn Aaron Heerboth, MD 2:45-3:00 Break

2:45-3:00 BREAK 3:00-4:00 Can the Registry help us survive? 3:00-3:45 ENT issues Caroline Fife, MD Nick Vandemoer, MD 4:00-5:00 Pulling it all together, Episodes of care, Q&A Note: New surveyors will move to Sierra 2 at 3:45-4:30 Trauma, aches and pains Marc Robins, DO / Panel 12:45; and Surveyor Refresher: Sierra 2 starting Jim Chimiak, MD at 3:15pm 4:30-5:00 Concluding remarks Petar Denoble and Alessandro Marroni

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 7 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

NON-PHYSICIAN BREAKOUT TRACK: THURSDAY, JUNE 28

8:00-8:30 President's Address Enoch Huang, MD in Fiesta 5 8:30-5:00 Non-Physician Track Kick Off 8:30-8:40 Welcome & Introductions Gus Gustavson, RN 8:40-8:50 UHMS Associates Update Kaye Moseley, RRT 8:50-9:00 BNA Update Annette Gwilliam, ACHRN 9:00-9:30 A decompression stop for fishermen divers of the Yucatán Peninsula Walter Chin

Ten-year period prevalence of decompression illness among small-scale fishermen divers

Rater reliability of a transthoracic bubble study among fishermen divers of the Yucatán Peninsula 9:30-9:45 Effect of rehydration schedule after four-hour head-out water immersion on running performance and recovery Rebeccah Stansbery 9:45-10:00 Physical disabilities after decompression illness among small-scale fishermen divers of the Yucatán Peninsula Sofia Aguinaga 10:00-10:30 Break/Exhibits Break/Exhibits 10:30-10:45 Preprogrammed bailout and surface decompression schedules for multiplace treatment profiles Greg Raleigh 10:45-11:00 Q & A

11:00-11:15 Achievement Recognition Scholarship Abstract: Chae Bliss Multiplace hyperbaric chamber modifications for safe utilization of a non-hyperbaric rated cardiac monitor 11:15-1130 DCS with incidental pulmonary cyst Mariesa N. Norton 11:30-11:45 Public awareness of carbon monoxide poisoning Annette Gwilliam 11:45-12:00 Responding to an active shooter – Learning from one facility’s experience Judy Ptak 12:00-1:00 Lunch Durango 2 1:00-2:00 Lambertsen Memorial Keynote: A long shot to a short shot: Hyperbaric oxygen augmented ACLS/ATLS spawned Keith Van Meter, MD in Fiesta 5 by commercial diving medicine experience 2:00-2:45 Risk factors for diving injuries Peter Buzzacott 2:45-3:00 Adapting contrast-enhanced imaging techniques to improve quantification of decompression bubbles in James E. H. Hensel humans 3:00-3:30 Break Break 3:30-3:45 Surviving an active shooter Paul Brown 3:45-4:00 Who’s listening? Ear health and diving: Data from 790 divers Marguerite St. Leger Dowse 4:00-4:20 Hyperbaric oxygen treatments for vasculitis induced by levamisole containing cocaine Judy Ptak Lyme disease developing during hyperbaric oxygen treatments 4:20-5:00 Wound healing centers and the bends Matias Nochetto *Note: There will be no physician CME credits for this track.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 8 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

GENERAL SESSION: THURSDAY, JUNE 28 – SATURDAY, JUNE 30: Fiesta 5

START END EVENT LOCATION TIME TIME THURSDAY, June 28 7:00 AM 8:00 AM CONTINENTAL BREAKFAST / EXHIBITS Fiesta 6 8:00 AM 8:30 AM President's Address: Enoch Huang, MD Fiesta 5 8:30 AM 12:00 PM Non-Physician Breakout Yucatan 1-3 (not approved for physician CME credits) 8:30 AM 10:00 AM Plenary Session: Hyperbaric Medicine and Cancer Fiesta 5 8:30-9:15 The role of hyperbaric medicine in cancer therapy John Feldmeier, DO 9:15-10:00 Hyperbaric oxygen radiation sensitization of squamous cell carcinomas of the oropharynx Dick Clarke, CHT 10:00 AM 10:30 AM BREAK / EXHIBITS Fiesta 6 10:30 AM 11:30 AM Session A: Diving / Decompression Illness: Theory & Mechanisms: Oral Presentations Fiesta 5 Moderators: Laurie Gesell, MD and Nick Bird, MD 10:30 - 10:45 A 1: Heliox in-water decompression schedules for the Interspiro IS-MIX mine clearance diving system Bouak F, van Ooij PJ, Nishi R, van Hulst RA Presenting Author: Pieter-Jan van Ooij, PHD 10:45 - 11:00 A 2: Provocative decompression causes diffuse vascular injury mediated by interleukin (IL)-1β and inhibited by hyperbaric oxygen (HBO2) Thom SR, Bhopale VM, Yang M Presenting Author: Stephen R Thom, MD 11:00 - 11:15 A 3: The effect of intermittent normobaric hyperoxia on stem cell mobilization and cytokine expression MacLaughlin KJ, Barton G, Braun R, Sobakin A, Eldridge M Presenting Author: Kent MacLaughlin 11:15 - 11:30 A 4: Pharmacological vasodilation and gas switching to carbon tetrafluoride during decompression to attenuate DCS Weis TW, Wilbur JC, Knaus DA, Buckley JC, Vann RD, Sevick JR, Stump DA, Deal DD, Ramsey M, Natoli MJ, Fellows A, Marshall C, Magari PJ, Cooter M, Moon RE Presenting Author: Trevor Weis 11:30 AM 12:00 PM Poster Session A Fiesta 7-10 A 1: Heliox in-water decompression schedules for the interspiro IS-MIX mine clearance diving system Bouak F, van Ooij PJ, Nishi R, van Hulst RA Presenting Author: Pieter-Jan van Ooij, PHD

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 9 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

A 2: Provocative decompression causes diffuse vascular injury mediated by interleukin (IL)-1β and inhibited by hyperbaric oxygen (HBO2) Thom SR, Bhopale VM, Yang M Presenting Author: Stephen R Thom, MD

A 3: The effect of intermittent normobaric hyperoxia on stem cell mobilization and cytokine expression MacLaughlin KJ, Barton G, Braun R, Sobakin A, Eldridge M Presenting Author: Kent MacLaughlin

A 4: Pharmacological vasodilation and gas switching to carbon tetrafluoride during decompression to attenuate DCS Weis TW, Wilbur JC, Knaus DA, Buckley JC, Vann RD, Sevick JR, Stump DA, Deal DD, Ramsey M, Natoli MJ, Fellows A, Marshall C, Magari PJ, Cooter M, Moon RE Presenting Author: Trevor Weis

A 5: Oxygen pre-breathe and decompression sickness outcomes in the uw sheep model Sobakin AS, Eldridge MW Presenting Author: Aleksey Sobakin, PHD

A 6: Microparticle and interleukin (IL)-1β production associated with human high-pressure exposures Brett KD, Nugent NZ, Fraser KN, Bhopale VM, Yang M, Thom SR Presenting Author: Kaighley Brett, MD

A 7: Hyperbaric and high-oxygen environments accelerate muscle strength recovery in contused rat skeletal muscle Yamamoto N Presenting Author: Naoki Yamamoto, MD

A 8: Effects of a hyperbaric environment on antioxidative mechanisms in the mouse Masaki H, Akira K, Naoki Y, Toshihiro K, Kazuyoshi Y Presenting Author: Masaki Horie, PHD

A 9: Consistency of venous gas emboli status after three controlled pool diving exposures: A pilot study Denoble PJ, Papadopoulou V, Buzzacott P, Edelson CJ, Pieri M, Cialoni D, Lambrechts K, Balestra C, Marroni A Presenting Author: Petar Denoble, MD

A 10: Augmentation of event related brain activity on cognitive control under hyperbaric environment Fujii T Presenting Author: Tatsufumi Fujii

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 10 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

A 11: Effect of rehydration schedule after four-hour head-out water immersion on running performance and recovery Stansbery RL, Hess HW, Schlader ZJ, Pendergast DR, Russo LN, Hostler D Presenting Author: Rebeccah Stansbery

A 12: Cold-water submersion attenuates post-submersion aerobic performance irrespective of rehydration strategy Hess HH, Schlader ZJ, Russo LN, Clemency BM, Stooks JJ, Carden CR, Hostler D Presenting Author: Hayden W Hess

A 13: Adapting contrast-enhanced imaging techniques to improve quantification of decompression bubbles in humans Hensel JSE, Le DQ, Balestra C, Tang M-X, Dayton PA, Papadopoulou V Presenting Author: James S. E. Hensel

A 14: Orthostatic intolerance following cold seawater submersion is likely independent of changes in body fluid status Hess H, Russo LN, Clemency BM, Stooks J, Carden C, Hostler D Presenting Author: Zachary J. Schlader, PHD

A 15: Quantifying pathologic changes in the heart and lung of swine due to “yo-yo” and square dive protocols Ofir D, Arieli Y, Mullokandov M, Liboff A, Yanir Y Presenting Author: Dror Ofir, PHD 12:00 PM 1:00 PM LUNCH ON OWN 12:00 PM 1:00 PM Associates Luncheon (sign-up required - limited to 50) Durango 2 1:00 PM 2:00 PM Lambertsen Memorial Keynote: Fiesta 5 A long shot to a short shot: Hyperbaric oxygen augmented ACLS/ATLS spawned by commercial diving medicine experience Keith Van Meter, MD 2:00 PM 5:00 PM Non-Physician Breakout Yucatan 1-3

2:00 PM 3:00 PM Session B: HBO2 Therapy Mechanisms Fiesta 5 Moderators: Stephen Thom, MD and John Feldmeier, DO 2:00 - 2:15 B 1: Oxygen microbubbles relieve tumor hypoxia and improve radiotherapy tumor control in a rat fibrosarcoma model Fix SM, Papadopoulou V, Velds H, Slagle C, Kasoji SK, Rivera JN, Borden MA, Chang S, Dayton PA Presenting Author: Samantha M. Fix 2:15 - 2:30 B 2: A hyperbaric and high-oxygen environment accelerates IL-6 synthesis, activates the IL-6/STAT3 pathway and suppress NFκB in rat contused skeletal muscle Oyaizu T, Enomoto M, Horie M, Yamamoto N, Yagishita K Presenting Author: Takuya Oyaizu, MD 2:30 - 2:45 B 9: Ketosis as a neuroprotective mechanism to CNS oxygen toxicity (CNSOT) in divers exposed to high partial pressures of oxygen (PO2) Dituri J, Renaldo C, Quirk B, D’Agostino D, Ari C, Annis H, Whelan HT Presenting Author: Harry T. Whelan, MD

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 11 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

2:45 - 3:00 B 8: Hyperbaric oxygen therapy for compromised flaps: Is there a role for delayed treatment? Francis A, Goldman JJ, Kleban SR, McNicoll CF, Mehta A, Phalke N, Doyle G, Nakhaima S, Rovig J, Williams SJ, Cross CL, Fang XH, Wang WZ, Baynosa RC Presenting Author: Aradhana Mehta, MD 3:00 PM 3:30 PM BREAK / EXHIBITS Fiesta 6 3:30 PM 4:00 PM Poster Session B Fiesta 7-10

B 1: Oxygen microbubbles relieve tumor hypoxia and improve radiotherapy tumor control in a rat fibrosarcoma model Fix SM, Papadopoulou V, Velds H, Slagle C, Kasoji SK, Rivera JN, Borden MA, Chang S, Dayton PA Presenting Author: Samantha M. Fix

B 2: A hyperbaric and high-oxygen environment accelerates IL-6 synthesis, activates the IL-6/STAT3 pathway and suppress NFκB in rat contused skeletal muscle Oyaizu T, Enomoto M, Horie M, Yamamoto N, Yagishita K Presenting Author: Takuya Oyaizu, MD

B 3: DUPLICATE - WITHDREW

B 4: Effects of high-intensity interval training while in a hyperbaric oxygen environment on exercise performance DeCato TW, Wilson EL, Weaver LK, Hegewald MJ Presenting Author: Matthew Hegewald, MD

B 5: Aseptic condylar necrosis and hyperbaric oxygen therapy Enten G, Bosco G, Vezzani G, Manelli D, Rao N, Mangar D, Bernasek T, Camporesi E Presenting Author: Enrico M. Camporesi, MD

B 6: Hyperbaric oxygen therapy ameliorates osteonecrosis in patients by modulating inflammation and oxidative stress Camporesi E, Enten G, Vezzani G, Rizzato A, Bosco G Presenting Author: Enrico M. Camporesi, MD

B 7: WITHDREW

B 8: Hyperbaric oxygen therapy for compromised flaps: Is there a role for delayed treatment? Francis A, Goldman JJ, Kleban SR, McNicoll CF, Mehta A, Phalke N, Doyle G, Nakhaima S, Rovig J, Williams SJ, Cross CL, Fang XH, Wang WZ, Baynosa RC Presenting Author: Aradhana Mehta, MD

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 12 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

B 9: Ketosis as a neuroprotective mechanism to CNS oxygen toxicity (CNSOT) in divers exposed to high partial pressures of oxygen (PO2) Dituri J, Renaldo C, Quirk B, D’Agostino D, Ari C, Annis H, Whelan HT Presenting Author: Harry T. Whelan, MD

B 10: Investigation of a cell-permeable mitochondrial prodrug on mitochondrial function in human blood cells from patients with CO poisoning Jang DH, Khatri UG, Kelly MP, Lambert DK, Hardy K Presenting Author: Matthew Kelly, MD

B 11: Physiologic and cognitive effects of nutritional ketosis, elevated PO2 and exercise (KetOX Study) Keuski BM, Freiberger JJ, Moon RE, Richardson C, Natoli MJ, Schinazi EA, D’Agostino DP, Kuchibhatla M, Tomoye EO, Derrick BJ Presenting Author: Brian M. Keuski, MD

B 12: Supraventricular tachycardia during hyperbaric oxygen treatment Mihai A, Morgan M, Heyboer M Presenting Author: Aurel Mihai, MD

B 13: Ketogenic diet for reduction of CNS oxygen toxicity in working divers (KetOX Study) Keuski BM, Freiberger JJ, Moon RE, Richardson C, Natoli MJ, Schinazi EA, D’Agostino DP, Kuchibhatla M, Tomoye EO, Derrick BJ Presenting Author: Brian Keuski, MD

B 14: Last resort salvage of failed below knee amputations Strauss MB, Lu LQ Presenting Author: Michael Strauss, MD

B 15: Decompression sickness in the multiplace hyperbaric chamber attendant Koca E, Mirasoglu B Presenting Author: Eylem Koca, MD

4:00 PM 5:00 PM Plenary Session: Mechanisms of HBO2 Fiesta 5 Hyperbaric oxygen therapy cell signaling and mechanisms of action Stephen Thom, MD 6:00 PM 7:00 PM Exhibitor Wine & Cheese Reception Fiesta 6

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 13 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

START END EVENT LOCATION TIME TIME FRIDAY, June 29 7:00 AM 8:00 AM CONTINENTAL BREAKFAST / EXHIBITS Fiesta 6 8:00 AM 10:00 AM Plenary Session: Research and Registries for Hyperbaric Oxygen Therapy Fiesta 5 8:00-8:30 The Hyperbaric Oxygen Therapy Registry and the role of a qualified clinical data registry in protecting reimbursement Caroline Fife, MD 8:30-9:00 The hyperbaric medicine registry at Dartmouth Jay Buckey, MD 9:00-9:30 The role of registries in medicine Judith Rees, MD, PhD 9:30-10:00 PANEL Discussion 10:00 AM 10:30 AM BREAK / EXHIBITS Fiesta 6 10:30 AM 11:30 AM Session C: Diving and Decompression Illness Fiesta 5 Nick Bird, MD and Bruce Derrick, MD 10:30 - 10:45 C 1: CNS oxygen toxicity – models vs practice Garbino A, Walker S, Sanders R Presenting Author: Alejandro Garbino, MD 10:45 - 11:00 C 3: Recreational diving-related injuries among insured Divers Alert Network Japan members: Retrospective analysis of 321 cases from 2010 to 2014 Kojima Y, Suzuki S, Niizeki Y, Kojima A, Kawaguchi H, Yagishita K Presenting Author: Yasushi Kojima, MD 11:00 - 11:15 C 4: Pulmonary fluid shifts are a common result of scuba diving exposures Sanders RW, Williams S, Ray K Presenting Author: Robert Sanders, MD 11:15 - 11:30 C 5: Analysis of 500 self-reported recreational scuba diving incidents Buzzacott P, Bennett CM, Denoble PJ Presenting Author: Peter Buzzacott, PHD 11:30 AM 12:00 PM Poster Session C-1 Fiesta 7-10

C 1: CNS oxygen toxicity – models vs. practice Garbino A, Walker S, Sanders R Presenting Author: Alejandro Garbino, MD

C 2: Withdrawn

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 14 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

C 3: Recreational diving-related injuries among insured Divers Alert Network Japan members: Retrospective analysis of 321 cases from 2010 to 2014 Kojima Y, Suzuki S, Niizeki Y, Kojima A, Kawaguchi H, Yagishita K Presenting Author: Yasushi Kojima, MD

C 4: Pulmonary fluid shifts are a common result of scuba diving exposures Sanders RW, Williams S, Ray K Presenting Author: Robert Sanders, MD

C 5: Analysis of 500 self-reported recreational scuba diving incidents Buzzacott P, Bennett CM, Denoble PJ. Presenting Author: Peter Buzzacott, PHD

C 6: Risk factors for middle ear barotrauma in subjects undergoing hyperbaric oxygen therapy Hatch JL, Wieland AM, High R, Cooper JS Presenting Author: Jeffrey Cooper, MD

C 7: A decompression stop for fishermen divers of the Yucatán Peninsula Chin W, Lik U, Huchim O, Markovitz G, Galovich J Presenting Author: Walter Chin, RN/CHRN

C 8: Upper- and lower-extremity altitude chamber DCS Hayes, WA Presenting Author: William A Hayes II, DO

C 9: Who’s listening? Ear health and diving: data from 790 divers St Leger Dowse M, Waterman M. Jones R, Smerdon GR. Presenting Author: Marguerite St Leger Dowse

C 10: Ten-year period prevalence of decompression illness among small-scale fishermen divers Chin W, Ramachandran M, Huchim-Lara O Presenting Author: Walter Chin, RN/CHRN

C 11: Cerebrovascular responses to thermoneutral head-out water immersion Schlader ZJ, Sackett JR Presenting Author: Blair D. Johnson, PHD

C 12: Rater reliability of a transthoracic bubble study among fishermen divers of the Yucatán Peninsula Chin W, Huchim O, Endo B, Medak A, Ramachandran M, Popa D Presenting Author: Walter Chin, RN/CHRN

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 15 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

C 13: Prevalence of right-to-left shunt among fishermen divers of the Yucatán Peninsula Chin W, Huchim O, Endo B, Medak A, Ramachandran M, Popa D Presenting Author: Walter Chin, RN/CHRN

C 14: Bubbles in vascular plexuses of the skin in the cutaneous decompression sickness. Report of cases Garcia E, Galicia P, Villanueva V Presenting Author: Eduardo Garcia, MD

C 15: Treatments of dysbaric osteonecrosis Kawashima M, Kawashima M, Tamura H, Nagayoshi I, Furue Y, Motoyama T, Sasaki T, Watanabe Y, Goto T, Takao K, Yamaguchi T, Miyata K Presenting Author: Mahito Kawashima, MD

C 31: The antimicrobial activity of commonly used wound care products Weis T, Tomoye E, Hazen K, Keuski BM, Shahbuddin Z, Moon RE, Derrick BJ, Freiberger JJ Presenting Author: Edward Tomoye, DO 12:00 PM 12:30 PM Poster Session C-2 Fiesta 7-10

C 16: Perilymphatic fistula after diving: A case series Johnson-Arbor K Presenting Author: Kelly Johnson-Arbor, MD

C 17: Withdrawn

C 18: Physical disabilities after decompression illness among small-scale fishermen divers of the Yucatán Peninsula Aguiñaga S, Huchim-Lara O, Chin W Presenting Author: Sofia Aguinaga

C 19: Oxygen exposures at NASA’s neutral buoyancy lab: a 20-year experience Walker SC, Garbino A, Ray K, Hardwick R, Fitzpatrick DT, Sanders RW Presenting Author: Robert Sanders, MD

C 20: Estimated workload intensity during volunteer aquarium dives Buzzacott P, Grier JW, Walker J, Bennett CM, Denoble PJ Presenting Author: Peter Buzzacott, PHD

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 16 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

C 21: Successful treatment of decompression illness complicated with acute hepatic infarction and acute kidney injury: A case report Oh SH, Choi SC, Cha YS, Lee YH, Kim GW, Kim H Presenting Author: Se Hyun Oh, MD

C 22: Recurrent facial baroparesia: A case report Gomez-Castillo JD, Esquivel-Garcia B Presenting Author: Dario Gomez, MD

C 23: Hyperbaric oxygen therapy for Type II DCS in an experienced dive master: A case study Boes T, Morgan M, Sharma D, Santiago W, Mariani P, Heyboer M Presenting Author: Tanner Boes, MD

C 24: Hyperbaric oxygen therapy for Type I DCS secondary to hypobaric challenge: A case study Boes T, Morgan M, Sharma D, Santiago W, Mariani P, Heyboer M Presenting Author: Tanner Boes, MD

C 25: Urinary obstruction following octopus bite Weaver LK Presenting Author: Lindell K. Weaver, MD

C 26: DCS with incidental pulmonary cyst Norton M, Weaver L, Uchida D Presenting Author: Mariesa N. Norton, ACNP/PA

C 27: Unusual response to a presumptive stingray spine injury Do R, Lu LQ, Strauss MB Presenting Author: Michael B. Strauss, MD

C 28: The impact of hyperbaric oxygen therapy on chronic lyme disease: A case study Linden RO, Zacher JE, LeDez KM, Cook T Presenting Author: Ron Linden, MD

C 29: A pilot study evaluating knowledge of indications for hyperbaric oxygen therapy among physicians in Mid-Michigan Jones MW, Henning WH Presenting Author: Werner Henning, DO

C 30: Underwater nasal decongestant use: A novel approach to middle ear equalization during a dive Covington DB, Pitkin AD Presenting Author: Derek Covington, MD

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 17 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

12:00 PM 1:00 PM LUNCH ON OWN 1:00 PM 2:00 PM Kindwall Memorial Keynote: Fiesta 5

HBO2 and diabetic foot ulcers: Do we have a leg to stand on Eugene Worth, MD 2:00 PM 3:00 PM Session D: Clinical HBO2 Therapy Fiesta 5 Moderators: Sandra Wainwright, MD and Heather Murphy-Lavoie 2:00 - 2:15 D 1: A randomized trial of one v. three hyperbaric oxygen sessions for acute carbon monoxide poisoning Weaver LK, Churchill S, Deru K, Handrahan D Presenting Author: Lindell K. Weaver, MD 2:15 - 2:30 D 2: A clinical practice guideline for the prevention and treatment of mandibular osteoradionecrosis (ORN) applying GRADE methodology UHMS CPG Authors: Feldmeier JJ, DuBose KJ, Gesell LB, Shah JB, Huang ET, Mansouri J, Marx RE UHMS CPG Oversight Committee: Feldmeier JJ, LeDez K, Le PNJ, Mansouri J, Moon R, Murad MH Presenting Author: John Feldmeier, DO 2:30 - 2:45 D 3: Sleep assessment in a randomized trial of hyperbaric oxygen in U.S. service members with post-concussive symptoms Walker JM, Mulatya C, Hebert D, Wilson SH, Lindblad AS, Weaver LK Presenting Author: Lindell K. Weaver, MD 2:45 - 3:00 D 4: A composite outcome for mild traumatic brain injury in trials of hyperbaric oxygen Weaver LK, Churchill S, Wilson SH, Hebert D, Deru K, Lindblad AS Presenting Author: Anne Lindblad, PHD 3:00 PM 3:30 PM BREAK / EXHIBITS Fiesta 6 3:30 PM 4:00 PM Poster Session D-1 Fiesta 7-10 D 1: A randomized trial of one V. three hyperbaric oxygen sessions for acute carbon monoxide poisoning Weaver LK, Churchill S, Deru K, Handrahan D Presenting Author: Lindell K. Weaver, MD

D 2: A clinical practice guideline for the prevention and treatment of mandibular osteoradionecrosis (ORN) applying GRADE methodology UHMS CPG Authors: Feldmeier JJ, DuBose KJ, Gesell LB, Shah JB, Huang ET, Mansouri J, Marx RE UHMS CPG Oversight Committee: Feldmeier JJ, LeDez K, Le PNJ, Mansouri J, Moon R, Murad MH Presenting Author: John Feldmeier, DO

D 3: Sleep assessment in a randomized trial of hyperbaric oxygen in U.S. service members with post-concussive symptoms Walker JM, Mulatya C, Hebert D, Wilson SH, Lindblad AS, Weaver LK Presenting Author: Lindell K. Weaver, MD

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 18 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

D 4: A composite outcome for mild traumatic brain injury in trials of hyperbaric oxygen Weaver LK, Churchill S, Wilson SH, Hebert D, Deru K, Lindblad AS Presenting Author: Anne Lindblad, PhD

D 5: Hyperbaric oxygen therapy effect on patients suffering from fibromyalgia due to childhood sexual abuse - randomized controlled trial Hadanny A, Bechor Y, Catalogna M, Daphna S, Lev R, Efrati S Presenting Author: Amir Hadanny, MD

D 6: Hyperbaric oxygen for TBI and PTSD: A meta-analysis of Department of Defense and other published study results Hart BB, Weaver LK, Gupta A, Wilson SH, Vifayarangan A, Deru K, Hebert D Presenting Author: Brett Hart, MD

D 7: Hyperbaric oxygen therapy can rescue ischemic breast flaps following skin-sparing mastectomy Rajpal N, Walters E, Elmarsafi T, Johnson-Arbor K, Pittman T Presenting Author: Kelly Johnson-Arbor, MD

D 8: A retrospective analysis of treatment of wounds caused by calciphylaxis: Hyperbaric oxygen therapy with and without sodium thiosulfate Armour D, Tailor Y, Preston-Hsu E Presenting Author: Doris Armour, MD

D 9: The effect of hyperbaric oxygen on erectile dysfunction – Pilot study Hadanny A, Lang E, Copel L, Meir O, Bechor Y, Fishlev G, Bergan J, Zisman A, Efrati S Presenting Author: Amir Hadanny, MD

D 10: Effects of hyperbaric oxygen therapy on non-diabetic serum glucose levels Boes T, Wojcik S, Heyboer M, Seargent S Presenting Author: Tanner Boes, MD

D 11: Case series review: Multicenter experience treating idiopathic sudden sensorineural hearing loss (ISSHL) with adjunctive hyperbaric oxygen therapy Robins MS, Gwilliam A, Weaver LK, Churchill S, Deru K, Cascio M, Pollack R, Nail S Presenting Author: Marc Robins, DO

D 12: Hyperbaric oxygen treatment course completion and time to drop-out in a large outpatient sample Brailsford JB, Gordon HM, Ennis, WJ Presenting Author: Jennifer Brailsford, PHD

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 19 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

D 13: Advanced wound care assessment as a pre-cursor to HBO2: Improving diabetic foot ulcer outcomes Tremblay R, Michael M Presenting Author: Roma Tremblay, PHD

D 14: Hyperbaric oxygen therapy: A review of adverse event rates during treatment for radiation cystitis Owen E, Perdrizet G Presenting Author: Elizabeth Owen, MD

D 15: Appraisal of six wound scoring systems and the Long Beach Wound Score Strauss MB, Moon H, Botros M, Lu LQ Presenting Author: Michael B. Strauss, MD 4:00 PM 4:30 PM Poster Session D-2 Fiesta 7-10 D 16: Radiation myelitis of cervical spinal cord successfully reversed by hyperbaric oxygen therapy Cianci PE, Costello PJ Presenting Author: Paul Cianci, MD

D 17: Adjunctive hyperbaric oxygen therapy with isavuconizonium in the treatment of mucor Evangelista J Presenting Author: Jose Evangelista, MD

D 18: Impact of hyperbaric oxygen therapy in a child with delayed soft tissue radiation necrosis of the brain Dapena JC, Siegel M Presenting Author: Juan C. Dapena, MD

D 19: Hyperbaric oxygen therapy for the treatment of delayed frostbite injury Johnson-Arbor K Presenting Author: Kelly Johnson-Arbor, MD

D 20: Use of hyperbaric oxygen therapy for lower-extremity sickle cell ulcerations Johnson-Arbor K Presenting Author: Kelly Johnson-Arbor, MD

D 21: Use of hyperbaric oxygen therapy for treatment of acute skin necrosis after a “Brazilian butt lift” Johnson-Arbor K Presenting Author: Kelly Johnson-Arbor, MD

D 22: Decision-making for limb-threatening wounds Strauss MB, Moon H, Miller SS, Lu LQ Presenting Author: Michael B. Strauss, MD

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 20 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

D 23: WITHDREW

D 24: WITHDREW

D 25: Femoropopliteal doppler velocities associated with hyperbaric oxygen treatment session of diabetic patients with leg ulcers Maran CA, Salles-Cunha SX, Millazo PAA, Farias PSR, Castro IJL, David JRN, David RAR Presenting Author: Cristiane Antequeira Maran, MD

D 26: Smoking paradox in the development of delayed neuropsychiatric sequelae among acute carbon monoxide (CO) intoxication patients with hyperbaric oxygen therapy Lee Y Presenting Author: Younghwan Lee, MD

D 27: The historical priority of South America in hyperbaric research and practice Brito T, Subbotina N Presenting Author: Tomaz Brito, MD and Nina Subbotina, MD

D 28: Successful artificial sphincter placement for urinary incontinence in the setting of radiation cystitis with adjunctive hyperbaric oxygen therapy: A case study Boes T, Morgan M, Sharma D, Santiago W, Mariani P, Heyboer M Presenting Author: Tanner Boes, MD

D 29: Hyperbaric oxygen treatments for vasculitis induced by levamisole containing cocaine Ptak J, Reetz S, Buckey J Presenting Author: Judy Ptak, RN/CHRN

D 30: Closing RICH-ART study: Radiation-induced cystitis treated with hyperbaric oxygen – A randomized controlled trail Oscarsson N, Bueller B, Seeman-Lodding H Presenting Author: Nicklas Oscarsson, MD 4:30 PM 5:30 PM Plenary Session: HBO and DFU Fiesta 5 4:30-5:00 The effectiveness and costs of hyperbaric oxygen therapy for diabetic ischemic ulcers: results of the DAMOCLES multicenter trial Dirk Ubbink, MD 5:00-5:30 The Long Beach Wound Score as a validated tool for comparative effectiveness research of wounds and objectifying the indications for hyperbaric oxygen Michael Strauss, MD 5:30 PM 6:30 PM UHMS Business Meeting - Open meeting Fiesta 5

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 21 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

START END EVENT LOCATION TIME TIME SATURDAY, June 30 7:00 AM 8:00 AM CONTINENTAL BREAKFAST / EXHIBITS Fiesta 6 8:00 AM 10:00 AM Plenary Session: Emerging Indications for Hyperbaric Oxygen Therapy Fiesta 5 8:00-8:30 Aseptic Bone Necrosis and Hyperbaric Oxygen Therapy Enrico Camporesi, MD 8:30-9:00 Hyperbaric pre-conditioning Gerardo Bosco, MD 9:00-9:30 Brain injury Shai Efrati, MD 9:30-10:00 PANEL Discussion 10:00 AM 10:30 AM BREAK / EXHIBITS Fiesta 6 10:30 AM 11:30 AM Session E: HBO2 Operations, Chambers, and Equipment Fiesta 5 Moderators: Gus Gustavson, RN and Kaye Moseley, RRT 10:30-10:45 E 5: Interim analysis of mucosal atomizer use to maintain myringotomy patency during elective hyperbaric treatments Walter J, Westgard B, Hendriksen S, Masters T, Logue C Presenting Author: Joe Walter, MD 10:45-11:00 E 2: Hyperbaric oxygen simulation education Arefieva CA, Duchnick J, Bermudez R, Witucki P, Shishlov K, Sadler C Presenting Author: Christa Arefieva 11:00-11:15 E 3: Performance characteristics of high-frequency percussive ventilation (HFPV) under hyperbaric conditions Huang ET, Heltborg JL, Apsey RT, Ray K Presenting Author: Kristi Ray, MD 11:15-11:30 E 4: Observations on O2% during air breathing periods using a non-rebreather face mask in a monoplace chamber Bell J , Koumandakis G, Churchill S , Weaver LK Presenting Author: James Bell, CHT 11:30 AM 12:00 PM Poster Session E Fiesta 5 E 1: Preprogrammed bailout and surface decompression schedules for multiplace treament profiles Raleigh GW Presenting Author: Greg Raleigh, CHT

E 2: Hyperbaric oxygen simulation education Arefieva CA, Duchnick J, Bermudez R, Witucki P, Shishlov K, Sadler C Presenting Author: Christa Arefieva

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 22 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

E 3: Performance characteristics of high-frequency percussive ventilation (HFPV) under hyperbaric conditions Huang ET, Heltborg JL, Apsey RT, Ray K Presenting Author: Kristi Ray, MD

E 4: Observations on O2% during air breathing periods using a non-rebreather face mask in a monoplace chamber Bell J , Koumandakis G, Churchill S , Weaver LK Presenting Author: James Bell, CHT

E 5: Interim analysis of mucosal atomizer use to maintain myringotomy patency during elective hyperbaric treatments Walter J, Westgard B, Hendriksen S, Masters T, Logue C Presenting Author: Joe Walter, MD

E 6: Multiplace hyperbaric chamber modifications for safe utilization of a non-hyperbaric rated cardiac monitor Bliss C, Mosteller J Presenting Author: Chae Bliss, CHT

E 7: Leg ulcer characterization by photographic imaging pre and post hyperbaric oxygen treatment: Lessons learned with first 10 cases Maran CA, Salles-Cunha SX, Millazo PAA, Farias PSR, Castro IJL, David JRN, David RAR Presenting Author: Cristiane Antequeira Maran, MD

E 8: Responding to an active shooter – Learning from one facility’s experience Ptak J, Cormier J Presenting Author: Judy Ptak, RN/CHRN

E 9: Use of high-frequency percussive ventilation (HFPV) in a patient with carbon monoxide poisoning Huang ET, Heltborg JL, Apsey RJ Presenting Author: Enoch Huang, MD

E 10: Continuous bladder irrigation in the monoplace hyperbaric chamber: A cautionary tale Cooper JS, Lagrange CA Presenting Author: Jeffrey Cooper, MD

E 11: The use of indocyanine green fluorescence angiography to assess perfusion of chronic wounds undergoing hyperbaric oxygen therapy Kim DU, Rao A, Kaplan S, Baksh F, Caprioli R, Haight J, Ferguson RG, Pliskin M, Oropallo A Presenting Author: Christina Delpin, MD

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 23 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

E 12: Utilization of fluorescence microangiography (LUNA) in a pediatric patient with acute compartment syndrome Walter J, Settypalli S, Westgard B, Hendriksen S, Masters T, Logue C Presenting Author: Joe Walter, MD

E 13: Public awareness of carbon monoxide poisoning Gwilliam AM, Williams B, Stewart JR, Robins MS Presenting Author: Annette Gwilliam, RN/CHRN

E 14: Surviving an active shooter event Brown P Presenting Author: Paul Brown, CHT

E 15: Compartment syndrome of the forearm related to carbon monoxide intoxication Kim GW Presenting Author: Gi Woon Kim, MD 12:00 PM 1:00 PM LUNCH 1:00 PM 2:00 PM Plenary Session: New Pearls of Wisdom in the Diving and Hyperbaric Medicine Literature Fiesta 5 1:00-1:30 Diving medicine literature update Brian Keuski, MD; Fellow, Duke Hyperbarics 1:30-2:00 Hyperbaric medicine literature update Lince Varughese, MD; Fellow, LSU Hyperbarics 2:00 PM 3:00 PM Session F: Top Case Reports Fiesta 5 Moderators: Davut Savaser, MD and Heather Murphy-Lavoie, MD 2:00-2:10 F 1: Case series of central retinal artery occlusion followed with bedside ultrasound Hendriksen SM, Masters TC, Westgard BC, Walter JW, Logue CJ Presenting Author: Stephen Hendriksen, MD 2:10-2:20 F 2: AGE during controlled ascent training in a Navy Diver trainee: A case report with video registration of the accident Wingelaar TT, van Ooij PJ, Koch D Presenting Author: Thijs Wingelaar, MD 2:20-2:30 F 3: Reversal of central pontine myelinolysis symptoms with hyperbaric oxygen therapy Bensusan AB, Staab P, LeGros TL, Murphy-Lavoie H Presenting Author: Ariana P Bensusan, DO 2:30-2:40 F 4: Taravana: A syndrome revisited: A case report Derksen BD, Savaser DJ Presenting Author: Brenna Derksen, MD

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 24 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

2:40-2:50 F 5: Acute scalp necrosis successfully treated with hyperbaric oxygen therapy Johnson-Arbor K Presenting Author: Kelly Johnson-Arbor, MD 2:50-3:00 F 6: Delayed hyperbaric oxygen therapy for cerebral arterial gas embolism following scuba diving: A case report Brett KD, Boni B, Latham E, Sadler C Presenting Author: Kaighley Brett, MD 3:00 PM 3:30 PM BREAK / EXHIBITS Fiesta 6 3:30 PM 4:00 PM Poster Session F Fiesta 7-10 F 1: Case series of central retinal artery occlusion followed with bedside ultrasound Hendriksen SM, Masters TC, Westgard BC, Walter JW, Logue CJ Presenting Author: Stephen Hendriksen, MD

F 2: AGE during controlled ascent training in a Navy Diver trainee: A case report with video registration of the accident Wingelaar TT, van Ooij PJ, Koch D Presenting Author: Thijs Wingelaar, MD

F 3: Reversal of central pontine myelinolysis symptoms with hyperbaric oxygen therapy Bensusan AB, Staab P, LeGros TL, Murphy-Lavoie H Presenting Author: Ariana P Bensusan, DO

F 4: Taravana: A syndrome revisited: A case report Derksen BD, Savaser DJ Presenting Author: Brenna Derksen, MD

F 5: Acute scalp necrosis successfully treated with hyperbaric oxygen therapy Johnson-Arbor K Presenting Author: Kelly Johnson-Arbor, MD

F 6: Delayed hyperbaric oxygen therapy for cerebral arterial gas embolism following scuba diving: A case report Brett KD, Boni B, Latham E, Sadler C Presenting Author: Kaighley Brett, MD

F 7: A case of trigeminal neuralgia treated with hyperbaric oxygen Huang ET Presenting Author: Enoch Huang, MD

F 8: Cerebral AGE from upper endodoscopy Popa DA, Witucki P Presenting Author: Daniel Popa, MD

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 25 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

F 9: Hyperbaric oxygen for late sequelae of carbon monoxide poisoning enhances neurological recovery Keim LW, Koneru S, Ramos V, Murr N, Hoffnung DS, Murman DL, Cooper JS, Torres-Russotto D Presenting Author: Jeffrey Cooper, MD

F 10: Facial baroparesis as a complication of HBO2: A previously unreported cause of a rare condition Sayers MP, Lopez E, Gutfreund Y Presenting Author: Martin P Sayers, MD

F 11: Cerebral arterial gas embolism in a scuba instructor: An interesting cause Garcia E, Galicia P, Villanueva V Presenting Author: Eduardo Garcia, MD

F 12: WITHDREW

F 13: Hypoglycemia after scuba diving with insulin pump Gomez-Castillo JD, Contreras U, Reyes-Silva KN Presenting Author: Jorge Dario Gomez Castillo, MD

F 14: Lyme disease developing during hyperbaric oxygen treatments Ptak J, Reetz S, Buckey J Presenting Author: Judy Ptak, RN/CHRN

F 15: WITHDREW 4:00 PM 5:00 PM Plenary Session: Clinical and Metabolic Aspects in Breath-hold Diving Fiesta 5 4:00-4:20 Adaptive mechanisms in breath-hold divers Gerardo Bosco, MD 4:20-4:40 Pulmonary pathophysiology in deep breath-hold diving Peter Lindholm, MD 4:40-5:00 Breaking news on breath-hold diving research Alessandro Marroni, MD 7:00 PM 10:00 PM Awards Banquet (separate fee) Fiesta 5 10:00 PM 12:00 AM After Party (separate fee) Monterrey & La Mesa Patio

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 26 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

COMMITTEE MEETING SCHEDULE

TUESDAY, TIME June 26 WEDNESDAY, June 27 THURSDAY, June 28 FRIDAY, June 29 SATURDAY, June 30 Sierra 2 Fiesta 1 Fiesta 2 Fiesta 3 Fiesta 1 Fiesta 2 Fiesta 3 Fiesta 1 Fiesta 2 Fiesta 3 Fiesta 1 Fiesta 2 Fiesta 3 Safety NBDHMT President's 7:00-7:30 Committee: Breakfast: Breakfast 7:30-8:00 7:00-8:00 7:00-8:00 8:00-8:30 NBDHMT 8:30-9:00 Board Meeting:

9:00-9:30 8:00-12:00 9:30-10:00 10:00-10:30 Specialty Accreditation ACEP UHM ECCHO Publication Chapter Diving ED & Council Section Working Committee: President s’ Committee QUARC Meeting: Meeting: Group (24/7 10:00-11:00 Committee: 10:00- 10:30-11:00 Team 10:00-12:00 10:00-11:00 committee): 10:00-11:00 12:00 Meeting: 10:00-11:00 10:00- 11:00-11:30 GME Membership 12:00 Committee: ACHM- Committee: 11:00-12:00 UHMS Registry 11:00-12:00 11:30-12:00 Meeting: Meeting

12:00-1:00 11:00-1:00 (Buckey): 11:30-12:30 ABPM 1:00-1:30 EXAM: 1:30-2:00 1:00-4:00 2:00-2:30 Material QUARC Surveyor

Testing Committee Refresher 2:30-3:00 Advisory Meeting: (invite (AD HOC) 2:00-3:00 only) Editorial Committee CHT-CHRN BNA Research 2:00-3:30 3:00-3:30 Board 2:00-3:30 Testing: General Committee

3:30-4:00 Meeting: 3:00-5:00 Meeting: 3:00-4:00 3:00-5:00 3:00-4:00 4:00-4:30 UHMS BOARD

OF 4:30-5:00 HBO Therapy DIRECTORS Committee: Education BNA Board Specialty 5:00-5:30 (private 4:45-7:45 Committee Meeting: Council meeting) Associates Meeting: 5:00-6:00 Meeting 5:30-6:00 4:00-11:00 Council Meeting: 5:00-6:00 (Dr. Toups): 5:30-7:30 Private 6:30-7:00 Meeting: 5:30-7:30

7:00-7:30 7:30-8:00 8:00-8:30 8:30-9:00 9:00-on ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 27 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY Overall Goal of the UHMS Annual Scientific Meeting

The primary goal of the Undersea and Hyperbaric Medical Society ASM is to provide a forum for professional scientific growth and development to the participants. The meeting provides a basis for exchange of ideas, both scientific and practical, among physicians, researchers, and other health professionals. It affords an opportunity for participants to meet and interact with past and present leaders of the Society, and to become active in societal affairs.

CONTINUING EDUCATION

Accreditation Statement: The Undersea and Hyperbaric Medical Society is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Designation Statements:

 2018 Annual Scientific Meeting: June 28-June 30: The Undersea and Hyperbaric Medical Society designates this live activity for a maximum of 22 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.  Differential Diagnosis of Decompression Illness: Wednesday, June 27 The Undersea and Hyperbaric Medical Society designates this live activity for a maximum of 7.5 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.  Mapping a course through the Reimbursement Quagmire: Wednesday, June 27: The Undersea and Hyperbaric Medical Society designates this live activity for a maximum of 7.5 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Nursing CEU: Licenses Types Approved: Advanced Registered Nurse Practitioner; Clinical Nurse Specialist; Licensed Practical Nurse; Registered Nurse; Certified Nursing Assistant; Respiratory Care Practitioner Critical Care; Respiratory Care Practitioner Non-Critical Care; Registered Respiratory Therapist; Certified Respiratory Therapist

 2018 Annual Scientific Meeting: June 28-June 30: is approved by the Florida Board of Registered Nursing Provider #50-10881. Credit hours approved 22.  Differential Diagnosis of Decompression Illness: Wednesday, June 27 is approved by the Florida Board of Registered Nursing Provider #50-10881. Credit hours approved 7.5.  How to Prepare for Accreditation: Wednesday, June 27: is approved by the Florida Board of Registered Nursing Provider #50-10881. Credit hours approved 6.  Mapping a course through the Reimbursement Quagmire: Wednesday, June 27: is approved by the Florida Board of Registered Nursing Provider #50-10881. Credit hours approved 7.5

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 28 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY NBDHMT:

 2018 Annual Scientific Meeting: June 28-June 30: This live activity is approved for 22 Category A credit hours by National Board of Diving and Hyperbaric Medical Technology, 9 Medical Park, Suite 330, Columbia, South Carolina 29203.  Differential Diagnosis of Decompression Illness: Wednesday, June 27: This live activity is approved for 7.5 of Category A credit hours by National Board of Diving and Hyperbaric Medical Technology, 9 Medical Park, Suite 330, Columbia, South Carolina 29203.  How to Prepare for Accreditation: Wednesday, June 27: This live activity is approved for 6.25 Category A credit hours by National Board of Diving and Hyperbaric Medical Technology, 9 Medical Park, Suite 330, Columbia, South Carolina 29203.  Mapping a course through the Reimbursement Quagmire: Wednesday, June 27: This live activity is approved for 7.5 Category A credit hours by National Board of Diving and Hyperbaric Medical Technology, 9 Medical Park, Suite 330, Columbia, South Carolina 29203.

Full Disclosure Statement: All faculty members and planners participating in continuing medical education activities sponsored by Undersea and Hyperbaric Medical Society are expected to disclose to the participants any relevant financial relationships with commercial interests. Full disclosure of all individuals in control of content with relevant financial relationships will be made at the activity.

Disclaimer: The information provided at this CME activity is for Continuing Medical Education purposes only. The lecture content, statements or opinions expressed however, do not necessarily represent those of the Undersea and Hyperbaric Medical Society.

EVALUATION LINKS

The evaluation link is below and will be emailed to you once the meeting is over. It will require answering questions and providing feedback on the educational program to help with future planning. Your credit certificate will be provided to your inbox of the email provided immediately upon submitting your evaluation. A hard-copy evaluation form can be provided upon request.

2018 Annual Scientific Meeting: June 28-June 30 (Includes Non-Physician Track): https://www.uhms.org/2018-asm-evaluation

Differential Diagnosis of Decompression Illness: Wednesday, June 27: https://www.uhms.org/dddi-evaluation

How to Prepare for Accreditation: Wednesday, June 27: https://www.uhms.org/2018-htpfa-evaluation

Mapping a course through the Reimbursement Quagmire: Wednesday, June 27: https://www.uhms.org/macttrq-evalaution

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 29 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY MAINTENANCE OF CERTIFICATION (MOC):

2018 Annual Scientific Meeting: June 28-June 30: MOC ABPM: This activity has been approved by the American Board of Preventive Medicine for up to 18 MOC credits. Claiming ABPM MOC credit is appropriate for those who are ABPM diplomates: https://www.uhms.org/2018-asm-moc

Differential Diagnosis of Decompression Illness: Wednesday, June 27: MOC ABPM: This activity has been approved by the American Board of Preventive Medicine for up to 7.5 MOC credits. Claiming ABPM MOC credit is appropriate for those who are ABPM diplomates: https://www.uhms.org/differential-diagnosis-of-decompression-illness-moc

For ABPM Requirements for Maintenance of Certification (MOC) please visit their website: https://www.theabpm.org/moc/index_moc.cfm.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 30 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY General Disclosure to Participants of Relevant Relationships with Commercial Interests UHMS Annual Scientific Meeting June 28-June 30, 2018

All individuals in control of content for this educational activity with their relevant financial relationships disclosed are listed below. ACCME defines a relevant financial relationship “as financial relationships in any amount occurring within the past 12 months that create a conflict of interest.” An individual who refuses to disclose relevant financial relationships will be disqualified from being a planning committee member, a teacher, or an author of CME, and cannot have control of, or responsibility for, the development, management, presentation or evaluation of the CME activity.

Name of Individual Individuals Role in Name of Nature of Name of Individual Individuals Name of Nature of Activity Commercial Relationship Role in Commercial Relationship Interest (If Activity Interest (If Applicable) Applicable) Enoch Huang Planner/Presenter None N/a Walter Chin Presenter None N/a Heather Murphy-Lavoie Planner/Reviewer None N/a Blair D. Johnson Presenter None N/a Nicholas "Nick" Bird Planner None N/a Brandon Endo Presenter None N/a John Feldmeier Planner/Faculty None N/a Eduardo Garcia Presenter None N/a Kaye Moseley Planner None N/a Mahito Kawashima Presenter None N/a Richard "Gus" Gustavson Planner None N/a Kelly Johnson-Arbor Presenter None N/a Laurie Gesell Planner None N/a Sofia Aguinaga Presenter None N/a Sandra Wainwright Planner None N/a Se Hyun Oh Presenter None N/a Bruce Derrick Planner None N/a Dario Gomez Presenter None N/a Stephen Thom Planner/Presenter None N/a Tanner Boes Presenter None N/a Lisa Tidd Planner None N/a Lindell K. Weaver Presenter None N/a Stacy Harmon, BS Planner/Reviewer None N/a Mariesa N. Norton Presenter None N/a Richard Clarke, CHT Faculty None N/a Ron Linden Presenter None N/a Keith Van Meter, MD Faculty None N/a Werner Henning Presenter None N/a Stephen Thom, MD Faculty None N/a Derek Covington Presenter None N/a Caroline Fife, MD Faculty None N/a Edward Tomoye Presenter None N/a Jay Buckey, MD Faculty None N/a Anne Lindblad Presenter None N/a Judy Rees, MD, PhD Faculty None N/a Amir Hadanny Presenter None N/a Gene Worth, MD Faculty None N/a Brett Hart Presenter None N/a Dirk Ubbink, MD Faculty None N/a Doris Armour Presenter None N/a Michael Strauss, MD Faculty/Presenter None N/a Amir Hadanny Presenter None N/a Enrico Camporesi Faculty None N/a Marc Robins Presenter None N/a Gerardo Bosco, MD Faculty None N/a Jennifer Brailsford Presenter None N/a Shai Efrati, MD Faculty None N/a Roma Tremblay Presenter None N/a Brian Keuski, MD Faculty/Presenter None N/a Elizabeth Owen Presenter None N/a Lince Varughese, MD Faculty None N/a Paul Cianci Presenter None N/a Peter Lindholm, MD Faculty None N/a Jose Evangelista Presenter None N/a Alessandro Marroni, MD Faculty None N/a Juan C. Dapena Presenter None N/a Pieter-Jan van Ooij Presenter None N/a Tomaz Brito Presenter None N/a Kent MacLaughlin Presenter None N/a Nina Subbotina Presenter None N/a Aleksey Sobakin Presenter None N/a Nicklas Oscarsson Presenter None N/a Kaighley Brett Presenter None N/a Greg Raleigh Presenter None N/a Naoki Yamamoto Presenter None N/a Christa Arefieva Presenter None N/a Masaki Horie Presenter None N/a Kristi Ray Presenter None N/a Petar Denoble Presenter None N/a James Bell Presenter None N/a Tatsufumi Fujii Presenter None N/a Joe Walter Presenter None N/a Rebeccah Stansbery Presenter None N/a Chae Bliss Presenter None N/a Hayden W Hess Presenter None N/a Cristiane Maran Presenter None N/a James S. E. Hensel Presenter None N/a Judy Ptak Presenter None N/a Zachary J. Schlader Presenter None N/a Jeffrey Cooper Presenter None N/a Dror Ofir Presenter None N/a Christina Del Pin, MD Presenter None N/a Samantha M. Fix Presenter None N/a Joe Walter Presenter None N/a Takuya Oyaizu Presenter None N/a Annette Gwilliam Presenter None N/a Matthew Hegewald Presenter None N/a Paul Brown Presenter None N/a Enrico M. Camporesi Presenter None N/a Gi Woon Kim Presenter None N/a Aradhana Mehta Presenter None N/a Stephen Hendriksen Presenter None N/a Harry T. Whelan Presenter None N/a Thijs Wingelaar Presenter None N/a Matthew Kelly Presenter None N/a Ariana P Bensusan Presenter None N/a Aurel Mihai Presenter None N/a Brenna Derksen Presenter None N/a Eylem Koca Presenter None N/a Daniel Popa Presenter None N/a Alejandro Garbino Presenter None N/a Jeffrey Cooper Presenter None N/a Yasushi Kojima Presenter None N/a Martin P Sayers Presenter None N/a Robert Sanders Presenter None N/a Jorge Gomez Castillo Presenter None N/a Peter Buzzacott Presenter None N/a Trevor Weis Presenter None N/a Jeffrey Cooper Presenter None N/a William A Hayes II Presenter None N/a Walter Chin Presenter None N/a Younghwan Lee Presenter None N/a Marguerite St Leger Dowse Presenter None N/a ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 31 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

Name of Commercial Supporter Amount of Monetary Commercial Support In-Kind (List what was provided) none

Please check the mechanism used below to identify and resolve all conflict of interest for all individuals in control of content prior to the start of the educational activity being delivered to the participants:

X No relevant relationship(s) to resolve Provided talking points/outline

Ensured that clinical recommendations are X Used peer-review of content (for authors/presenters) by evidence-based and free of commercial bias (e.g., peer reviewed person(s) that do not have conflicts of interest related to the literature, adhering to evidence-based practice guidelines) content Reassigned faculty’s lecture/topic Recused individual(s) from controlling aspects of planning and content with which they have a conflict of interest

Notes:

Signature of Activity Director/Coordinator Date: June 1, 2018

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 32 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY General Disclosure to Participants of Relevant Relationships with Commercial Interests Differential Diagnosis of Decompression Illness Wednesday, June 27th

Name of Individual Individuals Role in Name of Commercial Nature of Activity Interest (If Applicable) Relationship Petar Denoble, MD, D.Sc. Faculty/Planner None N/a Richard Moon, MD Faculty None N/a Wayne Massey, MD, FAAN, FACP Faculty None N/a Matias Nochetto, MD Faculty None N/a Ian Grover, MD, FACEP Faculty None N/a Jean Eric Blatteau, MD, PhD Faculty None N/a Bruce Derrick, MD Faculty None N/a Aaron Heerboth, MD Faculty None N/a Nick Vandemoer, MD Faculty None N/a Jim Chimiak, MD Faculty None N/a Alessandro Marroni, MD Faculty None N/a Lisa Tidd Planner None N/a Stacy Harmon, BS Planner/Reviewer None N/a Heather Murphy-LaVoie, MD Reviewer None N/a

Name of Commercial Supporter Amount of Monetary Commercial In-Kind Support (List what was provided) None N/a N/a

X No relevant relationship(s) to resolve Provided talking points/outline

Notes:

Signature of Activity Director/Coordinator Date: June 1, 2018

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 33 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY General Disclosure to Participants of Relevant Relationships with Commercial Interests How to Prepare for Accreditation/ Surveyor Training Wednesday, June 27th

Name of Individual Individuals Role in Name of Commercial Nature of Activity Interest (If Applicable) Relationship Derall Garrett Faculty/Planner None N/a Beth Hands Planner None N/a Jeff Mize RRT, CHT, CWCA Faculty None N/a Henry J. C. Schwartz, MD, FACP Faculty None N/a W.T. Workman, MS, CAsP, CHT-A, Faculty None N/a FAsMA Janet H Bello, RN, BSN, ACHRN Faculty Lisa Tidd Planner None N/a Stacy Harmon, BS Planner/Reviewer None N/a Heather Murphy-LaVoie, MD Reviewer None N/a

Name of Commercial Supporter Amount of Monetary Commercial In-Kind Support (List what was provided) None N/a N/a

X No relevant relationship(s) to resolve Provided talking points/outline

Notes:

Signature of Activity Director/Coordinator Date: June 1, 2018

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 34 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY General Disclosure to Participants of Relevant Relationships with Commercial Interests Mapping a course through the Reimbursement Quagmire Wednesday, June 27th

Name of Individual Individuals Role in Name of Commercial Nature of Activity Interest (If Applicable) Relationship Caroline Fife, MD Faculty None N/a Michael Crouch, CHT, CPC Faculty None N/a Marc Robins, DO, MPH Faculty/Planner None N/a Helen Gelly, MD, FUHM Faculty None N/a Walter Chin, MAS, CHT Faculty None N/a Lisa Tidd Planner None N/a Stacy Harmon, BS Planner/Reviewer None N/a Heather Murphy-LaVoie, MD Reviewer None N/a

Name of Commercial Supporter Amount of Monetary Commercial In-Kind Support (List what was provided) None N/a N/a

X No relevant relationship(s) to resolve Provided talking points/outline

Notes:

Signature of Activity Director/Coordinator Date: June 1, 2018

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 35 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY Sponsors

PLATINUM SPONSOR ASSOCIATES SCHOLARSHIP SPONSOR SATCHEL SPONSOR EXHIBITOR RECEPTION SPONSOR ASSOCIATES SCHOLARSHIP SPONSOR ASSOCIATES LUNCHEON SPONSOR

BANQUET WINE SPONSOR BANQUET WINE SPONSOR

BREAK SPONSOR

Exhibitors

American Board of Preventive Medicine, Chicago, IL: TABLE # 3: The American Board of Preventive Medicine, Incorporated (ABPM) is a member board of the American Board of Medical Specialties. ABPM originated from recommendations of a joint committee comprised of representatives from the Section of Preventive and Industrial Medicine and Public Health of the American Medical Association and the Committee on Professional Education of American Public Health Association. www.theabpm.org

Anacapa Technologies, Inc, San Dimas, CA: TABLE # 5: Anacapa Technologies, Inc. is a market leader and innovator in the formulation of antiseptic wound care products. Our offering has been expanded to serve the veterinarian. Our manufacturing site is in San Dimas, California. http://anacapa-tech.net/

Aventic Group LLC, Orlando, FL: BOOTH # 107: Aventic-Group business solutions help customers implement best-in-class solutions for operational excellence, business intelligence (BI), and risk compliance management. Aventic-Group addresses a range of customer needs, including customer relationship management, procurement, and supply chain management. http://aventic-group.snack.ws/

Baromedical Nurses Association, Gotha, FL: TABLE # 8: The BNA provides nurses with a professional organization in order to maintain and promote the status and standards of practice in hyperbaric nursing. http://www.hyperbaricnurses.org/

Best Publishing Company, Palm Beach Gardens, FL: BOOTH # 101: Best Publishing Company was founded in 1966 and has become the largest and one of the most respected publishers of educational books on diving, wound care, and hyperbaric medicine. We produce educational books along with professional periodicals such as the Wound Care & Hyperbaric Medicine Magazine, a peer-reviewed quarterly publication that covers all aspects of wound care, diving medicine, and hyperbaric oxygen (HBO2) therapy. We also produce the Wound Care & Hyperbaric Medicine Calendar that promotes diving, wound care, and hyperbaric education courses worldwide. www.bestpub.com

CoxHealth, Springfield, MO: TABLE # 12: A community-based, not-for-profit health system, CoxHealth is headquartered in Springfield, Mo. Established in 1906, CoxHealth serves a 24-county service area in southwest Missouri and northwest Arkansas, offering a comprehensive array of primary and specialty care through six hospitals and more than 80 clinics. The health system includes Cox Medical Center South, Cox Medical Center Branson, Cox Barton County Hospital, Cox Monett Hospital, Cox North Hospital, Meyer Orthopedic and Rehabilitation Hospital, Oxford HealthCare, Home Parenteral Services (home infusion therapy), CoxHealth Foundation, Cox College, Cox HealthPlans and more. https://www.coxhealth.com

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 36 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

DMMED Group: Las Vegas, NV: BOOTH # 102: DMMED Group provides a variety of healthcare solutions to many different industries. Innovation is what keeps us moving forward. Our strategy is to combine our pharmaceutical capabilities, scientific, expertise and values with the strengths which include genuine consumer understanding, speed and brand focus. Innovation and speed to market are critical parts of this mission, helping us to continually meet our consumers' changing needs all over the world. Our passion for creating quality products backed by science also gives us a unique advantage over the competition. Today, DMMED Group exists for one purpose: to provide everyday healthcare products that help more people to do more, feel better and live longer. The key to that success is our innovation partners. Through collaboration, we're able to help each other and do more together-exchanging insights and sharing resources to bring great healthcare solutions to life and to the people we serve. http://www.dmmedgroup.com/

Environmental Tectonics: Southampton, PA: TABLE #13: Environmental Tectonics Corporation (‘”ETC”) was founded in 1969. For over four decades, ETC has provided engineered solutions to its customers with products, service and support, which in many cases leads to better training which saves lives. Innovation, continuous technological improvement and enhancement, and product quality are core values that are critical to our success. ETC products are found in over 90 countries around the world. https://www.etcusa.com/

ERCH Technologies: Hallandale Beach, FL: TABLE #11: ERCH attends medical trade shows and conventions all over the country. We focus on selling an FDA approved medical device that repairs the skin. On the basis of LED Therapy. Red light treatment is completely safe and has no reported side effects. The LED light is known to promote the production of cells & collagen and by doing that it’s basically rejuvenating your skin. The red light also is known to reduce melanin (hormone) level in the skin and improve the appearance of age spot and dark spots. Today the LED technology is being also used by therapists for arthritis, joint pain relief, sports injuries of athletes and more. Research done by NASA, it was found that some common side effect of chemotherapy and radiation treatments can be reduced by using the LED light treatment. NASA also found it to aid in the healing of human wounds, burns and Diabetic skin ulcers. The kit comes with a high-end skin care to complete the treatment. https://numiere-microcurrent.com/

Fink Engineering, PTY, LTD, Warana, Australia: TABLE # 4: Fink Engineering Pty Ltd (a subsidiary of Fink International) was established in Victoria, Australia in 1987 to provide engineering design and consultancy to the offshore oil and diving industries. We have developed a world class set of Rectangular Hyperbaric Chamber Systems that are just beginning to be appreciated overseas as evidenced by systems shipped to New Zealand, Singapore, Canada and our recently completed projects in the USA. www.fink.com.au

Hyperbaric Modular Systems, Inc., National City, CA: BOOTH # 109: With a decorated history spanning over 45 years providing hyperbaric oxygen (HBO2) therapy clinical equipment and solutions to major hospitals and medical centers worldwide, HMS has a strong foundation and is uniquely qualified to bring innovative HBOT equipment and reliable maintenance services to healthcare providers whose patient outcomes are benefited from HBO2. In addition to providing clinical HBO2 equipment for hospitals, HMS will supply related products such as recompression chambers for diving and military applications, hyperbaric equipment for human sports medicine and equine athletes, and hyperbaric intervention equipment for tunneling projects worldwide. http://www.hms-incorporated.com/

International ATMO, Inc., San Antonio, TX: TABLE # 6: International ATMO, Inc. is one of the oldest continuous providers of hyperbaric medicine education services including hyperbaric consulting, hyperbaric safety training, hyperbaric oxygen treatment, wound center consulting, wound care education and wound center management. International ATMO’s continuing education courses in hyperbaric medicine, wound center management, wound care center education and safety training attract an international attendance of physicians, nurses, and technicians annually. The Hyperbaric Medicine Team Training Course is the original UHMS-Designated Introductory Course in Hyperbaric Medicine that meets the requirements of all Medicare Intermediaries. We also offer various hyperbaric education books, wound care center books as well as books from NFPA and UHMS. www.hyperbaricmedicine.com

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 37 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY Pan-America Hyperbarics, Inc., Richardson, TX: TABLE # 7: Pan-America Hyperbarics, Inc., “The Highest- Value Provider in Hyperbaric Technology” is a worldwide supplier of monoplace and multiplace hyperbaric chambers. Our expertise is not only in designing and building bold new cost effective hyperbaric treatment systems, but also in developing partnerships with our clients. To assist our clients in providing the best standard of care to their patients, Pan-America Hyperbarics, Inc. offers unprecedented purchase, finance, and lease options for our products. For more information please contact our Partnership Care Team: 1-888- PAHI-HBO, or visit www.panamericahbo.com

Perimed, Inc., North Royalton, OH: BOOTH # 103: With over 25 years of development, Perimed AB manufactures and markets state-of-the-art laser Doppler instruments for the measurement of microvascular perfusion. As a leader in the wound care and hyperbaric medicine departments, Perimed, Inc., offers the only combined laser Doppler and transcutaneous multi-channel monitor, the PeriFlux 5000 system. This system allows the user-friendly flexibility of multiple site monitoring. PeriFlux instruments represent a commitment that begins with quality and performance, and continues with technical and applications support. Please visit our website at www.perimed-instruments.com

Perry Baromedical, Riviera Beach, FL: TABLE # 9: Perry Baromedical is the only company in the world which designs, manufactures, installs and services monoplace, dualplace and multiplace hyperbaric chambers. We provide the highest quality product, and are focused on assisting hospitals with a comprehensive Hyperbaric Oxygen Therapy department. For further information visit our website at www.perrybaromedical.com or call us at 561-840-0395. www.perrybaromedical.com

Phelps Memorial Hospital Center, Sleepy Hollow, NY: TABLE # 1: Now part of Northwell HealthTM, Phelps Memorial Hospital Center is dedicated to: improving the health of the community we serve; sustaining an environment of excellence where medical, social and rehabilitative services are delivered proficiently, efficiently and effectively. https://phelpshospital.org/

Radiometer America, Westlake, OH: TABLE # 2: Radiometer is a leading provider of technologically advanced acute care solutions that simplify and automate all phases of acute care testing. Radiometer offers solutions for blood gas analysis, transcutaneous monitoring and immunoassay testing. http://www.radiometeramerica.com/

Reimers Systems Division of PCCI, Inc., Alexandria, VA: BOOTH # 106: With decades of experience, we offer hyperbaric chambers, research chambers, altitude chambers, oxygen service solutions, manifolds and other accessories like hood drivers, gas selection panels and utility penetrators, site development and engineering services, chamber installation and maintenance. Our sister company, Hyperbaric Clearinghouse, offers quality pre-owned chambers and equipment. www.reimersystems.com

Sechrist Industries, Anaheim, CA: BOOTH # 100: For over 30 years, Sechrist Industries, Inc., continues to be a leading worldwide manufacturer of hyperbaric chamber systems, neonatal, infant and pediatric intensive care ventilators, and air/oxygen mixers along with other ancillary accessories. All products are manufactured in accordance with FDA and GMP regulations. www.sechristusa.com

UHM Fellowship Programs: TABLE # 10: Fellowship training in Undersea and Hyperbaric Medicine recognizes special commitment and expertise in Undersea and/or Hyperbaric Medicine. In the United States, those eligible for Fellowship training must be board-certified in Undersea and Hyperbaric Medicine by a Board sanctioned by the American Board of Medical Specialties (ABMS) and must be in active practice in undersea and/or hyperbaric medicine. https://www.uhms.org/education/credentialing/fellowship- programs.html

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 38 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

THURSDAY, JUNE 28

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 39 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 40 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

PRESIDENT’S ADDRESS Enoch Huang, MD 8:00 AM – 8:30 AM

ABOUT THE LECTURE:

The annual President’s address will present a “State of the Society” review of the activities of the UHMS, focusing on the activities of the most recent year as well as the challenges and initiatives of the future.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 41 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

PLENARY SESSION: HYPERBARIC MEDICINE AND CANCER 8:30 AM – 10:00 AM

8:30-9:15 John Feldmeier, DO "Hyperbaric oxygen and cancer treatment with emphasis on its potential role combined with ketogenic diet and chemotherapy."

Some researchers have advocated hyperbaric oxygen as a primary treatment for malignant conditions, though the support is limited here. A number of studies done in Richard the late 1950s through the 1970s even on review many years later firmly establish Moon, MD simultaneous hyperbaric oxygen as a radiosensitizer. There are reasons to believe that sequential hyperbaric oxygen followed immediately by can enhance cancer cell kill. The pioneering work by several Japanese authors have reported encouraging results in applying this combined treatment in high-grade brain tumors. More recently, a similar study supported in part by the Baromedical Research Foundation has shown the feasibility of applying these principles to head and neck cancers receiving both chemotherapy and radiation therapy with impressive results and no unexpected toxicities.

There is a strong rationale and a bit of research that also suggest that chemotherapy’s antitumor effects can be enhanced by hyperbaric oxygen as well. Certainly, the logistics of delivering chemotherapy in the hyperbaric chamber are much easier than delivering radiation with HBO2.

In this session, Dr. John Feldmeier will introduce an overview of the above issues. These will include a discussion of the Warburg effect and its implications for combined HBO2 and chemotherapy and HBO2 combined with the ketogenic diet. A brief update will be presented on the status of HBO2 alone and how it effects malignant growth. Other mechanisms by which chemotherapy delivery and tumoricidal effects can likely be enhanced will be considered.

Mr. Richard Clarke will follow with a lecture updating the experience in a multicenter trial using sequential HBO2 and radiation with chemotherapy in advanced head and neck cancer patients.

9:15-10:00 Dick Clarke, CHT "Hyperbaric oxygen radiation sensitization of squamous cell carcinomas of the oropharynx"

This presentation summarizes the first study of hyperbaric oxygen chemo-radiation sensitization for locally advanced squamous cell carcinomas of the oropharynx. It took the form of a Stage I dose escalation trial, designed to determine safety, feasibility and tolerability when hyperbaric oxygen was added to standard care: namely intensity modulated radiation therapy and cisplatinum chemotherapy. The presentation will describe the biological plausibility and physiologic basis for pre- radiation hyperbaric hyperoxia, and the rationale for selection of this tumor type and tumor grade. The hyperbaric dosing regimen, one based upon previous human tumor oxygen response curves, is discussed, and the critical time window for radiation therapy “beam on” from exiting the chamber discussed. Evolution from earlier sensitization studies that employed concurrent hyperbaric oxygen-radiation therapy to the modern sequential approach are described, as well as its inherent advantages. A staging protocol employed to titrate hyperbaric dose against possible acute toxicities is described. Acute toxicities and five-year follow-up results are presented, as is a Stage III study design, in the form of a randomized, sham controlled clinical double-blind trial.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 42 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY SESSION A DIVING & DECOMPRESSION ILLNESS: THEORY & MECHANISMS Moderators:

THURSDAY, JUNE 28

Oral Presentations: 10:30 AM – 11:30 AM

Poster Presentations: Poster Session: 11:30 AM – 12:00 PM

Moderators: Laurie Gesell, MD Nick Bird, MD

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 43 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 44 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

A 1 Thursday, June 28 ORAL PRESENTATION TIME: 10:30-10:45 POSTER PRESENTATION TIME: 11:30-12:00 RESIDENT COMPETITION: No

Heliox in-water decompression schedules for the Interspiro IS-MIX mine clearance diving system Bouak F1, van Ooij PJ2, Nishi R3, van Hulst RA2,4 1Defence Research and Development Canada, Toronto Research Center, 1133 Sheppard Avenue West, Toronto, Canada 2Diving Medical Center, Royal Netherlands Navy, P.O. Box 10000, 1780 CA Den Helder, The Netherlands 3Defence R&D Canada Toronto (retired), Toronto, Canada 4Academic Medical Center, P.O. Box 22700, 1100 DE Amsterdam, The Netherlands Presenting Author: Pieter-Jan van Ooij, PHD [email protected]

Background: The IS-MIX is a semi-closed apparatus providing a breathing mixed-gas with a constant oxygen fraction. New helium-oxygen (84% He–16% O2) decompression tables are being developed and validated for use with the IS-MIX. In-water decompression involved a single gas switch, nitrox (40% N2– 60% O2) at 24 msw, to simplify and reduce the number of gas mixtures that must be carried to the dive site.

Methods: Profiles were tested in two series of dives at the Royal Netherlands Navy’s Diving Medical/ Technical Center under controlled conditions. Each dive included two wet-working divers on bicycle ergometers wearing dry suits in 6-10°C water and breathing from the IS-MIX, and two dry resting divers, acting as standby diver and team leader, at 2 msw shallower and breathing heliox from the chamber’s BIBS. To evaluate decompression stress, all divers were monitored post-dive for venous gas emboli (VGE) with Doppler ultrasound (Kisman-Masurel method) at the precordium and subclavian vein sites. The wet divers’ inhaled PO2 was monitored.

Results: In Series 2, eight profiles using 23 volunteer military divers (35±7 yr, 88.9±10.1 kg, BMI:27.0±2.8 kg·m-2) were tested for a total of 143 successful man-dives (69 wet, 74 dry). New operational procedures and modifications to the decompression schedules were implemented following Series 1, resulting in no DCI incidents and relatively lower VGE activity for wet divers, especially for short bottom times (<15 min). Dry divers (shallower than wet, using the same decompression schedules) produced significantly lower bubble grades.

Conclusions: Based on previous DRDC/DCIEM studies and given that the model’s parameters and rules were kept similar to those of DCIEM Table 7, schedules calculated using the DCIEM™ decompression algorithm are expected to have low DCS incidence. The proposed decompression table is recommended for interim operational use in deep and short IS-MIX military diving.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 45 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

A 2 Thursday, June 28 ORAL PRESENTATION TIME: 10:45-11:00 POSTER PRESENTATION TIME: 11:30-12:00 RESIDENT COMPETITION: No

Provocative decompression causes diffuse vascular injury mediated by interleukin (IL)-1β and inhibited by hyperbaric oxygen (HBO2) Thom SR, Bhopale VM, Yang M Department of Emergency Medicine, University of Maryland School of Medicine Presenting Author: Stephen R Thom, MD [email protected]

Introduction: Blood-borne microparticles (MPs), 0.1- 1 µm diameter vesicles, are increased by high pressure/decompression stress. How MPs cause injuries and whether HBO2 abrogates effects are unknown. MPs production and activation of the NLRP3 inflammasome that generates IL-1β are known to be linked. We hypothesized that MPs containing IL-1β mediate tissue damage, and HBO2 may inhibit responses.

Materials and Methods: Mice were exposed for 2 hours to 790 kPa air and euthanized 2 hours post- decompression (labeled Deco) to study blood-borne MPs and vascular leakage. Some mice received antibody to IL-1β (Ab group, 50 µg IP) or anakinra (Anak group, an IL-1β receptor inhibitor, 100 mg/kg IP) before pressure; some were exposed to HBO2 (2.8 ATA for 45 minutes) before or after pressure/decompression.

Results: MPs elevations occurred post-decompression, data are as follows [#/µl plasma (n=4-12, mean +SE,*=p<0.05)]: Control: 853 + 74, Deco group: 3913 + 1242*, Ab + Deco: 729 + 145, Anak + Deco: 784 + 250, HBO2 only: 532 + 66, HBO2 then Deco: 1619 + 768; Deco then HBO2: 4553 + 1560*). Capillary leak quantified as uptake of intravascular 2x106 Da dextran increased post-decompression by 1.6 to 3.1 fold over control in brain, omentum and muscle (p<0.05), but not in mice pre-treated with IL-1β antibody or anakinra, or mice exposed to HBO2 before or after pressure/decompression. Intra-MPs concentrations of IL-1β (pg/million MPs) were as follows: Control: 13.9 + 3.3; Deco 125.3 + 18.3*; Ab + Deco: 24.2 + 4.8, Anak + Deco: 40.5 + 14.8, HBO2 then Deco: 21.2 + 12.1, Deco then HBO2 13.4 + 5.4.

Summary: Vascular damage post-decompression is mediated by IL-1β and inhibited by IL-1β antagonists, consistent with IL-1β auto-activation of leukocytes. HBO2 inhibits IL-1β production/packaging within MPs, but only blocks MPs production when used prophylactically. Mechanisms for this novel action of hyperoxia are underway.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 46 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

A 3 Thursday, June 28 ORAL PRESENTATION TIME: 11:00-11:15 POSTER PRESENTATION TIME: 11:30-12:00 RESIDENT COMPETITION: Yes

The effect of intermittent normobaric hyperoxia on stem cell mobilization and cytokine expression MacLaughlin KJ1,2, Barton G1,2, Braun R1,2, Sobakin A1,2, Eldridge M1,2 Eldridge Lab/ University of Wisconsin - Madison 600 Highland Avenue, Madison WI 1Department of Pediatrics, 2John Rankin Laboratory of Pulmonary Medicine Presenting Author: Kent MacLaughlin [email protected]

Introduction/Background: Mechanisms of hyperbaric oxygen (HBO2) therapy putatively include inducing transduction cascades that modulate cytokine expression and mobilize proangiogenic stem/progenitor cells (PSC). Accepted clinical HBO2 inhaled oxygen tensions (PIO2) range minimally from 1520 Torr up to 2280 Torr, however, little is known about oxygen therapy below PIO2 760torr. A central dogma in contemporary oxygen therapy research asserts low values of hyperoxia are benign and a useful sham. In this experiment, we measure inflammatory cytokine expression and PSC mobilization at PIO2 320 Torr.

Materials/Methods: Twelve, 10-week-old-Sprague-Dawley rats were randomly divided into two-groups. The treatment group exposed to PIO2 319 torr (41%O2) and the control group exposed to room air. Treatments were administered 5 days/week, 2 hours/day, totaling 20hrs. After sacrifice, monocytes/cells harvested from venous blood were prepared for flow cytometry using antibodies for CD45+, CD34+ and CD133+. Flow cytometry using the BDLSRII/DIVA was analyzed with FlowJo software. Statistics performed using a non-parametric unpaired t-test (Mann-Whitney) with a p<0.05 to indicate significance.

Results: Treated animals showed an increase in mobilized CD45+/133+/34- PSC’s (p=0.009) compared to controls, but no difference in CD45+/133-/34+ (p=0.99). TNFα was significantly decreased in treated animals compared to controls (p=0.004).

Summary/Conclusions: To our knowledge, this is the first study to demonstrate biologic activity at PIO2 320 Torr. Previous research indicated HBO2 mobilizes PSC’s with PIO2 1520 Torr. Similar to this finding, our data demonstrates that a much smaller dose PIO2 320 Torr, also mobilizes PSC’s and additionally suggests a potential anti-inflammatory effect by reduction in TNFα. Together these findings support the likelihood of biologic activity, consubstantial with HBO2, being activated at much lower dose of hyperoxia than previously postulated. Future research examining oxygen/dose relationship will further elucidate the biological effect of various doses of hyperoxia, and establish differences between concentration and pressure, along with establishing basal active levels.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 47 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

A 4 Thursday, June 28 ORAL PRESENTATION TIME: 11:15-11:30 POSTER PRESENTATION TIME: 11:30-12:00 RESIDENT COMPETITION: Yes

Pharmacological vasodilation and gas switching to carbon tetrafluoride during decompression to attenuate DCS Weis TW, Wilbur JC, Knaus DA, Buckley JC, Vann RD, Sevick JR, Stump DA, Deal DD, Ramsey M, Natoli MJ, Fellows A, Marshall C, Magari PJ, Cooter M, Moon RE Duke University, 40 Duke Medicine Cir #0584, Durham, NC 27710 Presenting Author: Trevor Weis [email protected]

Introduction: It has been hypothesized that decompression stress could be reduced by increasing tissue blood flow during decompression via a vasodilator such as nitroglycerin (NTG), or by switching to a breathing gas with lower diffusivity. This study in anesthetized pigs was designed to test both NTG administration as well as a breathing gas switch from He-O2 to carbon tetrafluoride (CF4-O2) immediately before decompression.

Materials/Methods: Sixty-one juvenile pigs (20kg) were anesthetized and compressed to 200 fsw at 20 fsw/min and remained at depth for 20 minutes before decompressing at 60 fsw/min. Three animals breathed Ar-O2 (80-20) and 16 animals breathed He-O2 (80-20) throughout the entire dive. Immediately before decompression, 22 switched from He-O2 to CF4-O2 (80-20), 2 switched to 100% O2, and 18 received a nitroglycerin infusion while continuing to breathe He-O2. Two animals breathed He-O2 for the same period of time but did not change from atmospheric pressure. Upon returning to atmospheric pressure, animals were monitored for signs and symptoms of DCS for one hour or until death.

Results: Switching to a CF4-O2 mix before decompression resulted in decreased volatility of blood pressure and heart rate, lower rates of hypotension, decreased incidence of lumbar spinal cord hemorrhage, and smaller area of cutis marmorata compared to breathing He-O2 throughout the dive. Administration of NTG did not result in significant differences in DCS manifestations compared to the control.

Conclusions: In this model nitroglycerin administration did not attenuate DCS. Switching to CF4-O2 during decompression from a He-O2 dive seems to decrease the incidence and severity of DCS.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 48 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

A 5 Thursday, June 28 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 11:30-12:00 RESIDENT COMPETITION: No

Oxygen pre-breathe and decompression sickness outcomes in the UW sheep model Sobakin AS, Eldridge MW Deptartment of Pediatrics, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA Presenting Author: Aleksey Sobakin, PHD [email protected]

Introduction: Oxygen pre-breathe is used to minimize DCS risks in decompression from prolonged hyperbaric exposure. The sheep have been tested to evaluate the potential benefits of O2 pre-breathing before dropout decompression from 33 and 45 fsw.

Methods: Thirty-two adult female sheep (89.3±9.1 kg SD) underwent a 24-h hyperbaric exposure (33 or 45 fsw, 1.97 to 2.33 atm abs), followed by oxygen pre-breathe for 15, 30, 45 min before dropout decompression at a rate 30 fsw/min (0.91 atm abs/min) to atmospheric pressure and then observed four hour for clinical signs.

Results: Survivals in dropout decompressions from 24-h 33-fsw decompressions were 100% in each O2 pre-breathes groups. There were no significant differences between 45 min and 30 min oxygen pre- breathe vs. 15 min oxygen in terms of average bubble score at surface or one hour after drop-out decompression. However, Limb DCS was significantly lower in the 45 min O2 group (average score 1.2 vs. 2.6, p = 0.004). Also, there were no CNS-DCS and RDCS cases in 45 and 30 min O2 pre-breathe group vs. one case of CNS-DCS in 15 min O2 pre-breathe group. Survivals rates from 45 fsw dropout decompression schedule were 100%. Just one sheep from 15-min oxygen pre-breathe group has developed Type II DCS, both respiratory and neurological. All other animals from oxygen pre-breathe groups survived dropout decompression with Type I DCS. Signs of limb bends was significantly lower in the 45 min oxygen pre-breathe group (average score 1.6 vs. 3.1, p = 0.005).

Conclusions: Decompression outcomes in sheep point to the potentially-high risk from “drop-out” decompression after prolonged hyperbaric exposure at comparatively shallow depths. In these sheep experiments, even brief O2 pre-breathes afforded survival and strongly indicate that extraordinary survival benefit can be offered to submariners undergoing a DISSUB event or decompression from significant near-saturation air exposure.

Research was funded by NAVSEA the U.S. Navy.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 49 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

A 6 Thursday, June 28 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 11:30-12:00 RESIDENT COMPETITION: Yes

Microparticle and interleukin (IL)-1β production associated with human high-pressure exposures Brett KD, Nugent NZ, Fraser KN, Bhopale VM, Yang M, Thom SR Canadian Forces Health Services Presenting Author: Kaighley Brett, MD [email protected]

Introduction: Biochemical pathways for production of microparticles (MPs), 0.1- 1 µm diameter vesicles, and IL-1β are linked. Further, MPs increase in association with decompression from high-pressure in simulated and bona fide underwater diving. It is unknown whether this response is due to exposure to high-pressures or decompression. We hypothesized that MPs containing IL-1β are generated in humans while exposed to high gas pressures more so than as a response to decompression.

Materials and Methods: After informed consent, Canadian Armed Forces Clearance Diver research subjects were exposed in hyperbaric chambers to 18 msw for 60 minutes following Canadian Forces Standard Air Decompression Tables. Blood samples were obtained 30 min prior to pressurization, at the conclusion of the pressure exposure and 2 hours post-decompression. Blood was processed for MPs analysis and assays of intra-MPs IL-1β following published techniques (Fr Rad Biol Med 106: 406, 2017).

Results: MPs elevations occurred while at pressure. MPs numbers/µl plasma in the 18msw group (n=15) were: pre-dive 2261 + 743, at pressure 4097 + 1002 (p=0.004, repeated measures [RM] ANOVA on ranks), post-dive 2554 + 803 (NS). Intra-MPs concentrations of IL-1β (n=6; pg/million MPs) were as follows: Pre-dive: 0.4 + 0.1; at 18 msw: 3.0 + 0.1 (p=0.001); post-18msw dive 1.8 + 0.1 (p=0.05).

Summary: Exposures to high gas pressures trigger production of MPs containing elevated concentrations of IL-1β. While these events may pose adverse health threats, their contribution to decompression sickness development requires further study. Investigations of mechanisms for these novel actions are underway.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 50 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

A 7 Thursday, June 28 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 11:30-12:00 RESIDENT COMPETITION: Yes

Hyperbaric and high-oxygen environments accelerate muscle strength recovery in contused rat skeletal muscle Yamamoto N Hyperbaric Medical Center - Medical Hospital of Tokyo Medical and Dental University Presenting Author: Naoki Yamamoto, MD [email protected]

Introduction: Hyperbaric oxygen (HBO2) treatment is promoted as method to rapidly recover from sports-related soft tissue injuries. A previous study showed that HBO2 accelerated reduction of the volume of injured muscle, stimulated cell proliferation and promoted muscle regeneration via macrophage recruitment (2017 UHMS). However, it is not clear whether HBO2 accelerate functional recovery of injured skeletal muscle. The current study measured isometric tensile strength of muscle following injury to determine if HBO2 influences recovery of muscle strength.

Materials and Methods: A muscle contusion of the right calf was performed by the drop mass method. Rats were divided into non-treated (NT) and HBO2 group. The HBO2 protocol consisted of 2.5ATA 100% oxygen for 120 minutes. HBO2 treatment was performed once per day for 5 days. Maximum twitch (a single contraction) and tetanic (maximum contraction for one second) isometric tensile strengths of the injured and non-injured legs were measured at 1, 3, 5, 7, 9 days after injury. The strength ratio, strength of the injured muscle to the strength of the non-injured muscle, was calculated. Furthermore, at 7 days after injury, the strength ratio of rats that received one HBO2 treatment (soon after injury (HBO2-0D); 3days after injury (HBO2-3D)) were measured.

Results: Both twitch and tetanic force ratios were significantly higher in the HBO2 group at 7 days after injury (NT group: 0.77 ± 0.05, HBO2 group: 1.10 ± 0.04). In rats that received one HBO2 treatment soon after injury, the twitch force ratio was significantly higher compared to NT. However, the ratio was not significantly higher in the group that received HBO2 3 days after injury.

Conclusion: The current findings in a preclinical muscle injury model indicate that early HBO2 treatment, immediately after injury, accelerates muscle strength recovery, similar to that observed of repeated HBO2 treatment.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 51 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

A 8 Thursday, June 28 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 11:30-12:00 RESIDENT COMPETITION: No

Effects of a hyperbaric environment on antioxidative mechanisms in the mouse Masaki H1,2, Akira K1,2, Naoki Y1, Toshihiro K1,2, Kazuyoshi Y1,3 1Hyperbaric Medical Center, University Hospital of Medicine, Tokyo Medical and Dental University; 2Department of Technology, Oriental Shiraishi Corporation; 3Clinical Center for Sports Medicine and Sports Dentistry, Tokyo Medical and Dental University Presenting Author: Masaki Horie, PHD [email protected]

Introduction: Technical divers and pneumatic caisson workers experience health risks from working in hyperbaric environments. Oxidative stress is one known deleterious factor associated with this environment. Generally, NF-E2-related factor 2 (Nrf2)-related antioxidant signaling protects tissues and organs from oxidative damage. However, Nrf2 responses occurring during work in hyperbaric environments are not well understood. Therefore, we examined oxidative stress responses in mice using a hyperbaric environment simulator and in vivo Nrf2 imaging.

Methods: We performed in vivo imaging of Nrf2 using transgenic mice. In the hyperbaric simulation, mice were exposed to compressed air at 0.05 MPa/min up to 0.4 MPa (5ATA) and pressure was then maintained for 60 min. During this time, exercise groups (HBE+Ex) performed a running exercise, in a running wheel set at 10 m/min. Thereafter, decompression was performed at a rate of 0.03-0.01 MPa with three stopping periods: 5 min at 0.12 MPa, 12 min at 0.09 MPa and 30 min at 0.06 MPa. This decompression table was in accordance with a pneumatic caisson work protocol. After hyperbaric exposure, we performed in vivo imaging analysis and quantitative RT-PCR for Nrf2 and Nrf2 related factors.

Results: By in vivo imaging analysis, Nrf2 expression was decreased in the hyperbaric exposer (HBE) and HBE+Ex groups, compared with in mice under normobaric. Additionally, the decrease in Nrf2 expression was hyperbaric exposure times dependent. Expression of mRNAs for the Nrf2 related factors NQO1 and GPx was also significantly decreased in livers from HBE and HBE+Ex mice. However, carbonylated proteins, an oxidative stress marker, were increased in livers from both groups.

Conclusion: This study showed that a hyperbaric exposer caused decreased Nrf2 activation and increased levels of carbonylated proteins. These results suggested that hyperbaric exposure attenuates antioxidative mechanisms.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 52 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

A 9 Thursday, June 28 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 11:30-12:00 RESIDENT COMPETITION: No

Consistency of venous gas emboli status after three controlled pool diving exposures: A pilot study Denoble PJ1, Papadopoulou V2, Buzzacott P1, Edelson CJ1, Pieri M3, Cialoni D3, Lambrechts K4, Balestra C3,4, Marroni A3 1Divers Alert Network, 6 West Colony Place, Durham, NC 27705, USA; 2Joint Department of Biomedical Engineering, The University of North Carolina and North Carolina State University, Chapel Hill, NC, USA 3Divers Alert Network Europe Research Division, Italy; 4 Environmental & Occupational (Integrative) Physiology Laboratory, Haute Ecole Bruxelles-Brabant (HE2B), Brussels, Belgium Presenting Author: Petar Denoble, MD [email protected]

Introduction/Background: Venous gas emboli (VGE) are often observed after scuba diving and higher VGE grades have been correlated to higher decompression sickness (DCS) risk. Factors contributing to VGE inter- and intra- subject variability remain unclear. Our aim was to assess consistency of VGE status post-dive for the same subjects undergoing repeated dives in controlled conditions. This pilot study examined if VGE status after a series of consecutive day dives is random, or associated with VGE status after previous diving.

Materials and Methods: Divers performed three standardized scuba dives (24 h interval) to 25 mfw for 25 min at the Y40 pool in Italy. Echocardiography recordings were acquired pre-dive and at 15, 35, 55, 75, 95, 115 and 135 min post dive. Initial VGE assessment was determined for each time point and VGE status was binarily classed as observed or not. A conditional nested model design with likelihood ratio test was used to determine the likelihood of VGE outcome being independent of previous VGE status outcome.

Results: 30 divers participated in the study, with a total of 89 dives (of which, 2 DCS). Five showed no VGE on any dive, 20 did after all three dives, three were inconsistent and two did not complete the study. Post-dive VGE status was found dependent on previous day’s post-dive VGE status (p<0.001). Though bubble counts are yet to be formally validated, early indications are that bubble scores decayed faster with successive dives.

Summary/Conclusions: For consecutive day diving, VGE appear in this pilot study to have been associated with previous day’s post-dive VGE status. Future work will include validating bubble counts at each measurement time point for time-series analysis, exploring the potential effect of longer surface interval between dives, and the influence of other physiological variables.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 53 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

A 10 Thursday, June 28 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 11:30-12:00 RESIDENT COMPETITION: No

Augmentation of event related brain activity on cognitive control under hyperbaric environment Fujii T Undersea Medical Center, Japan Maritime Self-Defense Foce, Kanagawa, Japan Presenting Author: Tatsufumi Fujii [email protected]

Introduction/Background: Deep diving, below 150 m, causes augmented theta band activity in the human brain. However, this is not always followed by deteriorated cognitive performance. It is necessary to exercise cognitive control in reaction to external environment to perform cognitive tasks successfully. This study investigated the effect of exposure to a hyperbaric environment (up to 21 ATA) on cognitive control processes, using event-related brain potentials (ERP).

Material and Methods: Eight males participated (age = 33.50 years, SD = 8.90), of which four (age = 30.25 years, SD = 6.18) were undertook a simulated saturation dive using heliox. The remaining four (age = 36.75 years, SD = 10.78) were part of the control group. Participants performed a visual two- choice reaction task. In 80% of trials, when the LED illuminated green, participants had to press the response button immediately using the thumb of their dominant hand. Conversely, participants were instructed to suspend responses when the LED illuminated red (20%). ERP were recorded throughout from three Ag / AgCl electrodes placed along midline (Fz, Cz, Pz) with reference to linked earlobes. The averaging period was 100 ms prior to and 900 ms after stimulus onset. Additionally, an electrooculogram monitored blinking. Data exceeding 0.08 mV were excluded.

Results: The amplitude of the positive component 300 ms after stimulus onset (P3) during infrequent response suspension trials was larger than that during frequent response trials. Moreover, the tendency toward P3 augmentation between 1 ATA and approximately 21 ATA was observed.

Summary/Conclusions: Exposure to approximately 21 ATA augmented the P3 amplitude elicited by infrequent response suspension. At 1 ATA, the P3 amplitude in same task reflects strength of cognitive control effort. We propose that the augmented P3 amplitude suggests difficulties in behavior control in hyperbaric environments.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 54 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

A 11 Thursday, June 28 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 11:30-12:00 RESIDENT COMPETITION: No

Effect of rehydration schedule after four-hour head-out water immersion on running performance and recovery Stansbery RL, Hess HW, Schlader ZJ, Pendergast DR, Russo LN, Hostler D Center for Research and Education in Special Environments; 4 Sherman Hall, University at Buffalo; Buffalo, NY 14214 Presenting Author: Rebeccah Stansbery [email protected]

Introduction: Head-out water immersion (HOWI) results in a diuresis, which could potentially limit performance after egress to land. We examined the effect of rehydration on endurance, cardiovascular stability, and overnight recovery following a four-hour thermoneutral HOWI.

Materials and Methods: Twelve males completed a crossover design consisting of no hydration (NH), replacement of fluid loss during immersion (RD), and replacement of fluid after the immersion period (RA). Sixty minutes following immersion, subjects ran to exhaustion at ~80% maximum heart rate. After completing the run, each subject submitted to a head up tilt test (HUTT). Vital signs and ECG were monitored overnight.

Results: HOWI resulted in a transient diuresis in NH and RA, while it was sustained throughout immersion in the RD protocol resulting in greater urine (l) output (1.27 ± 0.48 (NH), 1.18 ± 0.43 (RA), 2.32 ± 0.77 (RD) (p < 0.001). Body mass change (%) was greater in NH than RD, but not RA (-1.58 ± 0.56 (NH), - 0.66 ± 0.47 (RD), and - 0.92 ± 0.76 (RA)). Run times were 17% vs 20% in NH compared to RD and RA, respectively, but were not statistically different. Time to orthostasis, during the HUTT did not differ by condition. Overnight heart rate variability and blood pressure were not different.

Summary: Rehydration during water immersion resulted in a large, sustained diuresis without improving performance or recovery after exiting the water. Loss of body water during thermoneutral HOWI was modest and both rehydration strategies minimally affected aerobic performance and overnight recovery in young, healthy males.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 55 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

A 12 Thursday, June 28 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 11:30-12:00 RESIDENT COMPETITION: Yes

Cold-water submersion attenuates post-submersion aerobic performance irrespective of rehydration strategy Hess HH, Schlader ZJ, Russo LN, Clemency BM, Stooks JJ, Carden CR, Hostler D University at Buffalo Department of Exercise and Nutrition Sciences Center for Research and Education in Special Environments 211 Kimball Tower Buffalo NY 14214 Presenting Author: Hayden W Hess [email protected] or [email protected]

Introduction: The diuretic effects of prolonged cold-water immersion are well documented; however, the implications of the subsequent hypohydration on high-intensity, aerobic performance are unknown. The compounding effects of water submersion and cold stress will induce hypohydration following egress to land and potentially limit post-dive performance. Therefore, we examined the independent effects of cold-water immersion and a rehydration strategy on an aerobic endurance performance following a four-hour dive in cold-water (10C).

Materials and Methods: Nine, young male subjects completed a baseline (CON) performance and two water immersion visits with either no rehydration (NR) or a post-immersion rehydration (R) with 1 L of water. Following submersion, subjects rested for 60 min and then ran to exhaustion at ~85% maximal oxygen consumption.

Results: Core body temperature declined during submersion and remained reduced from baseline until the run (p <0.001), but was not different between conditions (p = 0.13) Total urine output during submersion was not different between groups (1.69  0.49 (NR), 1.75  0.52 (R) L; p = 0.74) eliciting a body mass reduction of -2.2  0.3 and -2.0  0.4%, respectively. Run duration was not different (547.6  141.8 (NR), 566.7  152.4 (R) sec; p = 0.79); however, both NR and R run duration was shorter compared to CON (722.8  170.4 sec; p = 0.04).

Conclusion: Compared to a non-submersed state, run duration was reduced following a four-hour, cold- water submersion by 23% and 20% in the NR and R conditions, respectively. Replacement of 1 L fluid loss following submersion did not offer a performance advantage over no rehydration. The potential mechanism for impaired performance following submersion remains unclear.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 56 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

A 13 Thursday, June 28 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 11:30-12:00 RESIDENT COMPETITION: Yes

Adapting contrast-enhanced imaging techniques to improve quantification of decompression bubbles in humans Hensel JSE1, Le DQ1, Balestra C2,3, Tang M-X4, Dayton PA1,5, Papadopoulou V1 1Joint Department of Biomedical Engineering, The University of North Carolina and North Carolina State University, Chapel Hill, NC, USA; 2Environmental & Occupational Physiology Laboratory, Haute Ecole Paul Henri Spaak, Brussels, Belgium; 3Divers Alert Network (DAN) Europe Research Division; 4Department of Bioengineering, Imperial College London, London, UK; 5Eshelman School of Pharmacy, UNC Chapel Hill, Chapel Hill, NC, USA Presenting Author: James S. E. Hensel [email protected] or [email protected]

Introduction: Gas bubbles oscillate when sonicated with ultrasound near their natural resonant frequencies and return non-linear signals. It has previously been shown that dual-frequency ultrasound can detect smaller gas bubbles (1-10μm) in tissues prior the presence of venous gas emboli (VGE) in the circulation in a pig model (Swan et al, 2011). In medicine, contrast enhanced ultrasound imaging (CEUS) uses 1-8μm gas bubbles as vascular markers by selecting for these non-linear bubble signals while cancelling linear signals from tissue. We hypothesize that CEUS imaging techniques can be adapted for scuba research to selectively image small decompression emboli (<10μm) by effectively cancelling larger VGE (far from resonance) that are detectable on traditional B-mode ultrasound imaging (>35μm).

Materials and Methods: In-vitro: Microbubbles in a tissue-mimicking material are imaged using dual B- mode and contrast-mode, and/or ultra-high-frame-rate dual B-mode and pulse inversion on a programmable ultrasound system. In-vivo: Dual B-mode and contrast mode echocardiography recordings of 7 subjects, taken before (baseline) and 21, 56, 91 and 126min after a standardized pool scuba dive (400kPa for 20min), were analyzed: VGE were counted (B-mode) and signal intensity corresponding to small bubbles was compared over time.

Results: Large microbubbles are effectively cancelled out in contrast mode imaging, although higher frame rate imaging is needed to reduce motion artefacts. In-vivo, the intensity in both the arterial and venous heart chambers increases post-dive compared to baseline and decreases over time, even when no large emboli were observed on B-mode echocardiography. It therefore appears that smaller microbubbles (<10µm, which are not filtered in the lungs) are present and follow a different time-course post-dive than larger VGE.

Summary: Advanced ultrasound imaging techniques, inspired by CEUS, could be used to image both VGE and small emboli (1-10μm) at ultra-high frame rates (>1000 frames/sec), which could aid research in human decompression-induced degassing dynamics.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 57 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

A 14 Thursday, June 28 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 11:30-12:00 RESIDENT COMPETITION: No

Orthostatic intolerance following cold seawater submersion is likely independent of changes in body fluid status Hess H, Russo LN, Clemency BM, Stooks J, Carden C, Hostler D Center for Research and Education in Special Environments, Department of Exercise and Nutrition Sciences, University at Buffalo, Buffalo, NY Presenting Author: Zachary J. Schlader, PHD [email protected]

Introduction/Background: Orthostatic tolerance is likely impaired following thermoneutral water submersion. Submersion induced diuresis leads to hypovolemia upon egress, which may contribute to this effect. Diuresis is greater with cold water submersion. However, the effect of cold water submersion on orthostatic tolerance is unknown. We tested the hypothesis that prior cold seawater submersion impairs orthostatic tolerance and that fluid replacement following submersion restores orthostatic tolerance.

Materials and Methods: Nine males (23±2 y) completed a control visit (Con) and two 4 h cold (10°C) saltwater submersions. The saltwater approximated the constituents of seawater. During the 60 min following submersion subjects received either no rehydration (NoRehyd) or 1 L of water (Rehyd). This was followed by aerobic exercise to exhaustion (data not shown) and then progressive lower body negative pressure (LBNP) to pre-syncope. Orthostatic tolerance was quantified via the cumulative stress index (CSI), which is the sum of the product of LBNP level and the duration of each level until termination (e.g., 20 mmHg*3 min + 40 mmHg*3 min, etc.).

Results: Core temperature decreased with submersion (P<0.01), but did not differ between NoRehyd and Rehyd at any time point (P=0.45). Reductions in body weight were greater in NoRehyd (-2.2±0.3%) versus Rehyd (-0.8±0.3%, P<0.01) pre-LBNP, yet plasma volume changes did not differ (NoRehyd: - 17±10%, Rehyd: -15±3%, P=0.57). In all trials, heart rate increased (P<0.01) and mean arterial pressure decreased (P<0.01) throughout LBNP, with no differences between trials (P≥0.52). CSI was suppressed in NoRehyd (534±163 mmHg*min) and Rehyd (591±129 mmHg*min) compared to Con (707±170 mmHg*min, P≤0.03), with no differences between submersion trials (P=0.23).

Summary/Conclusions: Orthostatic tolerance is impaired following 4 h cold seawater submersion. Rehydration with 1 L of water following cold seawater submersion does not attenuate this effect.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 58 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

A 15 Thursday, June 28 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 11:30-12:00 RESIDENT COMPETITION: No

Quantifying pathologic changes in the heart and lung of swine due to “yo-yo” and square dive protocols Ofir D1, Arieli Y1, Mullokandov M1, Liboff A2, Yanir Y1 1Israel Naval Medical Institute, Haifa, and 2The Western Galile Hospital, Nahariya Presenting Author: Dror Ofir, PHD [email protected]

Background: Our previous study used a swine model to demonstrate that 4 peeps in "yo-yo" diving will increase the probability and severity of decompression illness (DCI). The role of the heart and lung in the evolution of the right-to-left shunt is the focal point of interest in our present reevaluation of the data.

Materials and Methods: Twenty-four Large White swine (~22 kg, males and females) were used in the experiment. The animals were subjected to one of four protocols (sham-control, square dive, two- or four-peep dive) to a depth of 5 ATA. Blood and urine samples were taken before and after decompression. After pathological evaluation, tissue were embedded in paraffin and stained with hematoxylin and eosin for histopathological evaluation.

Results: Two animals from the square dive, one from the two-peep dive, and two from the four-peep dive presented with either a cardiac thrombus or cardiac edema. Table 1 summarizes the results of pathological evaluation of the lungs. There was no significant difference between the three groups, other than a trend for higher prevalence of edema in the lung of animals subjected to "yo-yo" dives (both two- and four-peep), compared with the square dive. The pathological findings in the lung were further supported by significant changes in a number of indices suggesting the presence of damage tissue.

Table 1. Lung gross pathological evaluation Square dive Two-peep "yo-yo" Four-peep "yo-yo" Edema 1 2 3 Thrombus 2 2 Edema + Thrombus 1 2 1

Summary/Conclusions: Significant involvement of the lung in all three experimental groups did not allow us to draw clear conclusions regarding differences between the three dive protocols. Pathological evaluation, which established the presence of damage to the lung, was supported by hematological and urinary indices of tissue damage.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 59 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

CHRISTIAN J. LAMBERTSEN MEMORIAL LECTURE THURSDAY, JUNE 28: 1:00 pm - 2:00 pm

GUEST SPEAKER: Dr. Keith Van Meter LECTURE TITLE: “A long shot to a short shot: Hyperbaric oxygen augmented ACLS/ATLS spawned by commercial diving medicine experience"

ABOUT THE LECTURE:

The presentation will focus on observations gleaned from a forty-year history of responding to accidents on oil rigs and diving platforms in the Gulf of Mexico to care for seriously injured commercial divers. This experience afforded a look into the advantage of immediate use of high surface equivalent fraction of inhaled oxygen (SEFIO2) applied in short, intermittent breathing periods in the hyperbaric environment. Divers suffering from exsanguination, cardiopulmonary arrest, crush injury and severe heat shock have been successfully treated coincidentally because of requisite hyperbaric oxygen administration during surface or saturation decompression.

The favorable patient outcomes have been replicated in published animal experiments. In part, the physiological explanation might be better understood by looking into the role of mitochondria in shock. The hyperbaric chamber may be a virtual drawer of a code cart in future emergency medical systems and hospitals to improve outcomes from ACLS and ATLS.

ABOUT DR. VAN METER:

Dr. Van Meter attended George Washington School of Medicine in Washington, D.C. He trained at Tulane University / Charity Hospital in New Orleans, Louisiana. He is currently board certified in Emergency Medicine, Undersea and Hyperbaric Medicine, Pediatric Emergency Medicine, and Medical Toxicology. He has performed and published research in a number of topics. His current focus is on the use of hyperbaric medicine as an adjunct to ACLS and ATLS both in the clinical hospital setting and in the pre-hospital arenas.

Dr. Van Meter is the President and Medical Director of an emergency physician group which staffs a number of contracts in Louisiana and Mississippi. He is lead physician for a first response flight team that treats offshore, injured commercial divers on-site. He is the Medical Director for Baromedical Research Institute, a facility that specializes in research in the field of Hyperbaric Medicine. He is a Clinical Professor both at LSU Health Sciences Center and Tulane University School of Medicine.

Since 1989, Dr. Van Meter has served as the Chief of the Section of Emergency Medicine at LSU Health Sciences Center in New Orleans. He has provided steadfast leadership at Charity Hospital’s Level I Trauma Center before and during Hurricane Katrina and afterward at the Interim LSU Hospital. At University Medical Center in New Orleans, he participates in the training and education of physicians on the front lines of emergency and hyperbaric medicine.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 60 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

ABOUT CHRISTIAN J. LAMBERTSEN, MD, DSc (Hon)

Dr. Christian J. Lambertsen received a B.S. Degree from Rutgers University in 1938 and a M.D. Degree from the University of Pennsylvania in 1943. During his medical school period, he invented and first used forms of the initial U.S. self-contained closed-circuit oxygen rebreathing apparatus, for neutral buoyancy underwater swimming and diving. As a student, he aided the early Office of Strategic Services (O.S.S.) in establishing the first cadres of U.S. military operational combat swimmers. Dr. Lambertsen became a U.S. Army medical officer on graduation from medical school in early 1943, and immediately joined the O.S.S. Maritime Unit on active duty through its period of function in World War II. He joined the University of Pennsylvania Medical Faculty in 1946, and became Professor of Pharmacology in 1952. While a faculty member he combined diving research and further underwater rebreathing equipment developments for the Army and Navy. In 1967 he served as Founding President of the Undersea Medical Society (now Undersea and Hyperbaric Medical Society.) Dr. Lambertsen is recognized by the Naval Special Warfare community as "The Father of U.S. Combat Swimming.” His hand has touched every aspect of military and commercial diving. Dr. Lambertsen’s active contributions to diving began during WWII and became even more progressive in the post-war period through the evolutions of the U.S. Navy Deep Submergence and Naval Special Warfare developmental programs.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 61 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 62 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY SESSION B HBO2 THERAPY MECHANISMS Moderators:

THURSDAY, JUNE 28

Oral Presentations: 2:00 PM – 3:00 PM

Poster Presentations: Poster Session: 3:30 PM – 4:00 PM

Moderators:

Stephen Thom, MD John Feldmeier, DO

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 63 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 64 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

B 1 Thursday, June 28 ORAL PRESENTATION TIME: 2:00-2:15 POSTER PRESENTATION TIME: 3:30-4:00 RESIDENT COMPETITION: Yes

Oxygen microbubbles relieve tumor hypoxia and improve radiotherapy tumor control in a rat fibrosarcoma model Fix SM1, Papadopoulou V2, Velds H3, Slagle C3, Kasoji SK1, Rivera JN4,1, Borden MA3, Chang S4,1, Dayton PA1,2 1Eshelman School of Pharmacy, UNC Chapel Hill, Chapel Hill, NC; 2Joint Department of Biomedical Engineering, The University of North Carolina and North Carolina State University, Chapel Hill, NC; 3Department of Mechanical Engineering, University of Colorado, Boulder, CO; 4Department of Radiation Oncology, UNC Chapel Hill, Chapel Hill, NC Presenting Author: Samantha M. Fix [email protected] or [email protected]

Introduction: Hypoxia is established as a key factor in treatment failure or recurrence after radiotherapy (RT) of solid tumors. Attempts to alleviate tumor hypoxia include hyperbaric oxygen treatment (HBO), however practical administration difficulties have limited clinical translation. We propose using oxygen microbubbles (OMB), similarly formulated to micrometer-sized ultrasound vascular contrast agents but comprising an oxygen gas core.

Materials and Methods: After measuring manufactured OMB concentration, size and oxygen release potential in vitro, in vivo experiments were conducted in a validated tumor hypoxia model (Fisher 344 rats with fibrosarcoma allografts) for assessing (a) OMB tumoral reoxygenation and (b) RT outcome improvement: (a) Real-time non-invasive spectroscopic absorbance was used to assess tumor hypoxia modulation after OMB administrations (direct intratumoral (IT), intravenous (IV) or intra- peritoneal (IP) injection), where a 3min pure oxygen breathing served as a positive control, and nitrogen microbubble (NMB) administrations served as a negative control. (b) For the radiotherapy experiments, animals were divided between 5 treatment groups in a matched tumor volume study design: RT + OMB, RT alone, RT + NMB, no treatment and OMB alone. RT consisted of a single 15Gy dose of 6MV photons with a 2 by 2cm field size delivered using a clinical linear accelerator. After treatment, tumor volume was monitored longitudinally using ultrasound imaging every 3 days for 31 days. Tumor control time, defined as the time to reach the max tumor burden or 32 days for tumors below the maximum size on day 31, was compared between treatment groups.

Results: IT and IV OMB administrations were shown to transiently reoxygenate tumors, proportionally to baseline hypoxia. OMB were demonstrated to improve radiotherapy tumor control time, and the effect size was shown dependent on initial tumor volume.

Conclusions: These results offer an exciting development towards an image-guided, ultrasound- triggered oxygen release agent for RT.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 65 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

B 2 Thursday, June 28 ORAL PRESENTATION TIME: 2:15 - 2:30 POSTER PRESENTATION TIME: 3:30-4:00 RESIDENT COMPETITION: Yes

A hyperbaric and high-oxygen environment accelerates IL-6 synthesis, activates the IL-6/STAT3 pathway and suppress NFκB in rat contused skeletal muscle Oyaizu T, Enomoto M, Horie M, Yamamoto N, Yagishita K Hyperbaric Medical Center Medical Hospital of Tokyo Medical and Dental University 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8519, JAPAN Presenting Author: Takuya Oyaizu, MD [email protected]

Introduction: Hyperbaric oxygen (HBO2) treatment promotes rapid recovery from skeletal muscle injury. It was previously reported that HBO2 has an anti-inflammatory effect, accelerates macrophage infiltration and stimulates muscle regeneration in injured skeletal muscle. The mechanism mediating HBO2 needs further elaboration. Thus, injured muscle expression of anti-inflammatory substances and transcription factors was assessed during the acute phase of injury.

Materials and Methods: The rat calf muscle was contused using the drop-mass method. Rats then received either HBO2 treatment or no treatment. The HBO2 treatment protocol consisted of 2.5ATA 100% oxygen for 120 minutes, once per day for 5 days. Following euthanasia, calf muscles were obtained before injury and 3, 6, and 24 hours after contusion. Using enzyme-linked immunoassay (ELISA), the samples were homogenized and the supernatants were assayed for the myokine IL-6 and the anti-inflammatory cytokine IL-10 and transcription factors STAT3, phosphorylated and total STAT3, and NFκB.

Results: Interleukin-6 expression increased immediately after contusion, peaking 3 hours after contusion with HBO2 treatment and 6 hours after contusion without treatment. The expression of IL-10 tended to be increased with HBO2 treatment 24 hours after injury. Significantly lower levels of total STAT3 were found at 3 hours and 6 hours with HBO2 treatment compared to no treatment. Phosphorylated:total STAT3 ratio was significantly higher 3 hours after injury with HBO2 treatment. Lower levels of total NFκB were present at 6 hours after injury with HBO2 treatment.

Conclusions: The expression of IL-6 was induced earlier with HBO2 treatment, resulted in the rapid induction of STAT3 expression and activation STAT3. The anti-inflammatory effect of HBO2 treatment could be though suppression of NFκB and increased expression of transcription factors such as STAT3.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 66 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

B 3 Thursday, June 28 ORAL PRESENTATION TIME: POSTER PRESENTATION TIME: RESIDENT COMPETITION:

DUPLICATE - WITHDREW

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 67 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

B 4 Thursday, June 28 ORAL PRESENTATION TIME: 2:45-3:00 POSTER PRESENTATION TIME: 3:30-4:00 RESIDENT COMPETITION: Yes

Effects of high-intensity interval training while in a hyperbaric oxygen environment on exercise performance DeCato TW, Wilson EL, Weaver LK, Hegewald MJ Intermountain Medical Center, 5121 S Cottonwood Street, Murray, UT Presenting Author: Matthew Hegewald, MD [email protected]

Introduction: Hyperbaric oxygen (HBO2) exposure may enhance exercise performance. Both exercise training and HBO2 exposure stimulate mitochondrial biogenesis, increase capillary density, and induce adaptive antioxidant mechanisms. We hypothesized that an exercise regimen of high-intensity interval training (HIIT) while breathing HBO2 would lead to a greater improvement in exercise performance compared to the same training breathing ambient air.

Methods: Healthy long term intermediate-altitude residents (1,400 m), ages 20-39 years, with normal spirometry and cardiorespiratory fitness were randomized to two groups: one performing six sessions of an HIIT regimen over two weeks in an HBO2 chamber (1.4 ATA [141.9 kPa], FiO2=1.0); the other performing under ambient pressure conditions (0.85 ATA [86.1 kPa], FiO2=0.21). Training effect was evaluated by comparing incremental cycle ergometry cardiopulmonary exercise testing performed in ambient conditions before and after the training regimen. The primary outcome measure was peak oxygen consumption (푉̇ O2), while secondary outcomes included additional exercise parameters. Changes in exercise parameters for the two study groups were compared using t-tests. The participants who achieved >10% increase in peak 푉̇ O2 were described.

Results: Of 58 participants randomized, 49 completed the training program and all cardiopulmonary exercise tests (n = 23 HBO2, n = 26 ambient). Both groups experience an increase in peak 푉̇ O2: 8.1% HBO2 and 7.1% ambient; the differences were not significant (p = 0.72). There was no significant difference between the groups in other measures of cardiorespiratory fitness; there was a trend toward an increase in change of peak work rate and peak minute ventilation in the HBO2 group.

Conclusions: Cardiorespiratory fitness improved after a two week HIIT regimen, but the improvement was not significantly different between ambient and HBO2 groups.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 68 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

B 5 Thursday, June 28 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 3:30-4:00 RESIDENT COMPETITION: No

Aseptic condylar necrosis and hyperbaric oxygen therapy Enten G1, Camporesi EM1,2, Vezzani G3, Manelli D3, Rao N4, Mangar D2, Bernasek T5, Bosco G3 1TEAMHealth Anesthesia Research Institute, Tampa FL; 2TEAMHealth Anesthesia, Tampa FL; 3Department of Physiology, University of Padova, Italy; 4Department of Radiology, University of South Florida (USF), Tampa FL; 5Florida Orthopedic Institute, Tampa FL Presenting Author: Enrico M. Camporesi, MD [email protected]

Background: Osteonecrosis of the knee (ONK) results from ischemia to subchondral bone tissue. Most interventions are invasive. Hyperbaric oxygen therapy (HBO2) may provide a non-invasive alternative, improving oxygenation and reperfusion of ischemic areas. HBO2 has been shown to promote neovascularization and modulate pro-inflammatory cytokines in avascular necrosis of the femoral head [1]. We have evaluated the efficacy of HBO2 in a series of ONK patients.

Materials and Methods: After receiving approval from the Ethics Committee of the University of Padova, we reviewed the charts of 37 ONK patients (29 male, 8 female; mean age ±1 SD: 54±14). 83.7% of patients presented with Aglietti stage I-II; 16.3% presented with Aglietti Stage III. Patients were treated five times a week with HBO2 at 2.5 ATA with 100% inspired oxygen by mask for 60 minutes for an average of 67.9±15 sessions. Magnetic resonance imaging (MRI) was performed before HBO2, after completion of HBO2, and in 14 patients, 7 years post-treatment. Oxford Knee Scores (OKS) were recorded before HBO2 and after each HBO2 cycle.

Results: After 30 sessions of HBO2, 86% of patients experienced improvement in their OKS, 11% worsened, and 3% did not change. All patients improved in OKS after 50-90 sessions. MRI evaluation within 1 year of treatment completion showed that patient imaging at the femoral condyle had resolved in all but one patient. The 7 year follow-up MRI evaluation in 14 patients was normal in 11 patients and only minor deterioration from post-treatment evaluation was present in the remaining 3 patients.

Conclusions: HBO2 is beneficial in ONK. None of the 37 patients required total knee arthroplasty. Patients improved in pain and mobility, demonstrated by improvement in OKS. Radiographic improvements were also seen upon post-treatment follow-up. Aglietti Staging for the entire sample saw an aggregate decrease (p < 0.01) from 1.7 ± 0.7 to 0.3 ± 0.6.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 69 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

B 6 Thursday, June 28 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 3:30-4:00 RESIDENT COMPETITION: No

Hyperbaric oxygen therapy ameliorates osteonecrosis in patients by modulating inflammation and oxidative stress Camporesi E, Enten G, Vezzani G, Rizzato A, Bosco G TEAMHealth Research Institute Presenting Author: Enrico M. Camporesi, MD [email protected]

Introduction: Avascular necrosis of the femoral head (ANFH) is a result of a progressive reduction of blood perfusion within the femoral head. This results in an imbalance in bony remodeling. Etiology of the disease includes trauma, infection, and excessive use of steroids. If left untreated, ANFH may result in destruction of bony tissue and may progress to joint collapse.

Methods: Twenty-three patients were treated with two cycles of HBO2, 30 sessions each; with a 30 day break between cycles. Each session consisted of 90 minutes of 100% inspired oxygen at 2.5 ATA of pressure. Nineteen patients completed the study. Plasma levels of inflammatory markers were measured by ultrasensitive ELISA kits. An X-band EPR instrument (E-scan-Bruker BioSpin, GmbH, MA) was used for determination of ROS. ROS, IL-1β, IL-6, and TNF-α were measured before treatment (T0), after 15 and 30 sessions (T1 and T2), after the 30 day break (T3), and after 60 sessions (T4). Additionally, recovery was charted by self-reported pain scores and radiographically at each of these points of measure.

Results: All self-reported patient pain scores improved by T2. All patients’ MRI showed resolution of edema and bone marrow lesion at T4. Serum cytokine levels showed a significant reduction in TNF-α levels from T0 (111.87 ± 28.74 pg/mL) to T1 (90.32 ± 21, 26 pg/mL; p<0.01). This significant reduction remained from T0 with T2 (88.25 ± 23.32 pg/mL; p<0.001) and T3 (85.77 ± 23.72 pg/mL; p<0.01); lowest level was detected at T4 (74.46 ±11.81 pg/mL; p<0.001). Further, significant reduction in IL-6 levels between T0 (154.47 ± 30.52 pg/mL) and T1 (139.14 ± 22.82 pg/mL; p<0.0001) were observed. This significant reduction relative to the base line is also observed at T2 (131.69 ± 21.44 pg/mL; p<0.001), T3 (133.04 ± 22.50 pg/mL; p < 0.001), and T4 (133.38 ± 29.00 pg/mL; p<0.001). ROS levels increased significantly only from T0 (0.297 ± 0.075 μmol.min-1) to T1 (0.423 ± 0.116 μmol.min-1; p<0.01) followed by a gradual return to values comparable to the baseline (T3: 0.341 ± 0.072 μmol.min-1, T3: 0.307 ± 0.047 μmol.min-1, and T4: 0.274 ± 0.080 μmol.min-1). No significant difference was found between baseline IL-1β concentrations at T0 and any other point of measure.

Discussion: 60 sessions of HBO2 resulted in a decreased amount of circulating TNF-α. We propose the following mechanism: HBO2 leads to reduced levels of TNF- α leading to decreased binding of TNF- α to the p55r Type 1 receptor thus decreasing levels of RANK activation. Additionally, HBO2 enhances healing of necrotic wounds by stimulating angiogenesis, fibroblast proliferation, osteoblast proliferation, and collagen formation by increasing plasma ROS.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 70 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

B 7 Thursday, June 28 ORAL PRESENTATION TIME: POSTER PRESENTATION TIME: RESIDENT COMPETITION:

WITHDRAWN

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 71 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

B 8 Thursday, June 28 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 3:30-4:00 RESIDENT COMPETITION: Yes

Hyperbaric oxygen therapy for compromised flaps: Is there a role for delayed treatment? Francis A, Goldman JJ, Kleban SR, McNicoll CF, Mehta A, Phalke N, Doyle G, Nakhaima S, Rovig J, Williams SJ, Cross CL, Fang XH, Wang WZ, Baynosa RC University of Nevada, Las Vegas School of Medicine 1701 W. Charleston Blvd, Suite 400, Las Vegas, NV 89102 Presenting Author: Aradhana Mehta, MD [email protected]

Introduction/Background: Hyperbaric oxygen (HBO2) therapy can be used for compromised flaps. Failed flaps have significant clinical implications including flap loss, persistence of the original defect, and additional donor site with associated morbidity, and psychosocial sequelae. It is not uncommon for patients to present in a delayed fashion for salvage of the compromised tissue. The purpose of this study was to examine whether delayed HBO2 post-insult provides benefit to the threatened flap.

Materials and Methods: A dorsal rat random flap model was used. HBO2 was performed with 100% O2 @ 2.5 ATA for 90 minutes daily beginning on post-operative (POD) 7 and continued for 10 days (N=15). A control group did not receive HBO2 after surgery. Area and percentage of flap necrosis were measured between POD 7 and 17. Percentage differences between the groups were calculated, with a positive difference indicating increased necrosis. Statistical analysis was performed and p<0.05 was considered significant. Confidence intervals containing the value “0” indicate no significant differences between time periods.

Results: Decreased flap necrosis was seen to a greater extent at POD 17 following HBO2 (mean difference -5.97%) than at POD 7 (mean difference -1.78%) compared to control, but these differences were not statistically significant. Additionally, no statistical differences were found in the treatment group between days 7 and 17 (mean difference 3.29%, 95% CI=[-2.47, 9.60]). However, control subjects had a statistically significant increase in percent necrosis (mean difference 7.48%, 95% CI=[3.01, 11.67]).

Summary/Conclusions: Our data suggest there is no statistical benefit in delayed HBO2 starting at POD 7. However, the decreased necrosis, albeit a small percentage, may be clinically significant. It suggests a salvage role for HBO2, even in a delayed setting, for compromised flaps where preservation of small amounts of tissue can alter the reconstructive plan and limit further interventions.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 72 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

B 9 Thursday, June 28 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 3:30-4:00 RESIDENT COMPETITION: No

Ketosis as a neuroprotective mechanism to CNS oxygen toxicity (CNSOT) in divers exposed to high partial pressures of oxygen (PO2) Dituri J,1 Renaldo C,2 Quirk B,3 D’Agostino D,4 Ari C,5 Annis H,6 Whelan HT7 1University of South Florida, Biomedical Engineering, Tampa, FL USA; 2Conviva Physician Group, Internal Medicine, Tampa, FL USA; 3Medical College of Wisconsin, Department of Neurology, Milwaukee, Wisconsin USA; 4Metabolic Medicine Laboratory, University of South Florida, Tampa, USA; 5Hyperbaric Neuroscience Research Laboratory, University of South Florida, Tampa, USA; 6Naval Hospital Pensacola, Naval Air Station Pensacola, Florida USA; 7Medical College of Wisconsin, Department of Neurology, Undersea & Hyperbaric Medicine Program, Milwaukee, Wisconsin USA Presenting Author: Harry T. Whelan, MD [email protected]

Introduction: A significant drawback to diving at elevated PO2 is CNSOT, particularly seizures. Diver pre- treatment for seizures with conventional anti-convulsant medications, however does not prevent CNSOT seizures. Ketogenic diets can be beneficial to individuals who are afflicted with epilepsy where treatment is refractory to medication. We hypothesize that achieving ketosis either from diet or oral supplements would decrease the occurrence of seizures in those diving at higher PO2 for long durations. Ketogenic diet and supplements may act differently by decreasing oxidative stress.

Methods: This is a continuing retrospective study with divers recruited from various organizations who log dives on a secure website. Open circuit and closed-circuit rebreather divers logged data including diet (normal vs. 1.3:1 ketogenic ratio), dive depth and duration, gas mix, PO2 and symptoms specific to CNSOT and those unrelated to oxygen toxicity. Ketosis was confirmed with Ketostix. Divers logged all dives regardless of status, thus serving as their own controls.

Results: 236 dives were reported by 30 divers over the course of the study thus far. 86 of the 236 dives were in ketosis (achieved within 48hr) with no reported CNSOT symptom and 6 reported symptoms unrelated to oxygen toxicity. 150 of the 236 dives were done with a normal diet with one reported CNSOT symptom (auditory hallucinations) and 17 reported symptoms considered unrelated to oxygen toxicity. Oxygen exposure symptoms also reported included taste changes and palpitations. The average PO2 reported by divers was greater than 1.3 with the maximum reported PO2 of 2.1

Conclusion: Preliminary results demonstrate low incidence of CNSOT symptoms (1/236 dives) and symptoms unrelated to oxygen toxicity (23/236) overall. Many dives thus far were not conducted at high enough PO2 to expect CNSOT seizures, which may have led to low incidence of oxygen toxicity symptoms. More dives are required to confirm our hypothesis.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 73 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

B 10 Thursday, June 28 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 3:30-4:00 RESIDENT COMPETITION: No

Investigation of a cell-permeable mitochondrial prodrug on mitochondrial function in human blood cells from patients with CO poisoning Jang DH, Khatri UG, Kelly MP, Lambert DK, Hardy K University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104 Presenting Author: Matthew Kelly, MD [email protected]

Background: CO poisoning accounts for 50k ED visits and 2000 deaths/year. CO’s pathophysiology is multifactorial including hypoxia, oxidative stress, IR injury, endothelial injury and lipid peroxidation. Mitochondrial dysfunction has been implicated in carbon monoxide (CO) poisoning as well (Complex IV inhibition). Treatment is primarily supportive with high flow oxygen and selective use of hyperbaric oxygen therapy. Objectives: To evaluate mitochondrial dysfunction in blood cells obtained from subject with CO poisoning, and assess if succinate prodrug affects mitochondrial function in this pilot study o Mitochondrial bioenergetics: Respiration (Complex IV) o Mitochondrial dynamics: Movement, fusion, and fission Figure 2 shows a representative tracing. Methods: A prospective observational study at single site academic emergency department.  Two groups were enrolled: o (1) Carbon monoxide group: Confirmed CO Poisoning o (2) Control group: Healthy subjects Recorded clinical data including markers of end organ dysfunction, lactate levels, and mortality. Mitochondrial respiration and dynamic parameters followed by treatment (NV118). Peripheral blood mononuclear cells or PBMCs collected from all subjects. PBMCs analyzed with high resolution respirometry (OROBOROSO2K) for baseline parameters of respiration. Succinate (CII) prodrug NV118 administered to PBMCs. Parameter measurement repeated with DMSO (control). Results: PBMCs from the CO and Control groups differed in both routine and maximal respiration Conclusions: PBMCs from the Control groups differed in both routine and maximal respiration. Succinate prodrug NV118 bypassed CIV inhibition and partially supported mitochondrial function in blood cells from CO individuals. Mitochondrial-directed therapy offers a potential strategy in managing CO poisoning.

Funding: NHLBI KO8HL136858 (DJ), ONR N000141612100 (DME), ACMT Innovation award (DJ and UGK

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 74 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

B 11 Thursday, June 28 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 3:30-4:00 RESIDENT COMPETITION: Yes

Physiologic and cognitive effects of nutritional ketosis, elevated PO2 and exercise (KetOX Study) Keuski BM1,2, Freiberger JJ2, Moon RE2, Richardson C3, Natoli MJ2, Schinazi EA2, D’Agostino DP4, Kuchibhatla M2, Tomoye E2, Derrick BJ2 1United States Navy – *, +; 2Duke University Medical Center, Durham, NC; 3Richardson Keto Consulting LLC., Durham, NC; 4University of South Florida, Tampa, FL Presenting Author: Brian M. Keuski, MD [email protected]

Background: Central Nervous System (CNS) Oxygen Toxicity can cause seizures in Navy closed-circuit 100% oxygen rebreather, O2 decompression, and mixed gas diving operations. The U.S. Navy Dive Manual (Rev. 7) allows for 25 minutes dive time at 2.1 ATA PO2 (100% O2, 35 fsw). Previous studies demonstrated an increased latency to seizure in animals with elevated serum ketone levels achieved through starvation, diet modification, or ketone supplementation. Ketogenic diet (high fat, scarce carbohydrate, adequate protein) has been used to treat epilepsy in children and adults. There are limited human pathophysiologic data in divers suffering CNS oxygen toxicity. We will investigate the physiologic and cognitive effects of Nutritional Ketosis (NK), Elevated PO2 and Exercise.

Methods: Fifty human subjects will be studied over 3 years in this prospective, randomized, blinded, controlled study with crossover. Subjects conduct two closely monitored “head-out” dives, with and without nutritional ketosis, to a PO2 of 2.1 ATA (100% oxygen at 35 FSW) while exercising at 50 watts on a cycle ergometer until manifestation of CNS O2 Toxicity. Physiologic and cognitive parameters will be evaluated and compared between groups and individual crossover subjects. Height, weight, BMI, percent body fat, age, gender, pH, serum electrolytes, ECG intervals, urine acetoacetate, serum beta-hydroxybutyrate, pulmonary function testing, PaO2, PaCO2, heart rate and blood pressure (measured in real time via arterial catheter), continuous expiratory gas sampling and respiratory changes (by mass spectrometry), continuous electrocardiogram, standard and quantitative electroencephalogram (qEEG), cognitive performance assessment with NASA’s Multi- Attribute Task Battery II (MATB-II) software, and assessment of various ketone monitors for accuracy and consistency will be analyzed.

Summary: This adds to our understanding of the effects of high PO2, nutritional ketosis and exercise as related to cardiac output, hyperoxic hyperpnea, oxygen narcosis and toxicity, mapping of affected brain regions, and multitasking cognitive performance.

Acknowledgment: Funded by NAVSEA Contract: N0002418C4315 *-The views expressed in this article are those of the author(s) and do not necessarily reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government. “I am a military service member (or employee of the U.S. Government). This work was prepared as part of my official duties. Title 17, USC, §105 provides that ‘Copyright protection under this title is not available for any work of the U.S. Government.’ Title 17, USC, §101 defines a U.S. Government work as a work prepared by a military service member or employee of the U.S. Government as part of that person’s official duties. +-The study protocol was approved by the Duke University Hospital Institutional Review Board in compliance with all applicable Federal regulations governing the protection of human subjects.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 75 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

B 12 Thursday, June 28 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 3:30-4:00 RESIDENT COMPETITION: Yes

Supraventricular tachycardia during hyperbaric oxygen treatment Mihai A, Morgan M, Heyboer M SUNY Upstate Medical University, 750 East Adams St, Syracuse, NY 13210 Presenting Author: Aurel Mihai, MD [email protected]

Introduction: Typical cardiovascular changes with hyperbaric oxygen treatment (HBO2) include increased peripheral vascular resistance, decreased cardiac output, and bradycardia. There are isolated reports of atrial fibrillation following HBO2, tachycardia during prolonged hyperbaric air exposure, and pulmonary edema during HBO2 in patients with systolic heart failure, but there are no reports of supraventricular tachycardia (SVT) during HBO2.

Materials and Methods: 48 year old male with Wagner grade 3 right-sided diabetic foot ulcer (DFU), Charcot deformity, osteomyelitis, peripheral artery disease, hypertension, hyperlipidemia, diastolic heart failure, and hypothyroidism presented for initial HBO2 at 2.0 ATM for 90 minutes. Treatment course was unremarkable until decompression. At 7-8 PSI before completion he felt “funny” and reported tachycardia. Otherwise review of systems was normal. On exam he was diaphoretic and tachycardic. Bedside monitor rhythm strip showed a heart rate in the 180s with an atrial rhythm consistent with SVT. He was rushed to the emergency department where the first 12 lead EKG subsequently showed sinus tachycardia at 101 with PACs and he had become asymptomatic.

Results: The patient was admitted and showed neither return of symptoms nor arrhythmia. He was cleared by cardiology and HBO2 restart was recommended. Unfortunately, the patient refused further treatment.

Summary/Conclusions: There are several plausible reasons for this patient’s SVT. Anxiety may have precipitated the SVT, but this is unlikely since the patient denied this, the provider did not identify any clinical signs, the tachycardia presented late in treatment, and the degree of tachycardia was excessive. Heart failure decompensation was unlikely due to normal cardiac enzymes and no associated findings of pulmonary edema. Rebound tachycardia has only been described after multi-day hyperbaric dives. There is no convincing etiology for this patient’s SVT. Future cases should be recorded and reported so that a common cause may be discovered.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 76 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

B 13 Thursday, June 28 ORAL PRESENTATION TIME: POSTER PRESENTATION TIME: 3:30-4:00 RESIDENT COMPETITION: Yes

Ketogenic diet for reduction of CNS oxygen toxicity in working divers (KetOX Study) Keuski BM1,2, Freiberger JJ2, Moon RE2, Richardson C3, Natoli MJ2, Schinazi EA2, D’Agostino DP4, Kuchibhatla M2, Tomoye E2, Derrick BJ2 1United States Navy – *, +; 2Duke University Medical Center, Durham, NC; 3Richardson Keto Consulting LLC., Durham, NC; 4University of South Florida, Tampa, FL Presenting Author: Brian Keuski, MD [email protected]

Background: Central Nervous System (CNS) Oxygen Toxicity can cause seizures in Navy closed-circuit 100% oxygen rebreather, O2 decompression, and mixed gas diving operations. The U.S. Navy Dive Manual (Rev. 7) allows for 25 minutes dive time at 2.1 ATA PO2 (100% O2, 35 fsw). Previous studies demonstrated an increased latency to seizure in animals with elevated serum ketone levels achieved through starvation, diet modification, or ketone supplementation. Ketogenic diet (high fat, scarce carbohydrate, adequate protein) has been used to treat epilepsy in children and adults. Utilizing an operationally feasible nutritional ketotic (NK) state, we seek to compare latency to CNS O2 toxicity between regular versus ketogenic diets in divers breathing 100% oxygen.

Methods: This is a prospective, randomized, blinded, controlled study with crossover. Fifty human subjects will be studied (10 pilot phase + 40 study phase) over three years. Each subject will perform two “head-out” dives (one regular diet (RD), one ketogenic diet) to a PO2 of 2.1 ATA (100 % O2 at 35 FSW) with exercise, until the first manifestation of CNS oxygen toxicity (max 2 hours). Urine acetoacetate and serum beta-hydroxybutyrate will be used to confirm NK. Subjects will log their dietary intake and ketogenic diet subjects will consume a ketone supplement (similar placebo in RD) one hour prior to dive. The order/diet of subjects (NK vs RD) will be randomized and blinded. Outcomes include time to first symptom of CNS oxygen toxicity analyzed by survival analysis, and / or logistic regression.

Summary: If our hypothesis is confirmed, the ketogenic diet will expand the operational limits for high PO2 diving and improve diver and warfighter safety by adding to our understanding of human physiology related to CNS O2 toxicity.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 77 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

B 14 Thursday, June 28 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 3:30-4:00 RESIDENT COMPETITION: No

Last resort salvage of failed below-knee amputations Strauss MB, Lu LQ Memorial Care Long Beach Medical Center 2865 Atlantic Ave, Long Beach, CA 90806 Presenting Author: Michael Strauss, MD [email protected]

Introduction The consequence of failed transtibial amputations with short remaining tibia is an above- knee amputation (AKA). This has important ramifications regarding mobility, energy requirements for ambulation and function. Our protocol has been employed to maximize the likelihood of healing and maintaining a functional knee joint.

Methods Five severely vasculopathic patients with failed short transtibial (TT) amputations and greater than 60 degree knee flexion contractures were followed progressively with resecting the remaining fibula, releasing the hamstring insertions, debridement of bursa & cicatrix, osteotomy & beveling of the distal end of the tibia, creative flap closures, and maintenance of knee extension with pins or external fixation across the knee joint. All patients were referred for more proximal amputations, but wanted everything possible be done to salvage their knee joints. Four of the five patients were diabetic; one was a smoker with osteomyelitis at the end of the tibia.

Results Salvage of the knee joint occurred in 4 of 5 patients (80%) even though the remaining tibia lengths were 5 cm or less. Threaded 3/16th inch Steinmann pins placed cross-wise through the knee joints were used in 4 patients and an external fixator in a 5th patient. The pins remained for 3 to 6 weeks. Four of the 5 patients achieved healing with 2 of the 4 having initial minor wound dehiscences. The 4 patients who avoided an AKA were able to be fitted with TT prostheses and use them in a functional capacity.

Conclusions Our approach to salvage failed TT amputations served the purposes of maintaining knee extension during the healing period, allowing closure & healing of threatened and/or dehisced flaps and maintaining knee function. Motivated, compliant patients with failed; otherwise considered non- salvageable TT amputations should be considered for using our protocol in deference to proceeding to an AKA.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 78 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

B 15 Thursday, June 28 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 3:30-4:00 RESIDENT COMPETITION: No

Decompression sickness in the multiplace hyperbaric chamber attendant Koca E, Mirasoglu B Department of Underwater and Hyperbaric Medicine, Sakarya University Education and Research Hospital, Sakarya, Turkey; Department of Underwater and Hyperbaric Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey Presenting Author: Eylem Koca, MD [email protected]

Introduction: Decompression sickness (DCS) is an acute condition that occurs when the environmental pressure is sufficiently reduced to cause inert gas bubbles. Hyperbaric inside attendants may face risk of DCS due to their work.

Materials and Methods: To evaluate a specific case of DCS in a hyperbaric inside attendant routinely exposed to hyperbaric conditions.

Result: A patient who was receiving hyperbaric oxygen (HBO2) therapy due to a compromised flap was accompanied by our hyperbaric nurse as the inside attendant. The nurse was regularly exposed hyperbaric conditions every other day. The treatment profile was at 2.4 - 2.5 ATA. Both patient and attendant remained for 100 minutes, with a 15-minute compression and a 15-minute decompression. Approximately 25-30 minutes after finishing the HBO2 session, the attendant complained of joint pain in her right shoulder. A diagnosis of DCS was made based on her symptoms and her complete history. She received immediate recompression therapy in our multiplace chamber, with resolution of symptoms.

Conclusion: Hyperbaric inside attendants may be at risk for DCS. The diagnosis of DCS is based entirely on clinical manifestations. The treatment for DCS is recompression therapy. To reduce DCS risk chambers should take preventive measures, such as reducing the frequency of hyperbaric exposures, having more staff available, and utilizing oxygen breathing.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 79 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

PLENARY SESSION: MECHANISMS OF HBO2 4:00 PM – 5:00 PM

Stephen Thom, MD "Hyperbaric oxygen therapy cell signaling and mechanisms of action"

This lecture will summarize current knowledge on mechanisms of action for hyperbaric oxygen (HBO2) therapy. Information will include findings from peer-reviewed publications involving both animal and human studies. It will emphasize data from human investigations, with a focus on those actions most relevant to clinical HBO2 indications.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 80 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

FRIDAY, JUNE 29

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 81 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 82 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

PLENARY: RESEARCH AND REGISTRIES FOR HYPERBARIC OXYGEN THERAPY 8:00 AM – 10:00 AM

8:00 – 8:30 Caroline Fife, MD "The Hyperbaric Oxygen Therapy Registry and the role of a qualified clinical data registry in protecting reimbursement"

The field of hyperbaric oxygen therapy and hyperbaric practitioners are under unprecedented scrutiny, with a resulting 50% decrease in HBO2 utilization nationally. Most practitioners are now subject to The Merit Based Incentive Payment System (MIPS), which requires the submission of quality measures. Qualified Clinical Data Registries (QCDRs) can develop specialty-specific quality measures and transmit data to CMS on behalf of clinicians, increasing the opportunity for bonus payments.

The HBOTR, through the USWR, offers specialty registry participation as part of MIPS. Registry participation is possible via automated transmission of Continuity of Care Documents (CCDs) which can enable national benchmarking of many key parameters and can address patient selection bias for other types of registry participation by providing a “denominator” for patients/conditions treated. QCDRs manage identified data and can link to the Medicare data warehouse, facilitating HBO2 cost effectiveness research. Patient-reported questionnaires can be enshrined as quality measures, enabling practitioners to realize a small reimbursement benefit for performing them. Provider scores on specialty-specific quality measures are publicly available via the USWR website linked to “Physician Compare,” a welcome alternative to star ratings derived only from standard (and irrelevant) MIPS measures. Hyperbaric Centers may also benefit from quality measure reporting. The HBOTR leverages current mandatory reporting quality requirements and available electronic health record technology to automate registry participation, an important consideration given the lack of funding for HBO2 research.

The HBOTR has already saved physician payment from a substantial reduction and can be harnessed for clinical research. Since January 2012, data on 27,404 patients has been captured. Among the 62,843 DFUs with data, 9,908 DFUs (15.7%) were treated with HBO2 therapy, although in 2017, the benchmark rate for HBO2 was 7.3%, with an average of 28 treatments per patient. There are 2,100 providers who report data to the USWR by transmitting CCDs from their EHR and 688 who submit quality measure data, 300 (43.6%) of whom transmit HBO2 quality measure data.

8:30 -9:00 Jay Buckey, MD "The hyperbaric medicine registry at Dartmouth"

The value of hyperbaric oxygen is being questioned even for well-established UHMS- approved indications. Although every hyperbaric center treats cases for established indications, the outcomes are not gathered together at a central site, analyzed, and published. As a result, outcome data for hyperbaric oxygen are limited and hard to find. An outcomes registry collects outcomes data from multiple sites consistently, which could allow for more powerful analyses, and more widely accessible results. This talk will describe the outcomes-focused hyperbaric registry currently in use at Dartmouth, and how it could be used to advance the field of hyperbaric medicine.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 83 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

9:00 – 9:30 Judy Rees, MD, PhD "The role of registries in medicine"

The goal of a disease or treatment registry is to document important data systematically from a sample of patients and use it to make inferences to a larger population. This presentation will consider how registries can be used, some of the pitfalls awaiting the unsuspecting registry researcher; and approaches that will give the best chance of success.

9:30 – 10:00 PANEL DISCUSSION

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 84 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY SESSION C Diving and Decompression Illness Moderators:

FRIDAY, JUNE 29

Oral Presentations: 10:30 AM – 11:30 AM

Poster Presentations: Poster Session: 11:30 AM – 12:30 PM

Moderators: Nick Bird, MD Bruce Derrick, MD

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 85 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 86 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

C 1 Friday, June 29 ORAL PRESENTATION TIME: 10:30-10:45 POSTER PRESENTATION TIME: 11:30-12:00 RESIDENT COMPETITION: No

CNS oxygen toxicity – models vs. practice Garbino A, Walker S, Sanders R NASA NBL Presenting Author: Alejandro Garbino, MD [email protected]

Introduction/Background: Hyperbaric CNS oxygen toxicity (CNS OxTox) is a risk with hyperbaric oxygen exposures. It can lead to various clinical symptoms, with the highest concern being seizures. OxTox seizures are rare in hyperbaric oxygen (HBO2) therapy, however, the risk for a given oxygen exposure appears to be much higher during diving operations and is thought to be in part due to increased metabolic loads. OxTox seizures are relatively straightforward to manage in a hyperbaric chamber, but during dive operations can be fatal.

Materials and Methods: We conducted a retrospective analysis of 4420 dives over the course of 13 years at the Neutral Buoyancy Lab, and compared them to published models of oxygen toxicity in diving operations. No oxygen toxicity events were observed, despite close medical monitoring pre, during and post dive.

Results: At least 581 of the dives (13.1%) exceeded published NOAA limits, depending on the exact interpretation of the limits. Some published models and NOAA operational guidance is significantly more conservative than NBL dive operations, with expected cases even at the relatively low ppO2 of NBL exposures. However, no data at ppO2 higher than ~ 1.1 ATA was obtained as a result of the relatively shallow dive operations.

Summary/Conclusions: This data set shows that NOAA operational limits, and some published oxygen toxicity models appear to be overly conservative at low ppO2 exposures, which may result in poor estimates at higher ppO2 levels. This highlights the need for more operational data at higher exposures. Collecting and publishing this data can lead to better models of oxygen toxicity and thus better operational guidelines during dive operations.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 87 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

C 2

ORAL PRESENTATION TIME: POSTER PRESENTATION TIME: RESIDENT COMPETITION:

WITHDRAWN

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 88 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

C 3 Friday, June 29 ORAL PRESENTATION TIME: 10:45-11:00 POSTER PRESENTATION TIME: 11:30-12:00 RESIDENT COMPETITION: No

Recreational diving-related injuries among insured Divers Alert Network Japan members: Retrospective analysis of 321 cases from 2010 to 2014 Kojima Y1,2,3, Suzuki S1,4, Niizeki Y1,2,5, Kojima A1, Kawaguchi H1, Yagishita K1,2 1Divers Alert Network Japan (DAN JAPAN) / Japan Marine Recreation Association; 2Hyperbaric Medical Center, Medical Hospital of Tokyo Medical and Dental University; 3Medical Department #2, Tokio Marine & Nichido Medical Service Co., Ltd.; 4Department of Emergency and Trauma, Kameda Medical Center 5Department of Orthopedic Surgery, Soka Municipal Hospital Presenting Author: Yasushi Kojima, MD [email protected]

Introduction: It is essential to monitor the trends in diving injuries to plan effective strategies for diving safety. Membership of Divers Alert Network Japan (DAN JAPAN) automatically includes insurance, covering losses from recreational diving injuries. In this study, we investigated recreational diving- related injuries among insured DAN JAPAN members.

Materials and Methods: The study was performed as a retrospective records review. There were 325 recreational diving related injuries between January 1, 2010 and December 31, 2014 reported to DAN JAPAN for insurance claims. We analyzed 321 cases, excluding four fatal cases. There were 153 males and 168 females. Mean age was 46 years old (range: 20–77 years). We investigated the diving locations, diagnoses, usage frequency of a hotline service, incident frequency and delays in treatment of decompression illness (DCI). Incidence was calculated based on the number of members at the end of each year.

Results: In 236 cases, the diving location was Japan and in 85 cases it was overseas. The diagnosis was DCI in 109 cases (34%), barotrauma in 39 cases (12%), injury due to hazardous marine life in 20 cases (6%), trauma in 112 cases (35%), other causes in 20 cases and unknown in 21 cases. A hotline service was used in 24 cases, including 16 DCI cases. The DCI incidence rate was 13.5 cases (male 11.8, female 16.0) per 10,000 member-years. Twenty cases (18%) of DCI underwent recompression treatment at hospital within 24 hours after onset.

Conclusions: DCI accounts for one-third of the total number of injuries, and the most common diagnosis was trauma. Actions to prevent injuries other than DCI are also important. The hotline service was used and early recompression treatment commenced in less than one-fifth of DCI cases.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 89 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

C 4 Friday, June 29 ORAL PRESENTATION TIME: 11:00-11:15 POSTER PRESENTATION TIME: 11:30-12:00 RESIDENT COMPETITION: No

Pulmonary fluid shifts are a common result of scuba diving exposures Sanders RW, Williams S, Ray K University of Texas, Medical Branch, 201 University Ave Galveston TX 77555 Presenting Author: Robert Sanders, MD [email protected]

Objective: Immersion pulmonary edema (IPE) is a rare but life threatening complication of diving, where fluid shifts to the lung become pathologic. In this study, we aim to better classify the normal physiology of diving by determining the occurrence of fluid shifts in the lungs resulting from commercial diving work at NASA’s Neutral Buoyancy Laboratory (NBL) using ultrasound (US). These findings help to broaden the understanding of the occurrence of IPE.

Methods: In this controlled, prospective study, a chest US was used to evaluate for the baseline presence and resultant occurrence of B lines in divers working at the NBL. Per our protocol, each US study was performed by a board certified emergency physician with ultrasound fellowship training, serving as co-investigator. The US evaluated 12 intercostal points on the anterior, lateral and posterior aspects of the chest wall. Each subject had an US examination prior to entering the pool, followed by a second US examination by the same investigator within 30 minutes of leaving the pool. The number of B lines (B line score) in each of the 12 predetermined points was recorded in real time, and any increase in the number of B lines was considered a positive study. Each US clip obtained was later reviewed by another physician for the presence or absence of B lines.

Results: A total of 50 pre- and post-US studies were completed during the study period. The B line score was 0.02 + 0.14 pre-dive and 0.66 + 0.77 post dive (p<0.0001). One pre dive US was positive with one B line in one intercostal space; all other US scans were negative. Of the 50 post dive US scans, 24 were positive with 1-2 B lines in at least one intercostal space. Seven of the positive studies had B lines in 2 intercostal spaces and the remaining 17 only in one intercostal space. None of the divers had complaints of shortness of breath or coughing at any time during the study.

Conclusions: Immersion pulmonary edema has been described in less than 2% of swimmers and divers and is characterized by rapid onset of shortness of breath and cough. From our results, non-pathologic fluid shifts, as confirmed by the emergence of two B lines or less in one intercostal space (likely resulting from immersion) could be viewed as a normal, transient, physiologic process in commercial divers. Further study of US B lines in symptomatic divers may yield the usefulness of field US in the diagnosis and treatment of IPE.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 90 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

C 5 Friday, June 29 ORAL PRESENTATION TIME: 11:15-11:30 POSTER PRESENTATION TIME: 11:30-12:00 RESIDENT COMPETITION: No

Analysis of 500 self-reported recreational scuba diving incidents Buzzacott P, Bennett CM, Denoble PJ Divers Alert Network, Durham, North Carolina, USA Presenting Author: Peter Buzzacott, PHD [email protected]

Background: Voluntary reporting of diving incidents may provide details missed in fatality data, including the chain of events and root causes. We analysed the first 500 compressed gas incident reports collected September 2012 through February 2018 through the Diving Incident Reporting System (DIRS).

Methods: Reporters were prompted to describe divers’ training and experience, equipment, environment, profile, unplanned incidents and outcomes. Divers may opt to leave contact information in which case follow-up questions were possible.

Results: The types of incidents reported by divers often involved rapid ascents (15%), running out of gas (8%), loss of buoyancy control (5%), or starting the dive with the tank valve not fully open (2%). Seventy- five percent of reports involved an injury. In running out of gas incidents, proportionally more injuries were reported when consequential ascents were rapid than when ascents were controlled. The majority were reported by the diver who experienced the incident, most commonly within one month of the incident occurring. Of the divers in this study, 68% were male, and mean age was 45 years. Around half the incidents happened during the diver’s first visit to the dive site, often on the first day of a dive series, most often within the first year or two since certification. Most divers were in a group or with a buddy, engaged in a diving activity they reported having prior experience in. More than half the dives occurred during the day, in the sea, in water that would be considered warm (>20oC), with moderate/excellent visibility. More than half also occurred while diving from boats.

Conclusions: New dive sites or the start of a dive series featured in reported diving incidents, the majority of which resulted in self-reported injuries. Pre-dive safety checks and paying close attention to remaining gas pressure throughout diving may prevent many incidents.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 91 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

C 6 Friday, June 29 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 11:30-12:00 RESIDENT COMPETITION: No

Risk factors for middle ear barotrauma in subjects undergoing hyperbaric oxygen therapy Hatch JL, Wieland AM, High R, Cooper JS UNMC 981150 NMC Omaha NE 68198 Presenting Author: Jeffrey Cooper, MD [email protected]

Objective: To identify risk factors for middle ear barotrauma in patients undergoing hyperbaric oxygen therapy in a monoplace chamber.

Study Design: Retrospective Case-Control Study

Setting: Tertiary Academic Center

Subjects and Methods: Data were collected from all patients who received hyperbaric oxygen (HBO2) therapy from Jan. 2007 to Dec. 2011. Patients were divided into two groups; those who required tympanostomy (PE) tubes (study group) and those who did not (control group). Additional data points collected were age, gender, body mass index, indications for HBO2, history of head and neck surgery for malignancy, history of head and neck radiation, other body radiation, chemotherapy, altered mental status, prior ear surgery, tonsillectomy, adenoidectomy, antibiotics, intubation, smoking status and diabetes mellitus. A statistical analysis of the two groups was completed

Results: There were 337 patients included in study. 24.7% (n=68) patients required PE tubes and 75.3% (n=275) did not. There was a statistically significant association between a history of smoking (35.3% vs. 64.7%, p=0.001) and advanced age (53.3 vs. 60.7 years, p < 0.001) and the need for PE tubes. When combined in a logistic regression analysis there was a dependent relationship between smoking status, and advancing age. Other risk factors did not meet significance including prior head and neck irradiation or surgery, indications for HBO2, or intubation status.

Conclusions: Age and smoking status are risk factors contributing to middle ear barotrauma and PE tube placement. Smoking has not been previously described as such.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 92 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

C 7 Friday, June 29 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 11:30-12:00 RESIDENT COMPETITION: No

A decompression stop for fishermen divers of the Yucatán Peninsula Chin W, Lik U, Huchim O, Markovitz G, Galovich J UCLA Radiation Oncology/ UCLA Health 200 Medical Plaza Ste B265-110 Presenting Author: Walter Chin, RN/CHRN [email protected]

Introduction/Background: In the Yucatan Peninsula, small-scale artisanal fishermen divers (FD) dive for subsistence using hookah systems to breathe compressed air. Decompression illness is endemic among these FD. We report the dive behavior of 16 small-scale FD in a longitudinal five-year study.

Materials and Methods: This study, approved by the UCLA IRB 2 (#13-000532), was conducted over 4 fishing seasons between 2012 and 2016. 16 consenting, male fishermen between the ages of 41-49, were instructed to attach census Ultra dive recorders to their waists during dives throughout the study period. We created a subroutine in RStudio that extracted parameters of pressure, time, date, start of dive, end of dive. The data was tabulated into single row outputs. Daily dive profiles were generated using an exponential decay formula. Nitrogen loading pressures for nine theoretical compartments and final nitrogen pressures were calculated after controlling for theoretical compartments, trial first stop (TFS), and time at first stop.

Results: 4,961 dives were completed over 1,758 diving days. The average TFS was at 8.76 feet of sea water, with an average required decompression time of 42.44 minutes. Starting at 40 minutes, gas tissue was controlled for 98% of all the dives.

Parameter n Mean S.D. Median TB1 1758 97.61 52.4 88 TB2 1392 60.4 36.25 54 TB3 938 45.75 29.52 41 TB4 491 34.23 24.19 28 TB5 252 26.55 20.37 21 FSW1 1757 40.87 18.4 37 FSW2 1392 42.44 18.8 40 FSW3 933 42.94 19.9 40 FSW4 491 44.24 20.56 42 FSW5 252 43.79 21.1 41.5

Summary/Conclusions: These results indicate the necessary level of decompression and will serve as a future intervention for FD. There will be further investigation into intervention feasibility.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 93 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

C 8 Friday, June 29 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 11:30-12:00 RESIDENT COMPETITION: No

Upper- and lower-extremity altitude chamber DCS Hayes WA Undersea and Hyperbaric Medicine Clinic, Brook Army Medical Center Presenting Author: Lt Col William A Hayes II, DO, MPH [email protected]

Introduction/Background: The United States Air Force exposes aviators to controlled altitude pressure changes for hypoxia and decompression training. All chamber participants will pre-breath oxygen to reduce the accumulation of tissue nitrogen. The peak altitude is 25,000 feet so that hypoxia can be recognized. As they are exposed to environments that will place them at risk for DCS, the altitude chamber becomes a platform for observing the prevalence and patterns of symptoms while controlling most other environmental variables.

Materials and Methods: A medical record review was completed from January 2011 to February 2015 for data collection. Specific criteria was established to include symptoms of upper extremity, lower extremity, or both upper and lower extremity DCS. A Chi-Square Test for Equal Proportions was applied for statistical analysis.

Results: This study recognized a total of N=75 cases that met specific criteria with 27 cases of upper extremity DCS, 41 cases of lower extremity DCS, and 7 cases involving both upper and lower extremity DCS. A Chi-Square Test for Equal Proportions was applied resulting in a value of 23.36 and a p-value of less than 0.0001.

Summary/Conclusions: 36% of the cases had upper extremity DCS, 55% of the cases had lower extremity DCS, and 9% of the cases had both upper/lower extremity DCS. The Chi Square Test for Equal Proportions is a statistical method to test the null hypothesis. In this study, the p-value is less than 0.0001 which is statistically significant. This study supports that altitude chamber exposure poses a risk for the development of DCS and that pre-breathing oxygen does not entirely eliminate that risk. This study also strongly supports that lower extremity DCS is more likely to develop than upper extremity DCS after altitude chamber exposure.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 94 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

C 9 Friday, June 29 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 11:30-12:00 RESIDENT COMPETITION: No

Who’s listening? Ear health and diving: Data from 790 divers St Leger Dowse M, Waterman M. Jones R, Smerdon GR DDRC Healthcare, Plymouth Science Park, Research Way, Plymouth PL6 8BU, Devon, United Kingdom Presenting Author: Marguerite St Leger Dowse [email protected]

Introduction: Ear health and the observation of medical recommendations are important for safe SCUBA diving. Ear disorders in divers, including eustachian tube dysfunction (ETD), are commonly observed. Data were gathered to observe the prevalence of ear disorders and awareness of ear health recommendations for scuba divers the UK.

Methods: An anonymous online survey was publicized through diving exhibitions and social media. Measures included diver and diving demographics and the validated Eustachian Tube Dysfunction Questionnaire 7 (ETDQ-7), within which a mean score of >2 indicates the presence of dysfunction. Information pertaining to pre-existing ear health conditions, medications (including decongestants), and knowledge of diving and ear health guidance, were sought.

Results: A total of 790 divers (64% males, 36% females) responded (age range 16 – 80, median 47). Using the ETDQ-7 mean ETD scores of >2 were calculated in 40% (315/790) of respondents indicating varying degrees of ETD. Pre-existing ear conditions were reported in 18% (56/315) of this group.

Ear disorders since learning to dive were recorded by 80% (628/790) of respondents, with external, middle, and inner ear issues being reported. ETDQ-7 scores of >2 to 6.57 were reported by 47% (293/628) of this group. There were six reports of inner ear decompression sickness (IEDCS). Medical advice was not sought by 46% (291/628) of the respondents who reported ear problems.

Decongestants were used by 23% (183/790), with use before every dive reported by 5%. Thirty-five percent had aborted a dive due to ear problems.

Only 27% (214/790) of respondents were aware of the United Kingdom Diving Medical Committee (UKDMC) guidance regarding ear health and diving.

Conclusion: Ear problems and ETD since diving were widely reported in this cohort of divers, with not all divers in this study aware of ear health recommendations and advice.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 95 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

C 10 Friday, June 29 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 11:30-12:00 RESIDENT COMPETITION: No

Ten-year period prevalence of decompression illness among small- scale fishermen divers Chin W, Ramachandran M, Huchim-Lara O UCLA - Department of Hyperbaric Medicine Presenting Author: Walter Chin, RN/CHRN [email protected]

Introduction/Background: Decompression illness is endemic among fishermen divers (FD) in Yucatan Peninsula. We wanted to calculate what the ten-year period prevalence was among FD of the Yucatan Peninsula. Materials and Methods: Retrospective review of recompression treatments (1998-2007) conducted among FD in Tizimin Hyperbaric program. Input variables were extracted from treatment log books and digitized in Excel. Input variables collected were name, date of treatment, time fishing village, medical record number (MRN), age, and fishing Season. A subroutine was created in R-Studio that sorted and data by fishing village, then FD name, then age. The program then would assign a unique identification number to each unique FD. The program was recursive in that it would sweep through the entire data to match FD by name, fishing village, and age. We then examined the database to assess whether there where inconsistencies between records that were assigned the same ID. If inconsistencies were found, they were highlighted for further analysis and resolution. Database was validated by the local PI. DCS incidences were defined as treatments separated by 7 days or more. A ten-year window (1998 to 2007) was selected for analysis of period prevalence. A year to year prevalence was calculated. FD were excluded from the pool of distinct divers if they were over the age of 60 or under the age of 18 during the year of analysis. From this restricted dataset, total number of distinct fishermen as well as total treatments and DCS events were tabulated. Results:

Summary/Conclusions: The data yielded from these methods reveal several remarkable findings. Firstly, a general upward trend in period prevalence is observed despite smaller populations of unique divers in later years of the 10-year observed period. Additionally, total treatments and thus number of DCS hits observed, does not appear to vary as a function of temporal increase, and instead varies with no apparent correlation. According to the Divers Alert Network (DAN), approximately 1000 of the 3 million divers in the US, contract DCS annually. This suggests that a standard period prevalence for DCS is approximately 0.0003. The observed period prevalence for all recorded years is significantly higher than this defined standard period prevalence. These findings highlight the need for further research and analysis in the diving behaviors of fishermen divers with the hopes of increasing awareness of safe and sustainable diving practices and ultimately avoiding unnecessary deaths. References: Thalmann, E D. “Decompression Illness: What Is It and What Is the Treatment?” Mar. 2004. Alert Diver.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 96 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

C 11 Friday, June 29 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 11:30-12:00 RESIDENT COMPETITION: No

Cerebrovascular responses to thermoneutral head-out water immersion Schlader ZJ, Sackett JR Center for Research and Education in Special Environments, Department of Exercise and Nutrition Sciences, University at Buffalo, Buffalo, NY Presenting Author: Blair D. Johnson, PHD [email protected]

Introduction/Background: Thermoneutral head-out water immersion (HOWI) reduces total peripheral resistance (TPR) and increases arterial carbon dioxide (CO2) content. Middle cerebral artery blood velocity (MCAv) increases during hypercapnia and HOWI. We tested the hypotheses that cerebrovascular conductance and CO2 cerebrovascular reactivity would be elevated during HOWI.

Materials and Methods: Ten healthy subjects (age: 23±3 years, BMI: 26±3 kg/m2, 5 women) participated in one 60-minute thermoneutral (35C) HOWI study visit. PETCO2 (capnography), MCAv (transcranial Doppler), and mean arterial pressure (MAP, photoplethysmography) were measured throughout the trials. TPR was calculated by dividing MAP by cardiac output (calculated using heart rate and stroke volume derived from Modelflow). CO2 cerebrovascular reactivity was assessed using CO2 rebreathing (rebreathe 7% CO2, 93% oxygen from a 10 L anesthesia bag for 3.5 minutes) at baseline, 10, 30, and 60 minutes of each trial. CO2 cerebrovascular reactivity was calculated as the slope of the linear regression line of MCAv vs. PETCO2. Cerebrovascular conductance was calculated as the quotient of MCAv and MAP.

Results: PETCO2 was greater than baseline (423 mmHg) at 10 (442 mmHg, P<0.01), 30 (441 mmHg, P=0.02) and 60 min (452 mmHg; P<0.01). MCAv was greater than baseline (5819 cm/s) at 10 (6319 cm/s; P<0.01) and 30 min (6221 cm/s; P=0.01). TPR was lower than baseline (15.41.9 mmHg/L/min) at 10 (12.31.6 mmHg/L/min; P<0.01), 30 (12.61.6 mmHg/L/min; P<0.01), and 60 min (13.31.9 mmHg/L/min; P=0.01). CO2 cerebrovascular reactivity did not change from baseline throughout the trial (baseline: 1.780.70 cm/s/mmHg; 10 min: 1.510.46 cm/s/mmHg, P=0.09; 30 min: 1.610.56 cm/s/mmHg, P=0.24; 60 min: 1.660.57 cm/s/mmHg, P=0.67). Cerebrovascular conductance was greater than baseline at 10 min (0.650.25 vs. 0.730.24 cm/s/mmHg; P=0.02).

Summary/Conclusions: Increases in MCAv during HOWI appear to be due to reductions in TPR, including the cerebrovasculature.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 97 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

C 12 Friday, June 29 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 11:30-12:00 RESIDENT COMPETITION: No

Rater reliability of a transthoracic bubble study among fishermen divers of the Yucatán Peninsula Chin W, Huchim O, Endo B, Medak A, Ramachandran M, Popa D UCLA/UCLA Health Radiation Oncology 200 UCLA Medical Plaza Ste B265-29, Los Angeles California 90095 Presenting Author: Walter Chin, RN/CHRN [email protected]

Introduction/Background: Decompression illness (DCI) is endemic among fishermen divers (FD) of the Yucatán. We sought to assess interrater reliability of a transthoracic (TTE) bubble study conducted among FD with a known history of DCI.

Materials and Methods: The study was approved by Marista University of Mérida IRB #CE_009_2017. Risk and benefits were explained to each consenting subject. Fifty subjects were taught a modified valsalva (MV). An 18-gauge angiocatheter was inserted into the antecubital vein. A 3-way stopcock and two 10 mL syringes (2.5 mL of air, 10 mL saline) were used for contrast. A Philips Lumify ultrasound system using an S4-1 transducer (1-4 MHz) was used to record 10-second loops of an apical four chamber cardiac view. Three clinicians independently evaluated all the recorded video clips using the following criteria: visualization of contrast within the left side of the heart, and the degree of opacification (none, mild, complete). Interrater reliability was assessed with Cohen’s Kappa.

Results:

Contrast Seen On the Left side of the Heart Degree of Contrast Opacification All Raters Rater Kappa Z P Degree of opacification Kappa Z P 1-2 0.3759 3.18 0.0007 Complete 0.2420 2.96 0.0015

1-3 0.7396 5.23 0.0000 Mild 0.2178 2.67 0.0038 2-3 0.2291 1.94 0.0262 None 0.3839 4.70 0.0000 All 0.4096 5.02 0.0000 All 0.2930 4.38 0.0000

Summary/Conclusions: Moderate concordance was seen among all raters when visualizing contrast in the left side of the heart. Fair concordance was seen when classifying the degree of opacification among all raters. Limitation was image clarity, which could have added error. These cardiac abnormalities may play a role in DCI in this FD community.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 98 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

C 13 Friday, June 29 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 11:30-12:00 RESIDENT COMPETITION: No

Prevalence of right-to-left shunt among fishermen divers of the Yucatán Peninsula Chin W, Huchim O, Endo B, Medak A, Ramachandran M, Popa D UCLA/ UCLA Health Radiation Oncology. 200 Medical Plaza, Ste B265-110 Presenting Author: Walter Chin, RN/CHRN [email protected]

Introduction/Background: Decompression illness (DCI) is endemic among fishermen divers (FD) of the Yucatán. DCI arises from multiple pathophysiological mechanisms including inert gas bubbles trapped in a tissue or arterialized via a shunt. We sought to determine the prevalence of right-to-left shunting among FD with a known history of DCI.

Materials and Methods: The study was approved by Marista University of Mérida IRB #CE_009_2017. Risk and benefits were explained to each consenting subject. Fifty subjects were taught a modified valsalva (MV), consisting of normal breathing followed by deep inhalation, occlusion of nostrils and glottis, flexing of the abdominal muscles, and bending of the knees toward the chest while maintaining all previous steps. An 18-gauge angiocatheter was inserted into the antecubital vein. Three-way stopcock and two 10 mL syringes (2.5 mL of air, 10 mL of saline) were used for contrast. A Philips Lumify ultrasound system with an S4-1 transducer (1-4 MHz) was used to record 10-second loops of an apical four chamber cardiac view. While the subject lay in left lateral decubitus position, a count of 10 seconds was started, while the injector would agitate the saline. Next, the subject conducted a MV for 10 seconds followed by injection of agitated saline. The primary outcome was opacification within the left ventricle, and the secondary outcome was the extent of opacification (none, mild, complete).

Results: Complete opacification was found in five FD and mild opacification in 27 FD.

Variable Mean Standard Deviation Age 44.18 9.81 BMI 33.05 6.24 Years of diving 21.70 9.86 DCI 4 4.03

Summary/Conclusions: We detected a greater prevalence of right-to-left shunting than expected. These cardiac abnormalities may play a role in the endemic DCI amongst this FD community. This study was nonrandomized and had inferior image quality.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 99 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

C 14 Friday, June 29 ORAL PRESENTATION TIME: POSTER PRESENTATION TIME: 11:30-12:00 RESIDENT COMPETITION: No

Bubbles in vascular plexuses of the skin in the cutaneous decompression sickness: Report of cases Garcia E, Galicia P, Villanueva V Cozumel Internationl Hospital Presenting Author: Eduardo Garcia, MD [email protected]

Introduction: Decompression sickness (DCS) is the clinical expression of an inflammatory problem caused by inert gas bubbles that form in various tissues of the body, is essentially an ischemic event caused by gas embolism. The symptoms depend on the anatomical area where the bubbles block circulation and the degree to which the tissue reacts to this ischemia and inflammation. The Cutaneous decompression sickness (CDS) in one of the most frequent presentations of DCS, often taken as a mild problem, because it can occur in isolation and resolve spontaneously; CDS is also observed in divers with severe DCS and is associated with a high frequency of Right to left shunt (RLS). The cause of cutaneous decompression sickness (CDS) has several hypotheses, none of these tested. The precise pathophysiology of CDS remains unverified.

Material and Methods: We report clinical cases of 4 divers with decompression sickness, all had CDS at the time of the evaluation, Point of Care Ultrasound was performed on these divers, including an ultrasound to the epidermis, dermis and subcutaneous tissue in the area of the skin rash.

Results: Bubbles were observed in the circulation of the superficial and deep vascular plexuses of the skin, as well as in interconnected vessels of the plexuses. The four divers were treated with recompression, after the DCS, the four divers were evaluated with transthoracic ultrasound and bubble test with saline solution, all had positive PFO.

Conclusions: We conclude that CDS pathophysiological mechanism, is related to reactive vascular changes by arterialization of gas bubbles that is usually associated with a RLS with peripheral amplification when the emboli of the bubbles invade supersaturated nitrogen tissues.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 100 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

C 15 Friday, June 29 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 11:30-12:00 RESIDENT COMPETITION: No

Treatments of dysbaric osteonecrosis Kawashima M, Kawashima M, Tamura H, Nagayoshi I, Furue Y, Motoyama T, Sasaki T, Watanabe Y, Goto T, Takao K, Yamaguchi T, Miyata K Kawashima Orthopedic Hospital, 17, Miyabu, Nakatsu City, Oita, 871-0012, Japan Presenting Author: Mahito Kawashima, MD [email protected]

Introduction: It is well known that inappropriate or excessive diving can cause dysbaric osteonecrosis (DON). Although it is often not necessary to treat it immediately, if DON is causing painful joints or deformities, surgical treatment becomes necessary. Surgery for DON is divided into four types: arthroscopic synovectomy, varus trochanteric osteotomy, transtrochanteric anterior rotational osteotomy (ARO), and artificial joint replacement arthroplasty.

Methods and Results: Surgery for DON was undertaken for 21 patients (22 cases) from 1986 to 2017 at Kawashima Orthopaedic Hospital. All patients were male, with ages from 24 to 66 years old. DON of the femoral head was seen in 20 cases, while 2 cases were affected by DON of the humeral head. In our series, we utilized arthroscopic synovectomy in 2 cases, varus trochanteric osteotomy in 5 cases, ARO in 13 cases, and arthroplasty in 2 cases. However, reoperative surgical was carried out in 1 case of arthroscopic synovectomy, 4 cases of osteotomy and 1 case of hip resurfacing arthroplasty.

Conclusion: Osteotomy preserves the joint. It also maintains higher joint mobility than artificial arthroplasty and is most often carried out in young and early middle-aged patients. Osteotomy was effected in 18 cases, 17 of them under 50 years old. However, if the patient had extensive necrosis or advancing osteonecrosis after osteotomy, we conducted arthroplasty. Arthroplasty was carried out in 2 cases of first surgery, in 4 cases after osteotomy and in 1 case of hip resurfacing arthroplasty. We performed hip resurfacing arthroplasty in 3 cases (including a second operation). Hip resurfacing arthroplasty preserves joints, has higher joint mobility and is less invasive. However, past courses of hip resurfacing arthroplasty have not been optimal. Recently, total hip arthroplasty (THA) has become less invasive and it might have potential for a first surgical intervention. We believe it is important to inquire into a suitable treatment for each patient.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 101 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

C 16 Friday, June 29 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 12:00-12:30 RESIDENT COMPETITION: No

Perilymphatic fistula after diving: A case series Johnson-Arbor K MedStar Georgetown University Hospital, 3800 Reservoir Road NW, Washington DC 20007 Presenting Author: Kelly Johnson-Arbor, MD [email protected]

Introduction: While middle ear barotrauma (MEB) is a common complication of diving and hyperbaric operations, inner ear barotrauma (IEB) is less frequently encountered. We present a case series of patients who experienced IEB with perilymphatic fistula (PLF) after diving.

Case Report: Case 1: A 42-year-old female experienced difficulty with bilateral middle ear pressure equalization during descent on a dive to 40 feet of sea water (FSW). Upon surfacing, she experienced transient hearing loss and a feeling that her ears were “blocked” followed by nausea, lightheadedness, and vertigo. She flew home and sought medical attention; she was noted to have difficulties with ambulation; Romberg testing was positive. Otolaryngology consultation confirmed the diagnosis of PLF; conservative treatment, including bedrest and avoidance of valsava maneuvers, was recommended.

Case 2: A 28-year-old male developed vertigo, hearing loss and tinnitus after performing forceful valsava maneuvers to equalize his ear pressures while diving to 20 FSW. After returning home, he sought medical attention. Tympanic membranes were noted to be intact. He underwent an audiogram which showed moderate to severe high frequency hearing loss in the left ear. A presumptive diagnosis of PLF was established, and the patient was referred for otolaryngology consultation.

Discussion: MEB may result in PLF through transmission of pressures to the inner ear, resulting in rupture of the round window or oval window and leakage of perilymph fluid into the middle ear space. PLF is a clinical diagnosis characterized by hearing loss, tinnitus, and disequilibrium; otolaryngology consultation can help establish the diagnosis. Treatment may include conservative therapy or, in severe cases, surgical exploration and correction.

Conclusions: The diagnosis of PLF should be considered in divers who experience dizziness, vertigo, or hearing loss in the context of ear pressure equalization difficulties during descent.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 102 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

C 17 Friday, June 29 ORAL PRESENTATION TIME: POSTER PRESENTATION TIME: RESIDENT COMPETITION:

WITHDRAWN

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 103 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

C 18 Friday, June 29 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 12:00-12:30 RESIDENT COMPETITION: No

Physical disabilities after decompression illness among small-scale fishermen divers of the Yucatán Peninsula Aguiñaga S, Huchim-Lara O, Chin W Marista University of Merida Presenting Author: Sofia Aguiñaga [email protected]

Introduction: Fishing is one of the primary incomes for the coastal communities of the Yucatan Peninsula. Fishermen utilized surface supplied air to harvest high-value species, spiny lobster and sea cucumber. Decompression illness (DCI) is endemic in this region and hundreds of fishermen are treated annually. Physical disabilities resulting from DCI can impact activities of daily living and harvesting. These sequelae can be mitigated with a physical therapy program. The aim of this study was to describe the main disabilities due to DCI among fishermen divers of the Yucatan Peninsula.

Materials and Method: This study was approved by the UCLA-IRB2 (#13-000532). A cross-sectional study was conducted in the northeastern coast of the Yucatan. We utilized an ad hoc survey to describe the most common disabilities, medical history, and clinical manifestations of DCI. Motor disabilities and neurological symptomatology associated to non-diving traumatic injuries or congenital pathologies were exclusion criteria.

Preliminary results: Average age of participants was 50 (±9.2) years old, 11% had normal weight, 44% had high blood pressure and 22% had type 2 diabetes. Average number of DCI events was 14 (6-31). All subjects had physical impairments, 88% referred non-specific joint and muscle pain, paresthesias and numbness. Gait dysfunctions (88%), decrease in coordination (33%), and decrease in balance (44%). Main diagnose was spinal cord injury and dysbaric osteonecrosis. Despite the disabilities, 33% of the fishermen are still diving. Only 44% of the subjects had physical therapy assistance.

Conclusions: Physical disabilities are critical issue among Yucatan fishermen divers. However, knowing the benefits of physical therapy, receiving the proper and timely therapy after a DCI event, it is helpful to improve the fishers’ quality of life.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 104 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

C 19 Friday, June 29 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 12:00-12:30 RESIDENT COMPETITION: No

Oxygen exposures at NASA’s neutral buoyancy lab: A 20-year experience Walker SC, Garbino A, Ray K, Hardwick R, Fitzpatrick DT, Sanders RW University of Texas, Medical Branch, 201 University Ave Galveston TX 77555 Presenting Author: Robert Sanders, MD [email protected]

Astronauts training for extravehicular activity (EVA, spacewalk) operations can spend many hours submerged underwater in a pressurized suit, called an extravehicular mobility unit (EMU), exposed to absolute pressures exceeding 2 ATA. To minimize the risk of decompression sickness (DCS) a 46% nitrox mixture is used. This limits the nitrogen partial pressure, decreasing the risk of DCS. The trade-off with using a 46% nitrox mixture is the increased potential for oxygen toxicity, which can lead to severe neurologic symptoms including seizures. Suited runs, which typically expose astronauts to oxygen pressures of 0.9-1.1 atm for greater than 6 hours, routinely exceed the published National Oceanographic and Atmospheric Administration (NOAA) central nervous system oxygen toxicity limit (CNSOTL) recommendations. Fortunately, in over 50,000 hours of suited training dives spanning 20 years of EVA training operations at NASA’s Neutral Buoyancy Laboratory (NBL) there has never been an occurrence of oxygen toxicity. This lends support to anecdotal sentiment among certain members of the hyperbaric community that the NOAA CNSOTL recommendations might be overly conservative, at least for the oxygen pressure and time regime in which NBL operates. The NOAA CNSOTL recommendations are the result of expert consensus with a focus on safety and do not necessarily reflect rigorous experimental evidence. The data from the NBL suited dive operations provide a foundation of evidence that can help inform the expert discussion on dive-related neurologic oxygen toxicity.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 105 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

C 20 Friday, June 29 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 12:00-12:30 RESIDENT COMPETITION: No

Estimated workload intensity during volunteer aquarium dives Buzzacott P1,2 Grier JW3 Walker J4 Bennett CM1 Denoble PJ1 1Divers Alert Network, Durham, North Carolina, US; 2School of Sports Science Exercise and Health, University of Western Australia, Crawley, Western Australia, Australia; 3Department of Biological Sciences, North Dakota State University, Fargo, North Dakota, USA; 4Oregon Coast Aquarium, Newport, Oregon, USA Presenting Author: Peter Buzzacott, PHD [email protected]

Background: This study aimed to characterize the physiological demands of working dives on volunteer divers at a public aquarium in the US.

Methods: Participants completed a medical and diving history questionnaire. Measurements included blood pressure before and after diving and continuous ECG (Holter) monitoring during diving. Dive profiles were recorded using dive loggers attached to the Buoyancy Control Devices. Mean workload was estimated from total air consumption.

Results: Twenty-seven divers recorded 49 air dives over five days. Two thirds were male and ages ranged from 40-78 years. Typically, each diver made two dives with a 30-60 minutes surface interval between them. Mean heart rate during the dives was 100 beats per minute. Overall, the mean estimated workload during the dives recorded during this study was 5.8 METS, with a range from 4.1 to 10.5. The highest mean recorded heart-rate was 120 bpm over 40 minutes, while vacuuming the floor in the shark exhibit.

Conclusions: Given the mean age of this sample and the prevalence of cardiovascular risk factors (BMI, high cholesterol, and hypertension), it may be prudent for aquarium DSOs to regularly monitor SAC/kg and heart rate in volunteer divers, to identify which tasks consistently require the highest workload intensity. Divers with existing cardiovascular risk factors might then be employed in dives with lighter workloads. In conclusion, volunteer dives at this aquarium required a mean workload intensity that was described by recreational divers as moderate. The highest workload, at 10 METS for 23 minutes, would be considered by many recreational divers as exhausting.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 106 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

C 21 Friday, June 29 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 12:00-12:30 RESIDENT COMPETITION: No

Successful treatment of decompression illness complicated with acute hepatic infarction and acute kidney injury: A case report Oh SH, Choi SC, Cha YS, Lee YH, Kim GW, Kim H Gangneung Asan Hospital, Gangwon-do Gangneung-si Bangdong-gil 38 Presenting Author: Se Hyun Oh, MD [email protected]

Decompression sickness is a disease caused by abrupt pressure change, and presents various symptoms. Depending on the location of the bubble, it varies from mild musculoskeletal damage to severe forms of nervous system damage. Hepatic infarct was extremely rare. Until now, acute hepatic infarction has been rarely reported in non-transplant or non-trauma patients. Also, acute hepatic infarction associated with decompression sickness has yet to be reported. We treated the patient with severe decompression sickness complicated by acute kidney injury (AKI) and acute hepatic infarction without complication using hyperbaric oxygen (HBO2) therapy and dialysis. In our case, we found that the decrease of the effective circulating blood volume resulted in additional complications in severe decompression sickness. To our knowledge, our case was the first documented injury related to such volume depletion resulting in hypovolemic shock and hepatic infarct requiring vasopressors and a fluid volume resuscitation therapy.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 107 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

C 22 Friday, June 29 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 12:00-12:30 RESIDENT COMPETITION: No

Recurrent facial baroparesia: A case report Gomez-Castillo JD1, Esquivel-Garcia B2 1Costamed Hyperbaric Center/Divers Alert Network; 2ENT Department Costamed Cozumel Presenting Author: Dario Gomez, MD [email protected]

Facial baroparesis is a rare condition of facial nerve palsy that has been reported both in divers and aviators. It caused by ipsilateral middle ear overpressure resulting from the failure to equalize middle ear and ambient pressures during ascent from dive or during ascent to altitude. The presence of a dehiscence of facial nerve canal and excessive pressure may compress the facial nerves structure and causing hypoxia and consequently neuropraxia. This neuropraxia is transitory resolving between minutes to hours.

We report the case of 45 year old women who was referred for a second opinion after being , diagnosed with decompression sickness and proposed recompression treatment. She developed unilateral sudden right facial paralysis after scuba diving with ipsilateral regional numbness. She works as a flight attendant. Seven years ago, after a transcontinental flight she had similar symptoms, that resolved after two and a half hours. Clinical examination showed right facial paresis including upper and lower facial muscles, with a IV House-Brackmann classification and right middle ear barotrauma. Medical treatment for ear barotrauma was given and patient had complete resolution of symptoms after four hours.

Facial baroparesis is a rare temporary paresis of the seventh cranial nerve and can occur both in aviation and diving. It is associated with the presence of facial nerve dehiscence which has prevalence of 11.4% and thus one in ten divers may be at risk. Practicing proper equalization techniques during diving or flying can prevent it.. Recompression treatment is not indicated for this condition.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 108 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

C 23 Friday, June 29 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 12:00-12:30 RESIDENT COMPETITION: Yes

Hyperbaric oxygen therapy for Type II DCS in an experienced dive master – A case study Boes T, Morgan M, Sharma D, Santiago W, Mariani P, Heyboer M Division of Hyperbaric Medicine and Wound Care, Department of Emergency Medicine, Upstate Medical University, Syracuse, NY Presenting Author: Tanner Boes, MD [email protected]

Introduction/Background: Decompression illness (DCI) is a term used to describe illness that results from reduction in the ambient pressure surrounding a body. In recent years, DCI has encompassed both decompression sickness (DCS) and arterial gas embolism (AGE). The former has a range of related conditions which span from mild cutaneous, lymphatic, or pain-only syndromes (Type I DCS), to other more severe syndromes (Type II DCS) which can even progress to critical illness/shock.

Materials and Methods: Patient was a 49-year-old male who presented ~1.5 hours after a decompression dive with headache, neck “cracking”, and neck discomfort. Maximum dive depth was 133 FFW for 6-8 minutes, water temperature was ~60 degrees Fahrenheit, and work was moderate during the dive. Patient was trying a new dry suit, ran low on air, and needed to buddy breathe at 50 FFW. As both divers were running low on air, patient did not complete the 18 minute decompression stop recommended by his dive computer. Patient reported a dive master status, history of hundreds of dives without DCI, and no past medical history. Patient had a compromised Romberg on exam. Patient was diagnosed with Type II inner ear DCS. The patient was treated with a USN TT6.

Results: The patient had rapid resolution in his symptoms during treatment. He remained symptom- free with a normal neurological exam after therapy. No further hyperbaric oxygen therapy was recommended.

Summary/Conclusions: We present a case of an experienced recreational diver who underwent a computer diving profile which recommended decompression. The stop was not completed as low air reserves from testing of a new dry suit required ascent to surface. Patient’s symptoms were suggestive of Type II inner ear DCS, which resolved. We recommended patient refrain from diving until follow-up. We thought the utility of an outpatient echo was unwarranted at that time.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 109 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

C 24 Friday, June 29 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 12:00-12:30 RESIDENT COMPETITION: Yes

Hyperbaric oxygen therapy for Type I DCS secondary to hypobaric challenge – A case study Boes T, Morgan M, Sharma D, Santiago W, Mariani P, Heyboer M Division of Hyperbaric Medicine and Wound Care, Department of Emergency Medicine, Upstate Medical University, Syracuse, NY Presenting Author: Tanner Boes, MD [email protected]

Introduction: Decompression sickness (DCS) is an illness that results from reduction in the ambient pressure surrounding a body. While diving is more commonly thought be related to DCS, use of hypobaric chambers for training purposes can also predispose to this condition. DCS has a range of manifestations which span from mild cutaneous, lymphatic, or pain-only syndromes (Type I DCS), to more severe syndromes (Type II DCS) which can progress to critical illness/shock.

Materials and Methods: A 23-year-old male with no significant past medical history underwent hypobaric chamber exercises during training at a military facility. Exercises lasted approximately one hour. Several maneuvers occurred involving rapid altitude excursions and thus ambient pressure changes (sometimes dropping >18,000 ft in a matter of seconds). The patient reported no immediate symptoms, but gradual onset of proximal joint pain about 3.5 hours after hypobaric challenge. His symptoms improved over several hours on normobaric oxygen, but they returned when he was off oxygen. The patient was treated with a USN TT6.

Results: The patient underwent a maximum compression of 2.8 ATA using air breaks. His pain resolved. While at 2.0 ATA he became anxious, complaining of sweatiness and reproducible chest pain. The decision was made to abort USN TT6 after approximately 3 hours of treatment time. He had improvement of his in-chamber symptoms shortly after reaching the surface. Neurological exam was normal, CXR was negative, and he remained pain-free.

Conclusion: We present a case of Type I DCS resulting from hypobaric challenge. While it is unusual, symptoms can occur hours following re-pressurization. No other plausible alternate explanations for his symptoms were elucidated. The patient’s relative pressure changes were sufficient to cause DCS. He completed the majority of USN TT6 with resolution of his pain symptoms, despite a shortened treatment time secondary to confinement anxiety.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 110 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

C 25 Friday, June 29 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 12:00-12:30 RESIDENT COMPETITION: No

Urinary obstruction following octopus bite Weaver LK1,2 1Division of Hyperbaric Medicine Intermountain Medical Center, Murray, Utah, and Intermountain LDS Hospital, Salt Lake City, Utah; 2University of Utah School of Medicine, Salt Lake City, Utah Presenting Author: Lindell K. Weaver, MD [email protected]

Case report: A 44-year-old healthy diver was bitten by an octopus of unknown species in the southern Sea of Cortez. The bite occurred from handling the octopus to facilitate videography. The octopus bit the diver on the upper left arm. The diver was not wearing a shirt or diving garment. The bite resulted in epidermal bruising and a dermal full-thickness wound that bled slightly. Over time there were no signs of local infection. Approximately 4 hours later, the diver noted difficulty in urination, which was progressive and causing dysuria. He denied blurred vision or dry mouth. His vital signs were normal, and there was no anorexia, nausea or diarrhea. The diver was camping on the beach, without medical support beyond what his group had brought. Phenazopyridine relieved the dysuria and the obstruction. The diver also took sulfamethoxazole/trimethoprim, but a diagnosis of urethritis or urinary infection was not established. By the next morning, symptoms had resolved without need for phenazopyridine. Two weeks later a urological evaluation and intravenous pyelogram were negative. Similar urological problems have not recurred in the next 30 years.

Discussion: Little is known about bites from octopi residing in the Sea of Cortez. A 2009 Australian study found that all octopi are venomous1, but did not offer urinary obstruction as a possible symptom. Although causation is impossible to draw from this case report, we offer as a possibility that envenomation from this particular octopus species may cause transient urinary obstruction.

1Fry BG, et al. Tentacles of venom: toxic protein convergence in the Kingdom Animalia. J Mol Evol 2009;68(4):311-21

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 111 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

C 26 Friday, June 29 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 12:00-12:30 RESIDENT COMPETITION: Yes

DCS with incidental pulmonary cyst Norton M1, Weaver L1,2, Uchida D2 1Division of Hyperbaric Medicine, Intermountain Medical Center, Murray, Utah and Intermountain LDS Hospital, Salt Lake City, Utah; 2University of Utah School of Medicine Presenting Author: Mariesa N. Norton, ACNP/PA [email protected]

Case Report: A healthy 16-year-old male with history of premature birth at 27 weeks gestation, under SCUBA instruction presented with chest pain immediately upon surfacing from two of four open water dives at 6,000 feet, over a 2-week interval. After the first dive, he experienced left anterior pleuritic chest pain lasting two hours, immediately after surfacing from 30 feet. With the subsequent dive two weeks later, he noted multiple arthralgias and fatigue approximately 30 minutes after surfacing. Chest CT was obtained, and showed a gas-filled, thick-walled pulmonary cyst in the superior segment of the left lower lobe measuring 3.4 cm x 2.2 cm, without pulmonary barotrauma. He was evaluated by Hyperbaric Medicine.

He was treated with a US Navy Table 6 for decompression sickness, with immediate resolution of arthralgia at 2.8 ATA. His chest pain persisted and was treated with ketoralac. He was referred to pediatric pulmonology, and later seen by pediatric thoracic surgery for continued chest pain. Repeat CT Chest showed the cyst to be fluid-filled; the fluid had resolved on a subsequent CT three weeks later. He continues to complain of recurring chest pain triggered by travel involving changes in altitude. Thoracic surgery is considering excision of the cyst.

Conclusion: This case represents decompression sickness successfully treated in an individual found to have an incidental pulmonary cyst. The thick-walled nature of the cyst and lack of fluid do not support a barotrauma-related cause for the cyst; more likely the cyst is related to his premature birth. Also, there was no evidence of barotrauma lung injury due to treatment with hyperbaric oxygen. We postulate that tensile forces on the cyst during diving contributed to development of chronic inflammation, causing persistent chest pain that varies with changes in atmospheric pressure.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 112 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

C 27 Friday, June 29 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 12:00-12:30 RESIDENT COMPETITION: No

Unusual response to a presumptive stingray spine injury Do R, Lu LQ, Strauss MB Memorial Care Long Beach Medical Center 2865 Atlantic Ave, Long Beach, CA 90806 Presenting Author: Michael B. Strauss, MD [email protected]

Introduction Stingray spine injuries are well documented. Effects have ranged from pain to death. We report a case that had a unique clinical course that had not been previously described.

Case Description A 36-year-old poorly controlled diabetic male experienced sharp pain in his right foot while wading in shallow water. Due to Initial bleeding and pain, the patient presented to an ED where analgesics were prescribed and tetanus prophylaxis given. With increasing pain he came to our ED the next day, was admitted, and we were consulted to manage the wound.

After debridement of a 4 x 10 sq cm bullae over the lateral aspect of the foot, a full thickness slough to the periosteum over the underlying bones was present. Cultures grew two strep species. Even with Santyl, negative pressure wound therapy, and HBO2 treatments, the wound base remained necrotic and did not improve over a two week period. The patient was then discharged with a “stable non-healing wound.” Over a two month period, vascularity developed in the wound base and the wound epithelialized. At this point the patient returned to work.

Discussion This case was unique for several reasons. First, a full thickness slough in the absence of necrotizing fasciitis has not been previously reported. Second, failure for the wound base to develop an angiogenesis response during hospitalization even with HBO2 treatments is unusual for a diabetic wound where perfusion is not an issue. Third, the healing response began to occur when wound dressings were switched to normal saline. Finally, the patient’s clinical course suggests a toxic reaction to a stingray injury rather than infection from bacteria.

Conclusions The clinical course of a slough of this extent was not found in our literature review and is most consistent with a toxic reaction to envenomation from a stingray injury.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 113 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

C 28 Friday, June 29 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 12:00-12:30 RESIDENT COMPETITION: No

The impact of hyperbaric oxygen therapy on chronic Lyme disease: A case study Linden, RO, Zacher JE, LeDez KM, Cook T Judy Dan Research & Treatment Centre, 555 Finch Avenue West, 2nd Floor Toronto, Ontario, M2R 1N5 Presenting Author: Ron Linden, MD [email protected]

Introduction: A single case study is presented of a 58-year-old male treated with hyperbaric oxygen (HBO2) for chronic Lyme disease, unresponsive to standard treatment. Causative agent for Lyme disease is Borrelia burgdorferi, which sequesters intracellularly and protected against antibiotics. It will not survive in-vivo exposure to oxygen levels > 30 mm Hg, obtained by HBO2.

Materials and Methods: After baseline assessments and REB approval, 30 weekday HBO2 treatments (2.4 ATA, 90 min, 100% O2) were provided. After a partial response, a further 30 sessions were added and later, another 22 weekly sessions were undertaken to explore the possible benefit of a maintenance program. Daily reports of patient’s health were collected before each HBO2 to assess overall health (energy level, pain/discomfort, sweating, etc.) and standardized testing (HLQ, IPAQ, CESD-R, CD-RISC, BrDI) completed at 2 weeks, 1 and 6 months. The patient also provided a journal of progress throughout this process.

Results: Baseline measures demonstrated typical, chronic Lyme disease symptoms: fever, chills; polyarthralgia; polymyalgia; profound fatigue; insomnia; cognitive dysfunction; and characteristic antibiotic-related Herxheimer reactions that also occurred during HBO2 sessions 10-12, 23-29 and 47-49. Although IPAQ initially declined with these reactions, these scores exceeded baseline by 2.5 times at treatment completion. Similar gains in the patient’s mental health and function were noted in the scores in the standardized test battery, HLQ (89 to 49) and CESD-R (41 to 13). More specifically, the subscales addressing sleep, movement, concentration and tiredness indicated substantial improvements. Subjective patient reports suggested better stamina and cognitive function, especially in the latter stages of treatment, and continued subsequent improvement during post-treatment follow- up.

Conclusions: HBO2 appeared in this single case to be effective for chronic Lyme disease unresponsive to standard medical care and justifies additional investigation and clinical trials.

List of Acronyms

HLQ: Horowitz Lyme-MSIDS Questionnaire IPAQ: International Physical Activity Questionnaire CESD-R: Center for Epidemiological Studies Depression Scale CD-RISC: Connor-Davidson Resilience Scale BrDI: Brain Dysfunction Indicator

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 114 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

C 29 Friday, June 29 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 12:00-12:30 RESIDENT COMPETITION: Yes

A pilot study evaluating knowledge of indications for hyperbaric oxygen therapy among physicians in Mid-Michigan Jones MW, Henning WH McLaren Greater Lansing Wound and Hyperbaric Center 2720 S. Washington Ave. Suite 300 Lansing, MI 48910 Presenting Author: Werner Henning, DO [email protected]

A pilot study was done in Mid-Michigan to evaluate knowledge of appropriate hyperbaric oxygen therapy referrals in “first contact” physicians who did not have additional hyperbaric training. The hypothesis for this study is that many “first contact” physicians have little or no exposure to Hyperbaric Oxygen (HBO2) Therapy and its indications. A survey of accepted indications combined with conditions not currently approved or contraindicated for HBO2 was distributed. Answers were tallied for correct identification of approved indications, missed approved indications, and inappropriate identification of unapproved indications. Ninety surveys were distributed and 62 physicians of various specialties responded. There were notably high percentages of missed indications, as high as 93%. Many emergent/urgent indications were also missed. The highest percentage of wrong indications was 32%. Very concerning is the 13% who chose refractory pneumothorax as a condition responsive to HBO2.

This study showed significant lack of familiarity of HBO2 indications among physicians who did not have additional hyperbaric training. Inclusion of hyperbaric education during residencies may increase HBO2 referrals and improve outcomes for various disorders.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 115 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

C 30 Friday, June 29 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 12:00-12:30 RESIDENT COMPETITION: No

Underwater nasal decongestant use: A novel approach to middle ear equalization during a dive Covington DB, Pitkin AD University of Florida, Department of Anesthesiology, 1600 SW Archer Rd, PO Box 0254, Gainesville, FL 32610-0254 Presenting Author: Derek Covington, MD [email protected]

Introduction: Middle ear barotrauma is the most common diving-related injury. It is estimated to occur in more than 50% of experienced divers. Although divers learn how to effectively equalize their ears with various maneuvers, airway congestion may impede the ability to equalize the middle ear space via the Eustachian tube. In this case, one may have to avoid diving or abort a dive due to inability to descend. If a diver needs to descend before he can exit the water, it is imperative that the middle ear can be equalized or there is a risk of middle ear barotrauma

Case Description: A 46 year-old diver had started to routinely carry topical oxymetazoline after having difficulty with middle ear equalization during a multi-sump cave dive. He initially was able to self- administer it intranasally in an air bell before successfully attempting to descend again. During another cave dive, he was at a depth of 200 ffw (60 mfw) and proceeding towards the deepest point of the cave passage at 290 ffw (88 mfw) when he again experienced repeated difficulty with middle ear equalization. With the only other option of aborting the dive, he attempted to self-administer topical oxymetazoline underwater. This maneuver required removal of the face mask, occlusion of the contralateral nostril and careful sniffing. Despite the inevitable intranasal ingress of water, once he had replaced his mask he discovered he could easily equalize the problematic middle ear space and continue the dive. The diver has subsequently employed the same procedure on many occasions without complications and with consistent success.

Discussion: We believe this to be the first description of this particular technique. Although effective for this individual, this maneuver is not without risks. These include disorientation, loss of buoyancy, coughing, sneezing, laryngospasm, and a theoretical increased susceptibility to CNS oxygen toxicity.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 116 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

C 31 Friday, June 29 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 11:30-12:00 RESIDENT COMPETITION: Yes

The antimicrobial activity of commonly used wound care products Weis T, Tomoye E, Hazen K, Keuski BM, Shahbuddin Z, Moon RE, Derrick BJ, Freiberger JJ Duke Center for Hyperbaric Medicine and Environmental Physiology, Durham, NC Presenting Author: Edward Tomoye, DO [email protected]

Background: Many infected wounds are treated with systemic antimicrobials. However, in cases of extremity wounds in hosts with compromised perfusion and biofilm formation, topical antimicrobials should be considered. There is a wide range of wound care product (WCP) today making product selection overwhelming for providers. Suppression of bacterial growth is a useful metric for assessing product efficacy because the efficacy of a wound care agent as an antimicrobial lies in its ability to reduce organism formation and viability. Therefore, we are pilot testing a method that uses microbiological techniques to assess suppression of bacterial growth with select WCP.

Methods: Eleven products are currently under study. The reliability of the study will be assessed by triplicate analysis. An in-vitro protocol using the concepts of minimum inhibitory concentration will be used to evaluate the antimicrobial potency of 11 selected products against 7 standard reference microorganisms with designated ATCC identification numbers. Standard microbiological techniques were used including broth microdilution with McFarland turbidity analysis. Methods were congruent with that of CLSI of America. Products tested include: Dakin’s solution 0.25%, Cadexomer Iodine gel, Ciagel (x2), Hydrofera Blue, Leptospermum 100%, Puracyn hydrogel, Silvasorb gel, Silver sulfadiazine 1 %, Atorvastatin, and Lidocaine 2%. Microorganisms include: Staphylococcus sp., (MRSA). Pseudomonas sp., E-coli sp., Candida sp., Enterococcus sp., and Enterobacter sp.

Results: At full strength (1:1 dilution), all products, including Lidocaine 2 % and Atorvastatin demonstrated antimicrobial activity against Klebsiella (ESBL) and MRSA species. For both organisms, Silver sulfadiazine 1 % and Cadexomer Iodine gel were most effective: No microbes recovered at 1:16 dilution. Hydrofera Blue was also very effective in inhibiting MRSA (1:16).

Summary: Infected wounds can progress to septicemia and death. If successful our goal is to apply this method to test additional WCP to allow for development of an “antibiogram” similar to that used for systemic antibiotics.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 117 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

ERIC P. KINDWALL MEMORIAL LECTURE FRIDAY, JUNE 29: 1:00 pm - 2:00 pm

GUEST SPEAKER: Eugene Worth, MD, M.Ed., FABA, ABPM/UHM LECTURE TITLE: "HBO2 and diabetic foot ulcers: Do we have a leg to stand on?"

ABOUT THE LECTURE:

Use of hyperbaric oxygen as a means of therapy for the terrible complications of diabetes began in 1979 (Hart and Strauss). There have been at least 9 randomized controlled trials, of which 7 showed beneficial effects of hyperbaric oxygen as an adjunctive therapy combined with advanced wound care. Recently, there have been 3 negative studies (Margolis, et al; Fedorko, et al; and Santema, et al.) All three of these studies have been published in the same journal, Diabetes Care. (I wonder if that is by coincidence.)

In this presentation, I will trace the history of HBO2 and DFU. One of the overarching weaknesses in all of the trials is a simple fact: None of us practice ‘standard wound care’ or ‘advanced wound care’ in the same way. We can do a better job, and in today’s regulatory environment, we must improve.

Finally, I will review papers disproving some regulatory fallacies. HBO2 and DFU is cost-effective in a community limb salvage protocol. Hemoglobin A1c (HbA1c) has little or no bearing on whether a DFU will heal. Tight HbA1c control may lead to premature death from hypoglycemic episodes.

My goal for each DFU is to leave the patient with an ambulatory extremity. Failure to do that hastens morbidity and mortality. In summary, fasten your seatbelt. I will challenge current paradigms and lay out a pathway to improve patient care. Yes, we have a leg to stand on!

ABOUT DR. WORTH:

Dr. Eugene Worth is a retired Medical Director for Hyperbaric Medicine. He was most recently at Dixie Regional Medical Center in St. George, Utah. Dr. Worth received his A.B. and MD degrees from the University of Missouri-Columbia, in Columbia Missouri. He then completed an internship and residency in Anesthesiology at the University of Missouri-Columbia Hospital and Clinics. He is a board-certified Anesthesiologist and has served in private and academic practices. His subspecialty area was cardiac and major vascular anesthesia including heart transplantation. He has practiced wound care and hyperbaric medicine since 2002 and is subspecialty board-certified in Undersea and Hyperbaric Medicine. He retired from daily practice on July 3, 2017 after 38 years as a physician. He is currently a private consultant and owner of Worth Hyperbaric Consulting, LLC. He and his lovely wife live in Kearney, Missouri.

Dr. Worth completed a 3-year NIH-sponsored medical informatics fellowship (1994 – 1997) at the University of Missouri-Columbia. His Masters Degree is in Education, with an emphasis in curriculum and instruction and educational technology. His research involved using electronic mail discussion groups as “virtual colleagues,” enhancing information transfer to clinical practice by asymmetric communication.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 118 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

Dr. Worth has practiced undersea and hyperbaric medicine since 2002. In April, 2006, he became the medical director of Hyperbaric Medicine at the Utah Valley Regional Medical Center, Provo, Utah. In 2013, he was named the medical director at Dixie Regional Medical Center in St. George, Utah. He was an adjunct assistant professor for the Duke University Undersea and Hyperbaric Medicine program since 2013.

Dr. Worth is a long-time member of the Undersea and Hyperbaric Medical Society. He has served on the Education and Safety Committees. He is a physician surveyor for the UHMS Accreditation Team.

He is a recreational diver (PADI Advanced Open Water and Enriched Air) and a NOAA Diving Medical Officer. He has 30+ scientific publications, including two book chapters. He has given numerous presentations in anesthesiology, medical informatics, hyperbaric medicine and diving medicine.

Dr. Worth is the recipient of a number of awards and distinctions in undersea and hyperbaric medicine. In 2017, he received the founding “Circle of Excellence Award” from the Baromedical Nurses Association. This award recognizes mentoring and support of hyperbaric nurses worldwide. He is a reviewer for the journal, Undersea and Hyperbaric Medicine.

FABA = Fellow of the American Board of Anesthesiology ABPM/UHM = Sub-specialty certified in Undersea and Hyperbaric Medicine by the American Board of Preventive Medicine. NOAA = National Oceanic and Atmospheric Association

ABOUT ERIC P. KINDWALL, MD

Dr. Kindwall is known by many as the "Father of Hyperbaric Medicine.” Whether you knew him personally or simply by reputation, we have all benefited from his efforts, passion, wisdom, knowledge, energy and vision. Dr. Kindwall has played a great role in growing and shaping the specialty of Undersea and Hyperbaric Medicine. He was likewise instrumental in molding the UHMS into what it is today. Dr. Kindwall began diving in 1950. He cultivated his interest in the field and during the Vietnam War served as the Assistant Director of the U.S. Navy School of Submarine Medicine. He also was the Senior Officer responsible for the Diving Medicine Program. In 1969, after leaving the Navy, Dr. Kindwall became Chief of the Department of Hyperbaric Medicine at St. Luke’s Medical Center, Milwaukee, Wis. Shortly after the Undersea Medical Society was created in the mid-1960s, Dr. Kindwall identified the need for standardized education in the field. He created the UMS Education and Standards Committee to help elevate course content and ensure instructor competence. This committee later became our Education Committee. When the AMA initiated its Continuing Medical Education program, Dr. Kindwall persuaded the organization to recognize the UMS as a grantor of CME credits. In 1972, Dr. Kindwall felt that the Society’s members would benefit from improved communication. He created our first newsletter and was named editor. Dr. Kindwall chose the name Pressure because clinical hyperbaric medicine was rapidly developing. Even though the UHMS had not yet incorporated "Hyperbaric” into the Society’s name, he wanted a title for the newsletter that would encompass all who worked with increased atmospheric pressure. He stated: "The Society’s goal then, as it is now, is to serve all who deal with the effects of increased barometric pressure.” That same year, Dr. Kindwall recognized the need to have a relationship with Medicare to help provide insight on reputable clinical management. The UMS followed this lead, and a Medicare Panel was created. The recommendations were presented to the U.S. Public Health Service. The challenge was that no reliable hyperbaric medicine clinical guidelines were ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 119 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY available that addressed appropriate applications of Hyperbaric Medicine. To remedy this deficit, the UMS Executive Committee created an Ad Hoc Committee on hyperbaric oxygen therapy. Dr. Kindwall was named Chair. The committee created the first Hyperbaric Oxygen Therapy Committee Report. Again, this text was published 10 years before the UHMS incorporated "Hyperbaric” into its name. The report was sent to HCFA and the Blues and became their source document for reimbursement. Dr. Kindwall updated the text two more times and thus was the Editor and Chair of the Committee and text for three of its 12 editions. Dr. Kindwall later worked to expand the available information on the specialty by creating one of the first complete texts on the field. He created Hyperbaric Medicine Practice in 1994 and later updated and revised his text two more times. The Society’s first journal, Hyperbaric Oxygen Review, has also has been influenced by Dr. Kindwall. His love for research and education was clear: He became the initial editor, creating a journal that at first consisted of review articles and one original contribution. Over the years, it has grown to one full of original research. Dr. Kindwall’s presence is felt in so many of the UHMS’ activities and initiatives. Much of what we all take for granted – what is just "there” and "available” – has his touch and influence.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 120 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

SESSION D Clinical HBO2 Therapy Moderators:

FRIDAY, JUNE 29

Oral Presentations: 2:00 PM – 3:00 PM

Poster Presentations: Poster Session: 3:30 PM – 4:30 PM

Moderators:

Sandra Wainwright, MD Heather Murphy-Lavoie, MD

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 121 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 122 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

D 1 Friday, June 29 ORAL PRESENTATION TIME: 2:00-2:15 POSTER PRESENTATION TIME: 3:30-4:00 RESIDENT COMPETITION: No

A randomized trial of one v. three hyperbaric oxygen sessions for acute carbon monoxide poisoning Weaver LK1,2, Churchill S1, Deru K1, Handrahan D3 1Division of Hyperbaric Medicine Intermountain Medical Center, Murray, Utah, and Intermountain LDS Hospital, Salt Lake City, Utah; 2University of Utah School of Medicine, Salt Lake City, Utah; 3Statistical Data Center, Intermountain Medical Center, Murray, Utah Presenting Author: Lindell K. Weaver, MD [email protected]

Introduction: In this double-blind, sham-controlled randomized trial, we compared neuropsychological 1 sequelae at 6 weeks and 6 months in patients who received 3 HBO2 sessions or 1 HBO2 session and 2 sham chamber sessions after acute carbon monoxide (CO) poisoning.

Methods: CO-poisoned patients received 1 HBO2 session (3.0 ATA x50 minutes, then 2.0 ATA x60 minutes, with three 5-minute air periods),1 then were randomized (1:1) to 2 sham chamber sessions (1 ATA air, 120 minutes) or two additional HBO2 sessions (2.0 ATA, 90 minutes at pressure, two 5-minute air periods) completed in <24 hours. Eligible patients were within 24 hours of accidental poisoning, English-speaking, and not intubated. We planned 150 participants.

Results: The study was stopped early for enrollment futility. From 2006-2016, we screened 385 participants, 118 were deemed eligible to participate, and 75 signed informed consent. Two were later withdrawn for past brain injury/PTSD (1 sham, 1 HBO2), and 1 for malingering (sham). Of the 72 analyzed, mean age was 42±15 years, 39 (54%) were male, 20 (28%) had loss of consciousness, mean initial carboxyhemoglobin was 22±9%. 63 (88%) attended 6-week follow-up and 54 (75%) 6-month evaluations. At 6-weeks, rate of neuropsychological sequelae was 50% in the sham group and 52% in the HBO2 group (p=1.0), and at 6 weeks was 38% vs 36%, respectively (p=1.0).

Conclusions: There was no difference in the rate of neuropsychological sequelae in those who received 3 HBO2 sessions and those who received 1 HBO2 sessions and 2 sham sessions. For patients meeting this study’s inclusion criteria, one HBO2 treatment seems reasonable. The higher rate of neuropsychological sequelae compared to our earlier trial1 may be due to risk factors (age, cerebellar dysfunction), greater opportunity for neuropsychological test-retest learning in the original trial, and generational differences in neuropsychological performance.

1Weaver, et al. NEJM 2002;347(14):1057-67

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 123 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

D 2 Friday, June 29 ORAL PRESENTATION TIME: 2:15-2:30 POSTER PRESENTATION TIME: 3:30-4:00 RESIDENT COMPETITION: No

A clinical practice guideline for the prevention and treatment of mandibular osteoradionecrosis (ORN) applying GRADE methodology. UHMS CPG Authors: Feldmeier JJ, DuBose KJ, Gesell LB, Shah JB, Huang ET, Mansouri J, Marx RE UHMS CPG Oversight Committee: Feldmeier JJ, LeDez K, Le PNJ, Mansouri J, Moon R, Murad MH Presenting Author: John Feldmeier, DO [email protected]

Introduction: The UHMS Board of Directors has established the goal of applying GRADE evidence-based methodology in developing Clinical Practice Guidelines (CPG’s) for all indications approved by the UHMS. Material and Methods: Initially, the plan was to develop a single CPG for all late radiation tissue injuries (LRTI), but the disorders were found to be too inhomogeneous to summarize in a single CPG. Instead, a CPG for mandibular osteoradionecrosis prevention and treatment has been developed. Literature searches were accomplished utilizing PubMed as the primary source, but also manual searches of the papers’ reference lists were used to discover additional appropriate references. After review of the articles by at least two members of the committee, the authors met together for an intensive in-person three day meeting to review these publications, form PICO (Patient Intervention Comparison Outcome) Questions, and analyze the literature using GRADE methodology. Data were entered in the GRADE Pro software to facilitate judgements by the guideline panel. The ultimate certainty of evidence was determined by considering risk of bias, inconsistency, indirectness, imprecision and the likelihood of publication bias.

Results: The certainty in evidence supporting the effect of HBO2 on the outcome for the prevention of mandibular ORN is low. The certainty in evidence supporting the effect of HBO2 on the outcome for the treatment of already expressed mandibular ORN is moderate.

Recommendation 1: In patients with prior head and neck radiation who are undergoing surgery in the irradiated field and at risk of mandibular ORN, UHMS suggests pre- and post-surgery HBO2 (conditional recommendation, low certainty evidence).

Recommendation 2: In patients with prior head and neck radiation who develop expressed mandibular ORN, UHMS suggests HBO2 (conditional recommendation, moderate certainty evidence).

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 124 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

D 3 Friday, June 29 ORAL PRESENTATION TIME: 2:30-2:45 POSTER PRESENTATION TIME: 3:30-4:00 RESIDENT COMPETITION: No

Sleep assessment in a randomized trial of hyperbaric oxygen in U.S. service members with post-concussive symptoms Walker JM1, Mulatya C1, Hebert D2, Wilson SH2, Lindblad AS2, Weaver LK3,4 1PSG Professional Services, Inc, Farmington, UT, USA, 2The Emmes Corporation, Rockville, MD, USA, 3Division of Hyperbaric Medicine Intermountain Medical Center, Murray, UT and Intermountain LDS Hospital, Salt Lake City, UT, USA, 4Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA Presenting Author: Lindell K. Weaver, MD [email protected]

Introduction: In this exploratory, double-blind, longitudinal sham-controlled trial of hyperbaric oxygen (HBO2) for military personnel with mild TBI (mTBI), self-reports and actigraphic measures of sleep-wake disturbances were assessed.

Methods: Self-reports consisting of Pittsburg Sleep Quality Index (PSQI), sleep diary, screening for obstructive sleep apnea (OSA) risk, restless legs syndrome (RLS), cataplexy, and actigraphic measures of sleep-wake were obtained on 71 military personnel with mTBI (baseline, 13 weeks and 6 months post- randomization (post-intervention)), of which 35 met post-traumatic stress disorder (PTSD) criteria, and 75 healthy volunteers (baseline). The 71 mTBI participants, were randomized to forty 60-minute HBO2 (n=36) or sham chamber sessions (n=35). Baseline between-group and follow-up changes from baseline overall and within subgroups were evaluated.

Results: Sleep quality by self-reports was markedly degraded in the mTBI group at baseline compared to a normative cohort; insomnia 87.3 versus 2.8%, OSA risk 70% versus 1.3%, RLS 32.4% versus and 2.7%. (all p-values <0.001), but actigraphy measures did not differentiate between groups. HBO2 compared to sham exposures improved self-reports of PSQI sleep measures, reports (5 of 8 at 13-weeks and 2 of 8 at 6-months). However, other sleep-wake measures were not different. There were no consistent differences due to intervention between those with or PTSD without symptoms.

Conclusions: Perceived sleep quality was markedly disrupted in mTBI military personnel and sleep-wake disturbances were prevalent compared to a normative cohort. HBO2 relative to sham improved some measures of sleep quality on the PSQI, but other measures of sleep were not significantly different.

Acknowledgment: This work is supported by the US Army Medical Research and Materiel Command under Contract No. W81XWH-15-D-0039-0003; ClinicalTrials.gov numbers NCT01611194, NCT01925963.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 125 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

D 4 Friday, June 29 ORAL PRESENTATION TIME: 2:45-3:00 POSTER PRESENTATION TIME: 3:30-4:00 RESIDENT COMPETITION: No

A composite outcome for mild traumatic brain injury in trials of hyperbaric oxygen Weaver LK1,2, Churchill S1, Wilson SH3, Hebert D3, Deru K1, Lindblad AS3 1Division of Hyperbaric Medicine Intermountain Medical Center, Murray, UT and Intermountain LDS Hospital; 2University of Utah School of Medicine, Salt Lake City; 3The Emmes Corporation, Rockville, MD Presenting Author: Anne Lindblad, PhD [email protected]

Introduction/Background: Composite outcomes can strengthen inferences from clinical trials. In this report, we evaluate an ad hoc composite outcome for persistent post-concussive symptoms (PCS) after mild traumatic brain injury (mTBI) in two clinical trials of hyperbaric oxygen (HBO2) in United States service members.

Materials and Methods: During study design, outcomes planned for a clinical trial of HBO2 for PCS (HOPPS) were weighted and grouped into symptom, cognitive, and functional domains to be totaled into a composite outcome score, consisting of a discrete set of seven symptom, five cognitive, and five functional outcome scores. Differences in the composite outcome were compared between intervention groups in HOPPS and, as a method of validation, this outcome was also measured and compared between intervention groups in a subsequent HBO2 trial (BIMA). Additionally, three alternate post-hoc global statistical approaches were applied to the BIMA data, including a composite score calculation similar to that used in another TBI randomized trial (COBRIT).

Results: In total, 143 active duty or veteran military personnel were randomized to receive HBO2, sham chamber sessions, or local care across the two studies. Ad hoc composite outcome scores improved from baseline for HBO2 (mean ± SD -2.9±9.0) and sham (-2.9±6.6) groups in HOPPS, although no significant difference was found between HBO2 and the combined sham and local care groups (p=0.33). In BIMA,13-week changes from baseline favored the HBO2 group (-3.6±6.4) versus sham (-0.3±5.2; p=0.02). No between-group differences were found when COBRIT composite scoring was applied to BIMA. Overall, post-hoc global statistical approaches identified significantly greater HBO2 than sham effects using one of three composite measures in HOPPS and three of four composite measures in BIMA.

Summary/Conclusions: The ad hoc composite scores in HOPPS and BIMA were consistent with primary study results. Favorable HBO2 effects were more apparent with several post-hoc global statistical approaches.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 126 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

D 5 Friday, June 29 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 3:30-4:00 RESIDENT COMPETITION: Yes

Hyperbaric oxygen therapy effect on patients suffering from fibromyalgia due to childhood sexual abuse – randomized controlled trial Hadanny A, Bechor Y, Catalogna M, Daphna S, Lev R, Efrati S Sagol Center for Hyperbaric Medicine and Research, Asaf Harofeh Medical Center, Zerifin, Israel Presenting Author: Amir Hadanny, MD [email protected]

Background: Fibromyalgia syndrome (FMS), a condition considered to represent a prototype of central sensitization syndrome, can be induced by different triggers including childhood sexual abuse (CSA). Recent studies have demonstrated hyperbaric oxygen (HBO2) therapy can induce neuroplasticity and improve clinical outcome of FMS. The aim of the current study was to evaluate the effect of HBO2 on patients suffering from FMS due to CSA.

Methods: A prospective randomized clinical trial conducted between July 2015 and November 2017 included women with a history of CSA who fulfilled fibromyalgia diagnosis criteria for at least five years prior to inclusion. Included participants (N=30) were randomly assigned to treatment group, treated with 60 HBO2 sessions and a control/crossover group received psychotherapy. After the control period, the control/crossover group was crossed to HBO2. Clinical outcome included FMS, PTSD and quality of life questioners and brain function and structure imaging.

Results: Following HBO2, there was a significant improvement in all FMS questionnaires (WPI, SSS, FIQ), most domains of quality of life (SF-36) and PTSD questionnaires (BSI, PSS). The same significant improvements were demonstrated in the control following crossover to HBO2. Following HBO2, brain SPECT imaging demonstrated significant increase in brain activity in the prefrontal cortex, orbital frontal cortex and subgenual area (p<0.05). Brain microstructure improvement was seen by MRI-DTI in the anterior thalamic radiation (p=0.0001), left Insula (p=0.001) and the right Thalamus (p=0.001).

Conclusion: HBO2 induced significant clinical improvement that correlates with improved brain functionality and brain microstructure in CSA-related FMS patients.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 127 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

D 6 Friday, June 29 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 3:30-4:00 RESIDENT COMPETITION: No

Hyperbaric oxygen for TBI and PTSD: A meta-analysis of Department of Defense and other published study results Hart BB1, Weaver LK2,3, Gupta A4, Wilson SH1, Vifayarangan A1, Deru K2, Hebert D1 1The Emmes Corporation, Rockville, MD; 2Division of Hyperbaric Medicine Intermountain Medical Center, Murray, UT and Intermountain LDS Hospital; 3University of Utah School of Medicine, Salt Lake City; 4Emmes Services Pvt Ltd, Bangalore, India. Presenting Author: Brett Hart, MD [email protected]

Introduction: Hyperbaric oxygen (HBO2) has been considered as a potential treatment for post- concussive symptoms (PCS) and post-traumatic stress disorder (PTSD) after mild traumatic brain injury (mTBI), but questions remain regarding the utility of HBO2 for these conditions. This study reports a systematic review and meta-analysis of available data assessing HBO2 effects on PCS and PTSD in study participants with mTBIPTSD.

Materials and Methods: Systematic review identified four Department of Defense (DoD) and three non- DoD trials that reported individual-level data for participants with mTBIPTSD. Data from the DoD trials were aggregated (n=254) and participants pooled into HBO2 and sham exposure groups. Changes from baseline to post-intervention were assessed across PCS, PTSD, and neuropsychological assessments to evaluate main intervention and intervention-by-baseline PTSD effects. Potential dose-response relationships to oxygen and pressure in the HBO2 and sham arms were investigated. Intervention effects from the non-DoD studies were also summarized.

Results: For pooled DoD trials, ten outcome measures were common across three of four trials, whereas only the PTSD Checklist (PCL) was common to all four studies. Analysis indicated trends toward improvement in PCS (Rivermead Total Score: HBO2 vs. sham mean difference -2.3, 95% CI [-5.6, 1.0], p=0.18), PTSD (PCL Total Score: HBO2 vs. sham mean difference -2.7, 95% CI [-5.8, 0.4], p=0.09), and verbal memory (CVLT-II Trial 1-5 Free Recall: HBO2 vs. sham mean difference 3.8; 95% CI [1.0, 6.7], p=0.01) favoring HBO2 and suggesting a greater HBO2 effect in mTBI+PTSD. Additionally, a direct dose- response trend was found. The overall direction of these results was consistent with non-DoD trial findings.

Summary/Conclusionss: Although the small number of available clinical trials and their exploratory nature limit ability to draw definitive conclusions, the trends identified from this meta-analysis suggest PCS improves in a dose-response fashion to increasing oxygen partial pressure, particularly in those with concomitant PTSD. A controlled, dose-ranging clinical trial designed to definitively assess effects of HBO2 on PTSD and PCS should be considered.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 128 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

D 7 Friday, June 29 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 3:30-4:00 RESIDENT COMPETITION: No

Hyperbaric oxygen therapy can rescue ischemic breast flaps following skin-sparing mastectomy Rajpal N, Walters E, Elmarsafi T, Johnson-Arbor K, Pittman T MedStar Georgetown University Hospital, 3800 Reservoir Road NW, Washington DC 20007 Presenting Author: Kelly Johnson-Arbor, MD [email protected]

Introduction/Background: Mastectomy skin flap necrosis represents a significant complication of breast reconstructive procedures, and is reported to occur in 30-52% of patients undergoing breast reconstruction. Early identification of ischemia and early initiation of hyperbaric oxygen therapy (HBO2) can mitigate the effects of ischemia and rescue otherwise non-viable breast flap tissue.

Materials and Methods: We retrospectively examined the outcomes of HBO2 in eight breast cancer patients with compromised mastectomy skin flaps between September 2015 and January 2017. Indocyanine green angiography (ICGA) was used to assess perfusion intraoperatively and post- hyperbaric oxygen administration. Seven patients were referred for HBO2 therapy within 24 hours of mastectomy. One patient was referred for HBO2 therapy at 3 months post-reconstruction due to wound dehiscence. HBO2 was administered twice daily on weekdays, and once daily on weekends. All patients received 10 HBO2 treatments except for one who received 17 treatments. Flap perfusion was assessed using ICGA immediately following the final hyperbaric treatment.

Results: One patient failed to improve despite starting hyperbaric treatment within 24hrs. All other patients manifested successful healing of their mastectomy skin flaps with acceptable cosmesis. Two patients did not complete the post-treatment ICG angiography and were excluded from the ICGA analysis. The mean relative perfusion pre-hyperbaric oxygen was 13.8% (±3.7%) within the area of contour and 101.6% (±37.3%) post- HBO2 within the area of contour. Relative perfusion values after HBO2 were found to be 6.8 (±3.4) times greater than those measured prior to HBO2. The average area of 2 contour pre-hyperbaric oxygen was 17.1 cm and reduced to zero post- HBO2.

Summary/Conclusions: 10 treatments of HBO2 therapy can successfully rescue at risk post-mastectomy breast flaps, especially when treatments are initiated within 24 hours of mastectomy. ICGA is a useful adjunct for evaluating post-mastectomy breast flap perfusion before and after HBO2 therapy.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 129 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

D 8 Friday, June 29 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 3:30-4:00 RESIDENT COMPETITION: No

A retrospective analysis of treatment of wounds caused by calciphylaxis: Hyperbaric oxygen therapy with and without sodium thiosulfate Armour D, Tailor Y, Preston-Hsu E Emory University Hospital at Midtown, Atlanta, GA Presenting Author: Doris Armour, MD [email protected]

Introduction: Calciphylaxis, or calcific uremic arteriolopathy, is a rare, but devastating condition with a mortality approaching 80%, most often seen in patients with chronic kidney disease. It is characterized by calcification and intimal fibrosis with arteriolar stenosis and subsequent thrombosis. Skin changes such as livedo reticularis, tender papules, and violaceous plaques result and progress to necrotic ulceration.

Materials and Methods: Management of calciphylaxis includes maintenance of normal levels of calcium, phosphorus and parathyroid hormone, and optimization of hemodialysis and nutritional status. In our cohort, aggressive wound management coupled with hyperbaric oxygen (HBO2) therapy and sodium thiosulfate has achieved improvement in rates of healing for recalcitrant wounds associated with calciphylaxis but limited evidence for the efficacy of either treatment exists.

We conducted a retrospective analysis of 104 patients treated for calciphylaxis at a Wound and Hyperbaric Center at an academic institution between 2000 and 2016 who were considered for HBO2. We assessed whether response to therapy as measured by wound healing varied among patients who received sodium thiosulfate, hyperbaric oxygen treatment, both therapies, or neither therapy.

Results: We found HBO2 to be beneficial in healing compared to no therapy – 81.7% or 36 of 44 patients with complete or substantial resolution of their wounds vs neither therapy – 11.4% or 3 of 26 patients. We found sodium thiosulfate to be beneficial in healing compared to neither therapy – 66.6% or 2 of 3 patients with complete or substantial resolution of their wounds vs no therapy. Additionally we found combined HBO2 & sodium thiosulfate to be more beneficial in healing compared to either therapy alone and to neither therapy – 86.3% or 19 of 22 patients with complete or substantial resolution of wounds.

Conclusions: Given the dramatic clinical improvement, we feel that HBO2 in combination with sodium thiosulfate may have an important adjunctive role in the treatment of calciphylaxis.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 130 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

D 9 Friday, June 29 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 3:30-4:00 RESIDENT COMPETITION: Yes

The effect of hyperbaric oxygen on erectile dysfunction – Pilot study Hadanny A, Lang E, Copel L, Meir O, Bechor Y, Fishlev G, Bergan J, Zisman A, Efrati S Sagol Center for Hyperbaric Medicine and Research, Asaf Harofeh Medical Center, Zerifin, Israel Presenting Author: Amir Hadanny, MD [email protected]

Introduction: Erectile dysfunction (ED) is caused by micro- or macrovascular insufficiency in the majority of patients. Recent studies have shown that hyperbaric oxygen (HBO2) therapy can induce angiogenesis in different body organs. The effect of HBO2 on the non-surgery-related ED has not yet been investigated.

Objective: Evaluate the effects of HBO2 on sexual function and penile vascular bed in non-surgical ED patients.

Methods: A prospective analysis of patients suffering from chronic ED treated with 40 daily HBO2 sessions. Clinical efficacy was assessed using the International Index of Erectile Function questionnaire (IIEF) and a global efficacy question (GEQ). The effect on the penile vascular bed was evaluated by perfusion MRI.

Results: Thirty men (mean age of 59.2±1.4) suffering from ED for 4.2±0.6 years completed the protocol. HBO2 significantly improved all IIEF domains by 15-88% (p<0.01). Erectile function improved by 88% (p<0.0001) and 80% of the patients reported positive outcome according to the GEQ.

Angiogenesis was indicated by perfusion MRI that showed a significant increased by 153.3±43.2% of K- trans values in the corpous cavernous (p<0.0001).

Conclusions: HBO2 can induce penile angiogenesis and improve erectile function in men suffering from ED. HBO2 reverses the basic common pathophysiology, atherosclerosis and decreased penile perfusion, responsible for most cases of ED.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 131 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

D 10 Friday, June 29 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 3:30-4:00 RESIDENT COMPETITION: Yes

Effects of hyperbaric oxygen therapy on non-diabetic serum glucose levels Boes T, Wojcik S, Heyboer M, Seargent S Department of Emergency Medicine, Division of Hyperbaric Medicine and Wound Care, SUNY Upstate Medical University, Syracuse, New York Presenting Author: Tanner Boes, MD [email protected]

Introduction/Background: Hyperbaric oxygen (HBO2) therapy is believed to decrease serum glucose in diabetics. Guidelines require minimum glucose levels prior to HBO2 in this population. Little is known, however, regarding glucose changes with HBO2 in non-diabetic populations. We are completing a prospective study on pre- and post-treatment glucose levels in non-diabetics undergoing HBO2. This is an interim report of those results.

Materials and Methods: IRB approval was obtained. Pre- and post-treatment serum glucose levels were recorded prospectively. Additional data included age, gender, past medical history, treatment diagnosis, and HBO2 parameters.

Results: Information was available on 26 patients who underwent 145 HBO2 treatments. Overall median decrease in serum glucose was 1 mg/dL, maximum decrease was 100 mg/dL. Serum glucose decreased in 52.4% of treatments, increased in 44.8%, and 2.8% had no change. Comparison of the proportion of treatments that increased versus decreased showed a difference of 7.6% (95% CI -9.83 to 24.54, p=0.37). Thus, no significant difference in direction of glucose change was observed. Overall, pre-treatment glucose median (range) was 103 (70-191) mg/dL and post-treatment was 101 (76-156) mg/dL. Pre-treatment glucose was <90 mg/dL for 17 treatments (11.7%). In this group, pre-treatment glucose median (range) was 84 (70-89) mg/dL and post-treatment was 91 (76-137) mg/dL. Post- treatment glucose was <90 mg/dL for 16 treatments (11%). In this group, pre-treatment glucose median (range) was 92 (73-131) mg/dL and post-treatment was 86 (76-89) mg/dL. No patient with a glucose < 90 mg/dL was symptomatic.

Summary/Conclusions: Our interim findings suggest no clinically significant decrease in serum glucose levels among non-diabetics undergoing HBO2. This supports current practice guidelines to check serum glucose levels only in diabetic patients. It also suggests that the mechanism which causes the significant decrease in serum glucose among diabetic patients undergoing HBO2 is related specifically to their diabetic disease process or medications.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 132 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

D 11 Friday, June 29 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 3:30-4:00 RESIDENT COMPETITION: No

Case series review: Multicenter experience treating idiopathic sudden sensorineural hearing Loss (ISSHL) with adjunctive hyperbaric oxygen therapy Robins MS1, Gwilliam A1, Weaver LK2,3, Churchill S2, Foust K2, Cascio M4, Pollock R4, Nail S5, Frye S5, Crookston T5 , Moffat AD6, Robins SM6 1Hyperbaric Medicine, Utah Valley Hospital, Intermountain Healthcare, Provo, UT; 2Division of Hyperbaric Medicine Intermountain Medical Center, Murray, UT and Intermountain LDS Hospital, Salt Lake City, UT, USA, 3University of Utah School of Medicine, Salt Lake City, Utah; 4Hyperbaric Medicine, Dixie Regional Medical Center, St. George, UT; 5Hyperbaric Medicine, Logan Regional Medical Center, Logan, UT, USA; 6Hyperbaric Medicine, Jordan Valley Medical Center, West Jordan, UT

Introduction: Hyperbaric oxygen (HBO2) in combination with corticosteroid therapy is approved by the UHMS for idiopathic sudden sensorineural hearing loss (ISSHL). We present a retrospective review of 14 cases of ISSHL treated with a combination of corticosteroid and HBO2 in 6 different hyperbaric facilities. ISSHL is defined as unilateral hearing loss of at least 30 dB occurring within 3 days over at least 3 contiguous frequencies.

Methods: ISSHL was confirmed in all patients by an otolaryngologist and all had pre- HBO2 audiograms. Steroid administration was oral, intra-tympanic injections (IT) or combination of both. HBO2 was initiated in either monoplace or multiplace chambers at 2.0 -2.4ATA x 90 -100 minutes. The patients were reassessed after each set of 10 HBO2 treatments, up to 20 treatments, or as needed according to improvement or worsening on repeat audiogram evaluations. If no improvement was noted after 20 HBO2 treatments the HBO2 was discontinued and a final audiometric evaluation performed.

Results: HBO2 was initiated on 14 patients (4 female, 10 male) meeting criteria for ISSHL with age range from 25 to 67 years. Seven patients began HBO2 within 2 weeks from onset, 6 within 15-33 days and 1 after 5 months. One patient (7%) had complete recovery (post-treatment dB loss within 10dB of pre- treatment baseline), 9 patients (64%) had partial recovery (> 10 dB improvement in PTA), 3 of these reported recovery within 15-30 dB from pretreatment baseline), 4 (28%) reporting no improvement in hearing thresholds. Seven patients (50%) had > 20% improvement in Word Recognition Scores and 8 patients (57%) had >10dB improvement in Speech Recognition Thresholds.

Conclusions: HBO2 improved overall hearing in 71% (10) in our case series. One had complete return to baseline, 64% (9) achieved modest hearing improvement with 57% (8) showing improvement in speech discrimination, including one patient with profound hearing loss and no improvement in sound pressure (dB).

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 133 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

D 12 Friday, June 29 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 3:30-4:00 RESIDENT COMPETITION: No

Hyperbaric oxygen treatment course completion and time to drop-out in a large outpatient sample Brailsford JB, Gordon HM, Ennis, WJ Healogics, 5220 Belfort Rd, Jacksonville, FL 32256 Presenting Author: Jennifer Brailsford, PHD [email protected]

Background: Consistent treatment adherence is important for the success of a medical treatment, oxygen included. Most early studies of hyperbaric oxygen (HBO2) therapy were efficacy trials in hospital settings, thereby ensuring full adherence to the treatment1. Although adherence inconsistencies have been noted in larger observational studies2, consequences of non-adherence have not been fully explored. Further, the reasons and average time to the discontinuation of HBO2 have not been examined. This study uses population level data from a large sample of patients treated with HBO2 in an outpatient setting to examine patterns in treatment course completion, reasons for discontinuation of care, and average time to drop-out by HBO2 indication.

Methods: This is a retrospective study using data from a nationwide outpatient wound care sample of patients who received at least one HBO2 treatment between 1/2014 and 7/2017 (N=37,119). Descriptive and bivariate statistics are used to examine patterns in treatment course completion and reasons for drop-out by HBO2 indication. Kaplan-Meier curves and Cox proportional-hazard models are used to assess time to drop out by indication and reason for quitting care.

Results: Preliminary analyses find substantial variation in treatment course completion with an average of 75% of physician ordered treatments completed per treatment course. Patients prescribed HBO2 for soft tissue radio necrosis and osteoradionecrosis have the highest completion rate and those prescribed HBO2 for diabetic ulcers having the lowest. On average, patients who did not complete the prescribed course of care only received 50% of ordered treatments. The most common reason selected for discontinuing care early was patient preference (43.3%).

Conclusion: In order to improve patient outcomes HBO2 treatment success, interventions aimed at identifying and eliminating barriers to consistent and successful treatment completion are critical. Efforts such as case management, patient education, and retention are critical to the success of HBO2.

1. Gijs H.J. de Smet, Leonard F. Kroese, Anand G. Menon, Johannes Jeekel, Antoon W.J. van Pelt, Gert-Jan Kleinrensink, and Johan F. Lange. (2017)“Oxygen therapies and their effects on wound healing.” Wound Repair and Regeneration 25:591-608 2. Margolis, D. J., Gupta, J., Hoffstad, O., Papdopoulos, M., Glick, H. A., Thom, S. R., & Mitra, N. (2013). Lack of effectiveness of hyperbaric oxygen therapy for the treatment of diabetic foot ulcer and the prevention of amputation: a cohort study. Diabetes care, 36(7), 1961-1966.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 134 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

D 13 Friday, June 29 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 3:30-4:00 RESIDENT COMPETITION: No

Advanced wound care assessment as a pre-cursor to HBO2: Improving diabetic foot ulcer outcomes Tremblay R, Michael M Florida Hospital, Wesley Chapel; University of South Florida, Tampa Presenting Author: Roma Tremblay, PHD [email protected]

Introduction: Diabetic foot ulcers (DFU), affect one in four persons with diabetes and leads to amputation for six in 1,000 persons. Despite recent evidence-based guidelines established by the International Working Group on the Diabetic Foot and the Society of Vascular Surgery recommending comprehensive vascular assessment of diabetic foot ulcers including pulse-volume-recording (PVR) with ankle-brachial-index (ABI), healthcare providers are slow to implement PVR with ABI as an assessment tool in early examination of patients with DFU as means to enhance identification of patients who may benefit from advanced wound treatments including HBO2.

Methods: To improve practice, this project implemented an evidence-based education intervention at a local advanced wound care and hyperbaric medicine clinic, with the aim of increasing the use of PVR with ABI in diabetic patients aged 40 to 60 with Wagner stage 2 or 3 DFU. A pre-test/post-test model was used to compare rates of PVR with ABI utilization in the 90 days prior and post intervention and to examine impact on HBO2 use.

Results: Findings indicated that the program was well-received by providers who reported increases in knowledge, self-efficacy, and intent to use PVR with ABI as an assessment strategy for DFU as a result of program participation. Providers self-reported intentions translated into actual practice change, and use of PVR with ABI increased 3-fold from 26% to 77% (p=.001) across the pre and post-intervention periods. While pre-and post-intervention groups were not significantly different at treatment onset, or 30 days after treatment start, significant differences were noted in rates of HBO2 utilization, Wagner Diabetic Foot Ulcer Grade, DFU volume, and in the rate of change (decrease) in DFU volume at 60 and 90 day follow up.

Conclusion: The educational intervention was effective at increasing use of PVR with ABI in health care providers. Implications for policy and practice are identified.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 135 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

D 14 Friday, June 29 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 3:30-4:00 RESIDENT COMPETITION: Yes

Hyperbaric oxygen therapy: A review of adverse event rates during treatment for radiation cystitis Owen E, Perdrizet G Division of Hyperbaric and Undersea Medicine, Department of Emergency Medicine, University of California, San Diego. 200 W. Arbor Dr. #8676 San Diego, CA 92103 Presenting Author: Elizabeth Owen, MD [email protected]

Introduction/Background: Hyperbaric oxygen (HBO2) therapy has been reported to treat many urinary bladder conditions. Chronic radiation cystitis is an Undersea and Hyperbaric Medicine Society approved indication under the diagnosis of delayed radiation injury. Various unapproved inflammatory diseases of the bladder, such as chronic interstitial cystitis/painful bladder syndrome (CIC/PBS), hemorrhagic cystitis, or viral cystitis have also been treated. This review was compiled in support of an investigational new drug application for the treatment of CIC/PBS. We focused this review on literature reports of adverse events related to HBO2 and secondarily include outcomes from these studies.

Materials and Methods: 54 publications were reviewed, encompassing diagnoses of radiation cystitis, CIC/PBS, hemorrhagic cystitis and others. A total of 68,256 hyperbaric treatment sessions were administered to 2,134 patients. The majority of patients received 30 treatment sessions at 2.0 or 2.5 ATA for 60 or 90 minutes.

Results: The overall mean severe adverse event rate is 1.3 ± 4.0% and clinical response rate is 82 ± 17%. The serious adverse events were exclusively generalized seizures due to CNS-oxygen toxicity and occurred once in six patients. The most common minor adverse events included ear pain, myopia and confinement anxiety.

Summary/Conclusions: The strength of this review is the demonstration of a consistently low incidence of severe adverse events from a large number of clinical reports representing diverse clinical settings. Patients consistently experienced clinical benefit with minimal risk of harm. This is especially noteworthy as the conditions that were successfully treated lack effective and safe alternative therapies.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 136 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

D 15 Friday, June 29 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 3:30-4:00 RESIDENT COMPETITION: No

Appraisal of six wound scoring systems and the Long Beach Wound Score Strauss MB, Moon H, Botros M, Lu LQ Memorial Care Long Beach Medical Center 2865 Atlantic Ave, Long Beach, CA 90806 Presenting Author: Michael B. Strauss, MD [email protected]

Introduction: Wound scoring systems grade wounds. Obviously, some have more value than others for comprehensiveness. This study evaluates six scoring systems, how they generate their scores, and how well they predict outcomes. This information is then integrated with our recently established reliability and validated Long Beach Wound Score (LBWS).

Methods: In addition to discussing the merits, scoring methods, and weaknesses of the Wagner, NPUAP, UTSADWC, IDSA-IWGDF, PEDIS and SINBAD wound scoring system, the items they used to generate their scores were categorized as Essential, Helpful, or Inconsequently for E & M of wounds. The frequency each item was used in the six systems was tabulated and compared with the features of the LBWS.

Results: Based on the effectiveness for wound E &M and Comparative Effectiveness Research (CER), only three of the six scoring systems were possibly Helpful. Only two were useful for assessing Minimal Clinical Import Improvement (MCII). The perfusion assessment was used in 4 of the 6 scoring systems and considered an Essential wound-scoring item. Wound appearance was the next most frequently used and was consider a Helpful item. Not unexpected, these two assessments gave the highest correlations with the validated outcomes from the previously published LBWS. Depth and infection of the wound were next in frequency and importance. Neuropathy was used in two scoring systems; it was considered Inconsequently for evaluation and only of limited value for wound management.

Conclusions: The utilization of the essential elements of six wound scoring systems, its intuitive 0 to 10 (best) score, and its ability to quantify severity of each assessment makes the LBWS a logical tool for E & M of wounds, CER, and MCII.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 137 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

D 16 Friday, June 29 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 4:00-4:30 RESIDENT COMPETITION: No

Radiation myelitis of cervical spinal cord successfully reversed by hyperbaric oxygen therapy Cianci PE, Costello PJ Dept. Of Hyperbaric Medicine Doctors Hospital San Pablo, California Presenting Author: Paul Cianci, MD [email protected]

Introduction: Radiation myelitis is a very serious but fortunately rare consequence of radiation therapy. Few cases treated with HBO2 have been reported. We present the case of a 14-year-old female adolescent who developed myelitis as a result of cervical melanoma treated with 5000 cGy after a radical neck dissection showing multiple node and sternocleidomastoid involvement.

Sequence of events: The patient underwent a radical neck dissection followed by radiation therapy. Six months post radiation she developed paresthesias, incontinence of bowel and bladder and inability to walk. These signs and symptoms were rapidly progressive. An MRI showed edema of the cervicolmedullary junction of the cord with extension to T1. At this point (7 months post-radiation), she was referred for hyperbaric oxygen therapy.

Patient course: Marked improvement was observed within the first month after 20 treatments at 2 ATA for 120 minutes daily. Over a two month period her symptoms and signs resolved. She regained bowel and bladder control and was ambulating without difficulty. An MRI showed complete resolution of prior abnormalities.

Follow-up: The patient entered high school, made a straight A average, passed her drivers exam, went to her prom and entered the University California, Berkeley. This case underscores the need for early hyperbaric consultation in spinal cord myelitis secondary to radiation therapy and the importance of educating our colleagues as to the benefit of hyperbaric oxygen therapy in these difficult cases.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 138 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

D 17 Friday, June 29 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 4:00-4:30 RESIDENT COMPETITION: No

Adjunctive hyperbaric oxygen therapy with isavuconazonium in the treatment of mucor Evangelista J Henry Ford Hospital 2799 West Grand Boulevard, Detroit, MI 48202 Presenting Author: Jose Evangelista, MD [email protected]

Background/Introduction: Invasive rhino-orbito-cerebral mucormycosis is notoriously difficult to treat. Previously, it was thought that use of HBO2 as adjunctive therapy was of marginal evidence, however a recent number of case reports have demonstrated success in improving outcomes of these patients.

Results: 39-year-old female with DM2 (HbA1c 13.7), presented with right eye pain, vision loss, ptosis, exophthalmos, loss of pupil reactivity, and progressive ophthalmoplegia. Initial radiologic, microbiologic cultures, and endoscopic evaluation was not suggestive of invasive mucor. MRI demonstrated right cavernous sinus thrombosis. Repeat MRI 3 days later showed progression of the disease with necrosis. She was then taken to the OR for sphenoidotomy / washout / and orbital skeletal muscle and soft palate biopsies that grew rhizopus as well as Candida albicans. Amphotericin B and isavuconazonium therapy was initiated. Due to acute renal failure, Amphotericin B was discontinued and she was discharged on mono therapy with isavuconazonium. Adjunctive HBO2 was started 27 days later and she completed 60 sessions. Repeat MRI 4 months later showed slight improvement of periorbital and intraorbital soft tissue enhancement and edema within the right orbit. ENT evaluation at that time showed healthy mucosa and no necrosis. At 9 months, mucosal findings remained stable and ocular chemosis was improved.

Conclusions: HBO2 with anti-fungal therapy and surgical debridement should be considered standard of care for patients with invasive rhino-orbito-cerebral mucormycosis. Isavuconazonium is usually considered second line therapy; however, in this case report, it is used in combination with HBO2, resulting in a good clinical outcome. This is in contrary to previous literature which suggests that azole therapy is inferior. Consideration should be made to pursue combination therapy with isavuconazonium and HBO2 especially in patients intolerant to amphotericin B. Further studies need to be completed to evaluate the optimal duration of therapy.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 139 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

D 18 Friday, June 29 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 4:00-4:30 RESIDENT COMPETITION:Yes

Impact of hyperbaric oxygen therapy in a child with delayed soft tissue radiation necrosis of the brain Dapena JC, Siegel M Department of Undersea and Hyperbaric Medicine, University Medical Center, New Orleans LA Presenting Author: Juan C. Dapena, MD [email protected]

Introduction: Radiation necrosis of the brain is a well-known toxic effect in the treatment of brain tumors. In the absence of available effective treatments other than surgery, hyperbaric oxygen therapy continues to be a viable option.

Case Report: A 6-years-old male developed emesis, constipation, hypersomnia, and complained of “brain pain” over a month, with multiple normal evaluations by a pediatrician. Pediatric gastroenterology was consulted with concerns for reflux. Physical exam was “normal” except for the child’s extreme somnolence, for which he was referred to the emergency department for a CT scan of the head which revealed multiple tumors in the brain. Neurosurgery department was consulted and surgery was scheduled for next day, resulting in the diagnosis of Medulloblastoma Type 4. He remained in the hospital to undergo physical therapy and rehabilitation. Upon discharge he started chemotherapy in combination with radiotherapy for 6 weeks, followed by “aggressive chemotherapy”. Two months later he stopped eating, for which he was fed via a nasogastric tube for a short period of time. Four months later he was afflicted with. He was admitted for treatment with steroids, resulting in the resolution of his respiratory and gastrointestinal conditions. During that same admission, he developed respiratory failure requiring endotracheal intubation for one week, resulting in self-extubation while trying to wean him off the ventilator. A subsequent ENT evaluation resulted in the diagnosis of vocal cord dysfunction for which a tracheostomy was performed. At the same time a G-tube was placed to protect the child from aspiration pneumonia. The following month his level of activity and development was as expected from an otherwise healthy 6-years-old child, meeting all developmental milestones. Five months later the child became weak, stopped playing, and his hypersomnia reoccurred. Evaluation by Hematology-Oncology did not reveal any etiology at that time, but a month later a CT scan revealed brain soft tissue changes that were confirmed by a subsequent MRI as radiation necrosis of the brain. Upon discharge from inpatient rehabilitation the child was quadriplegic, with minimal facial movements or expressions, and no somatic reflexes. Consultation to the Hyperbaric Medicine Department was done and treatment initiated immediately, in conjunction with aggressive physical therapy at home. Progressive improvement in the child’s spontaneous and intentional use of his upper body muscles has been documented.

Conclusions: This case illustrates the importance of hyperbaric oxygen therapy for the treatment of delayed radiation necrosis of the brain, a condition with severe repercussions in the absence of available treatments other than surgical intervention. It also emphasizes the importance of keeping a high suspicion for known toxic effects of radiation therapy to the brain.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 140 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

D 19 Friday, June 29 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 4:00-4:30 RESIDENT COMPETITION: No

Hyperbaric oxygen therapy for the treatment of delayed frostbite injury Johnson-Arbor K MedStar Georgetown University Hospital, 3800 Reservoir Road NW, Washington DC 20007 Presenting Author: Kelly Johnson-Arbor, MD [email protected]

Introduction: Frostbite injury involves repeated freeze-thaw cycles which lead to arterial insufficiency and tissue ischemia. Hyperbaric oxygen (HBO2) therapy is often suggested as a treatment for acute frostbite injury, but may also be beneficial in delayed presentations of frostbite injury.

Case Report: A 28-year-old female with no past medical history, sustained frostbite to her feet during a 36-hour winter hike in the California mountains. Her toes, which initially appeared edematous and purple after she descended from the mountain, developed progressively gangrenous changes within days of the hike. She sought care from an orthopedic surgeon who advised her to wait for full demarcation of the injury before proceeding with amputations. Unsatisfied with this recommendation, she presented for HBO2 consultation three weeks after the initial injury. At this time, she was noted to have triphasic Doppler signals in her pedal arteries, but her toes were dusky with dry necrosis present. She started HBO2 treatments and received a total of 40 treatments. She was prescribed pentoxifylline and ibuprofen in accordance with Wilderness Medical Society recommendations, and also underwent serial lumbar sympathetic nerve blocks. Her toes gradually became less necrotic in appearance; at the conclusion of her HBO2 regimen, the patient’s toes were pink and fully sensate.

Discussion: The mechanisms of action of HBO2 in frostbite injury are likely multifactorial and include hyperoxygenation of ischemic tissue, increased red blood cell deformability, edema reduction, and reduction of ischemia/reperfusion injury. The timing of HBO2 administration is not well established; HBO2 may have a beneficial effect in frostbite injury patients even when administered weeks after the initial injury.

Conclusions: Administration of HBO2 in frostbite patients can result in reduced need for amputations and surgical intervention. Even in cases of delayed presentation, HBO2 should be considered as primary treatment for frostbite injury.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 141 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

D 20 Friday, June 29 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 4:00-4:30 RESIDENT COMPETITION: No

Use of hyperbaric oxygen therapy for lower-extremity sickle cell ulcerations Johnson-Arbor K MedStar Georgetown University Hospital Presenting Author: Kelly Johnson-Arbor, MD [email protected]

Introduction: The treatment of lower-extremity ulcers related to sickle cell anemia can be challenging. We present the successful use of hyperbaric oxygen (HBO2) therapy in a patient with sickle cell leg ulcerations.

Case Report: A 45-year-old non-diabetic female was referred for hyperbaric medicine consultation due to non-healing and refractory right ankle wounds which had been present for over a year. The patient had a history of sickle cell anemia; her disease typically manifested as hemolytic crises, not pain crises. Her medications included folic acid, naproxen, and gabapentin; she had previously been prescribed hydroxyurea, but had discontinued this several months earlier due to the presence of the wounds. She had a history of a previous wound which healed after a course of HBO2 five years earlier. Her current wounds had not shown signs of improvement despite use of topical wound products, serial debridements, and culture-directed antibiotics. On examination, the patient had two full thickness wounds present on her right lateral ankle with a sloughy appearing wound base; there was no surrounding warmth, erythema, or other signs of infection. Triphasic Doppler signals were present in the right dorsalis pedis and posterior tibial distributions. After insurance authorization was obtained, the patient underwent daily hyperbaric compression to 2.5 ATA. After 35 HBO2 treatments, the right leg wounds had healed, and HBO2 treatments were discontinued.

Discussion: The mechanisms of action of HBO2 in patients with sickle cell ulcerations may include stem cell induced neovascularization and enhanced oxygen delivery to the ischemic wound tissue. Hydroxyurea use is associated with lower extremity ulcerations in this patient population; this medication should ideally be discontinued should ulcerations occur.

Conclusions: In patients with refractory or hard-to-heal lower-extremity ulcerations due to sickle cell anemia, use of HBO2 may result in a markedly improved wound healing ability.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 142 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

D 21 Friday, June 29 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 4:00-4:30 RESIDENT COMPETITION: No

Use of hyperbaric oxygen therapy for treatment of acute skin necrosis after a “Brazilian butt lift” Johnson-Arbor K MedStar Georgetown University Hospital Presenting Author: Kelly Johnson-Arbor, MD [email protected]

Introduction: The “Brazilian butt lift” (BBL) procedure, involving autologous fat transfer from other parts of the body to the buttocks for the purposes of buttock augmentation, is an increasingly commonly performed cosmetic surgical procedure in the United States. Acute skin necrosis is a recognized complication of this procedure. We report the successful use of hyperbaric oxygen (HBO2) therapy to treat two cases of acute skin necrosis after BBL.

Case Report: Case 1: A 33-year-old, 44-kg female underwent BBL with 1000 CCs of fat transfer into each buttock cheek. On postoperative day #2, she was noted to have bruising and erythema of her buttocks consistent with acute skin necrosis, and she was referred for HBO2 consultation. She underwent 7 HBO2 treatments to 2.5 absolute atmospheres (ATA), after which she experienced complete resolution of her skin necrosis with a satisfactory aesthetic outcome.

Case 2: A 42-year-old female underwent BBL with 150 CCs of fat transfer into each buttock cheek. She developed blistering to the right buttock on postoperative day #1 which progressed into dusky discoloration by the following day. She was referred for HBO2 consultation, and underwent 7 HBO2 treatments with compression to 2.5 ATA. Her buttock blistering and discoloration resolved by the conclusion of her HBO2 treatment course.

Discussion: During autologous fat transfer procedures, injection of large amounts of fat into a confined space can lead to acute tissue necrosis. Prompt administration of HBO2 can restore oxygenation to the ischemic tissue regions, leading to resolution of necrosis.

Conclusions: In patients who exhibit skin discoloration and necrosis after cosmetic procedures such as the BBL, prompt administration of HBO2 can improve tissue oxygenation and achieve an acceptable cosmetic outcome.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 143 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

D 22 Friday, June 29 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 4:00-4:30 RESIDENT COMPETITION: No

Decision-making for limb-threatening wounds Strauss MB, Moon H, Miller SS, Lu LQ Memorial Care Long Beach Medical Center 2865 Atlantic Ave, Long Beach, CA 90806 Presenting Author: Michael B. Strauss, MD [email protected]

Introduction: All wound-scoring systems use assessments to determine severity, which may or may not help make decisions about management. Especially important are scoring criteria that help make decisions for life and limb threatening conditions. We provide an approach that uses tangible, quantifiable parameters to help make decisions for the care provider as well as the patient and/or the patient’s advocate.

Methods: Over a 12-year period we developed a reliable and validated wound scoring system that objectifies the wound evaluation and management decision process. Our 0 to 10-point Long Beach Wound Score (LBWS) is used to categorize wounds as Healthy, Problem, or End-stage. If in a Transition Zone between Problem and End-stage (2 ½ to 4 points), we utilize supplemental information from Wellness and Goal Scores (WGS), each using five 0 to 2-point graded objective findings to generate 0 to 10-point scores.

Results: This approach using objective WGS has made it possible to offer sensible recommendations and initiate appropriate management for Transition Zone LBWS wounds. The result is that advice is offered to the patient or advocate for which of three permutations, 1) Limb salvage = WGS each >4 points, 2) Palliative care = one or the other WGS >4 points, or 3) Comfort/hospice support = WGS each <4-points would best serve the patient.

Conclusions: Our system has become a useful tool for evaluating and managing wounds in the Transition Zone where additional information is needed to justify doing everything possible to salvage the wound versus palliative (including amputation) or comfort care only measures. We feel our WGS are equally applicable for helping to make “End of Life” decisions and is being shared with our hospital’s Bioethics Committee.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 144 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

D 23 Friday, June 29 ORAL PRESENTATION TIME: POSTER PRESENTATION TIME: RESIDENT COMPETITION: No

WITHDRAWN

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 145 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

D 24 Friday, June 29 ORAL PRESENTATION TIME: POSTER PRESENTATION TIME: RESIDENT COMPETITION: No

WITHDRAWN

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 146 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

D 25 Friday, June 29 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 4:00-4:30 RESIDENT COMPETITION: No

Femoropopliteal Doppler velocities associated with hyperbaric oxygen treatment session of diabetic patients with leg ulcers Maran CA1, Salles-Cunha SX2, Millazo PAA1, Farias PSR1, Castro IJL1, David JRN1, David RAR1 1Centro de Medicina Hiperbárica do Nordeste. Salvador, BA, Brazil; 2Consultant, Itanhaém, SP, Brazil Presenting Author: Cristiane Antequeira Maran, MD [email protected]

Introduction/background. Hyperbaric oxygen (HBO2) therapy improves healing of leg ulcers. HBO2 effectiveness still demands investigation. Doppler measurement of peak systolic velocity (PSV) is a simple technique to note blood flow changes. HBO2 is vasocostrictive: increased oxygen content reduces blood flow. In contrast, ulcers cause vasodilatation. The initial question was “What are the femoropopliteal PSV responses pre and post an HBO2 session?” Future research will address if PSV responses to HBO2 are associated with faster, improved ulcer healing.

Methods. Common femoral and popliteal PVS were measured in 32 legs of 30 patients, 61±12 (SD) (range 29-85) years old; 97% hypertensive, 80% diabetic, and 23% insulin-treated. Prevalence of increased (≥10%), unchanged (within 10%) or decreased ((≥10%) PSV were determined. Absolute values of specific subgroups were compared by t-test statistics.

Results. Common femoral or popliteal PSV changed with equal prevalence: increase in 11 (34%), unchanged in 8 (25%) and decrease in 13 (41%) extremities. Subgroups identified included: I) decreased velocities (n=12, 37.5%), II) contradictory femoropopliteal differences with increased/decreased velocities (n=10, 31%), III) increased velocities (n=6, 19%), and IV) unchanged velocities (n=4, 12.5%).Common femoral PSV were similar pre HBO2 for subgroups I and III, 123±37 vs 116±19 cm/s (p=.66), changing to 104±26 and 144±29 cm/s (p=.01) post HBO2. In general, popliteal PSV either decreased (d)-increased(i) from 79±22(d)-59±19(i) cm/s (p=.02) to 58±18(d)-82/20 (i) cm/sec (p=.004).

Conclusions. Doppler PSV was a simple technique to pinpoint HBO2 blood flow responses. Expected vasoconstriction with HBO2, based on decreased PSV, may have occurred in most extremities (69%, 22/32), suggesting return to normal, physiological behavior. Complex responses, however, predominated: e.g. popliteal PSV being affected by femoral stenosis. These data suggest research to monitor PSV during HBO2: detection of expected, normal vasoconstriction could contribute to predict effective, faster ulcer healing.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 147 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

D 26 Friday, June 29 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 4:00-4:30 RESIDENT COMPETITION: No

Smoking paradox in the development of delayed neuropsychiatric sequelae among acute carbon monoxide (CO) intoxication patients with hyperbaric oxygen therapy Lee Y 170, Jomaru-ro, Bucheon-si, Gyeonggi-do, Republic of Korea Presenting Author: Younghwan Lee, MD [email protected]

Smoking is a major risk factor for myocardial infarction (MI), ischemic stroke (IS), and cardiovascular death. However, several recent studies observed reduced recurrence of cardiovascular events and an improved survival in smokers with antithrombotic therapy. This phenomenon is called “smoker’s paradox.” We performed this study to determine whether the difference in delayed neuropsychiatric sequelae (DNS) after acute carbon monoxide (CO) intoxication by current smoking status. We retrospectively reviewed medical records for patients who visited an emergency medical center of our university hospital over a 12-month period from December 2016 to December 2017.

Among 160 patients with acute monoxide poisoning, 121 patients with hyperbaric oxygen therapy were enrolled in this study. Enrolled patients were divided into 2 groups, patients with or without DNS. DNS developed in 10 patients. In bivariate analysis, there was also a statistical difference between the non- DNS group and the DNS group in terms of CO exposure time, Glasgow Coma Scale (GCS), loss of consciousness, creatinine kinase, and troponin I, current smoking (p= 0.03). The area under the curve according to the receiver operating characteristic curves of current smoking was 0.793 respectively. In conclusion, there is no clear explanation for this association, which seems to be the true unyielding smoker’s paradox in our data. Current smoking is associated with lower rate of DNS.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 148 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

D 27 Friday, June 29 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 4:00-4:30 RESIDENT COMPETITION: No

The historical priority of South America in hyperbaric research and practice Brito T1, Subbotina N2 1OHB-RIO Hiperbárica, Brazil and 2Centro de Medicina Hiperbárica Buenos Aires, Argentina Presenting Authors: Tomaz Brito, MD and Nina Subbotina, MD [email protected]

Introduction. The beginning of scientific hyperbaric oxygen treatment is attributed to the late 50s in Europe and USA. Due to limited spread of information, researches done in Brazil and in Argentina thirty years before are still unknown.

Material & Methods: The original papers of Ozório de Almeida et Cols. in Brazil and Sebastian A. Rosasco et Cols., in Argentine.

Results: Ozório de Almeida and his associates noted clinical improvement in Hansen disease patients participating in experimental HBO2 anticancer therapy. His scientific results were published in 1938 in Brazil, France and Germany. He showed favorable outcome in HBO2 application simultaneously with methylene blue.

The Argentinean group was unaware of the previous Brazilian studies at the time of their investigation, but later, they were informed about the pioneer work of Dr. Ozório de Almeida. Therefore, their publications in 1969, were independent from the Brazilian experience. They investigated the effects of high-pressure oxygen on the Mycobacterium leprae, the clinical protocols of HBO2 for the lepromatous leprae patients, the Warburg metabolic coefficient in the lepromatous skin bioptates (bioptic specimens) and the response to hyperbaric oxygen by bacteriological, anatomic-pathological and clinical findings. The patients were grouped in accordance with the clinical stages of their disease. Biochemical data such as AMP, ADP, ATP, lactic and pyruvic acids, some dehydrogenases, lipids and free glycerol in blood, before and after HBO2 treatment with different protocols, were obtained.

Discussion: This review of Brazilian and Argentinian articles highlights the role of HBO2 as an innovative Hansen´s disease treatment, but also calls for the historic fact that HBO2 in the American Continent begin in Brazil and Argentine.

Conclusion. The chronological and scientific priority of South American researchers in HBO2 in Leprae lepromatous and gas gangrene must considered in the history of hyperbaric medicine.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 149 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

D 28 Friday, June 29 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 4:00-4:30 RESIDENT COMPETITION: No

Successful artificial sphincter placement for urinary incontinence in the setting of radiation cystitis with adjunctive hyperbaric oxygen therapy: A case study Boes T, Morgan M, Sharma D, Santiago W, Mariani P, Heyboer M Upstate University Hospital - Downtown Campus Rm. 1528, 750 East Adams Street Syracuse, NY 13210 Presenting Author: Tanner Boes, MD [email protected]

Introduction/Background: Radiation cystitis is a recognized complication of pelvic radiotherapy, with frequencies quoted in the region of 5% to 10% depending on the series. Urinary symptoms include dysuria, frequency, urgency, incontinence, and hematuria. Treatment modalities are sub-classified into systemic therapies, intravesical therapies, and hyperbaric oxygen and interventional procedures. Cure rates range from 76 to 95% for hyperbaric oxygen (HBO2) therapy.

Materials and Methods: 52 year old male with a history of prostate cancer, robotic prostatectomy, and adjuvant radiation who presented with over one year of urinary incontinence and secondary groin dermatitis. Radiation cystitis diagnosis was made via cystoscopy. He failed macroplastique injection, then developed a bladder neck contraction. He required bladder neck reconstruction with buccal mucosa graft (BMG), which also failed. He then agreed to artificial sphincter placement with the hope of a definitive correction for his incontinence. He was referred for hyperbaric oxygen therapy (HBO2) prior to the surgery.

Results: The patient underwent HBO2 to a maximum compression of 2.5 ATA for 90 minutes. He completed 40 treatments pre-procedure. His cystoscopy during artificial sphincter placement showed significant improvement in his radiation cystitis. He completed an additional 17 treatments post- operatively for a total of 57 treatments. While the patient did require a small location adjustment of the pump activation button due to scar tissue, the device functioned well, he regained continence, and his secondary groin dermatitis resolved.

Summary/Conclusions: We present a case of urinary incontinence and groin dermatitis in the context of radiation cystitis. The patient failed two separate incontinence procedures prior to undergoing HBO2, and was noted to have friable, unhealthy soft tissue radionecrosis by his urologist. He completed 40 pre-procedure and 17 post-procedure hyperbaric oxygen treatments. He now has robust urological tissues in a prior irradiated field, a successful incontinence procedure, and a greatly improved quality of life.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 150 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

D 29 Friday, June 29 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 4:00-4:30 RESIDENT COMPETITION: No

Hyperbaric oxygen treatments for vasculitis induced by levamisole containing cocaine Ptak J, Reetz S, Buckey J Center for Hyperbaric Medicine at DHMC, One Medical Center Drive, Lebanon, NH 03756 Presenting Author: Judy Ptak, RN/CHRN [email protected]

Introduction/Background: Levamisole is an antihelminthic drug currently approved for use only in animals. The FDA banned its use in humans in 2000 due to adverse side effects. In late 2009, cases showing the characteristic cutaneous lesions from levamisole were seen in cocaine users and were attributed to cocaine which had been mixed with levamisole. Current estimates suggest 70% of cocaine in the United States contains levamisole.

Materials and Methods: We were called to evaluate a 44-year-old woman with a history of cocaine abuse who had been admitted 2 days earlier with a 2-day history of rapidly spreading, painful ecchymosis that developed into bullae which ruptured. These lesions were widespread over her entire body. The patient had been using cocaine and the dermatology service diagnosed levamisole-induced vasculitis. Since ischemia was felt to be a significant component of these lesions, hyperbaric oxygen treatments (HBO2) at 2.4 ATM once a day were initiated.

Results: After 10 HBO2 treatments, the acute phase of the illness was felt to be over with no more ongoing ischemia and necrosis. HBO2 was stopped and lesions continued to heal over an extended period of time.

Summary: The introduction of HBO2 early in the patient’s course likely reduced tissue necrosis and reduced hospital stay time. HBO2 may be a useful adjunct early in the course of levamisole- induced vasculitis.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 151 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

D 30 Friday, June 29 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 4:00-4:30 RESIDENT COMPETITION: No

Closing RICH-ART study: Radiation-induced cystitis treated with hyperbaric oxygen – A randomized controlled trail Oscarsson N, Bueller B, Seeman-Lodding H Anesthesiology and Intensive Care, Institute of Clinical Science, Gothenburg University, Gothenburg Presenting Author: Nicklas Oscarsson, MD [email protected]

Introduction/Background: Evidence for the treatment of radiation-induced cystitis with HBO2 therapy is scarce, and only one randomized trial on the issue has been published. Here, we present the methodology and preliminary inclusion-numbers of a randomized controlled trial soon to be finished.

Materials and Methods: RICH-ART is a multicenter study with contribution from five hyperbaric centers. We aimed to include 80 patients with relevant clinical symptoms of late radiation induced cystitis and cystoscopic sign of radiation injury. Measurements at baseline included patient-reported symptoms (EPIC), Quality of life (SF-36), cystoscopy with urologic measures (bladder-capacity, residual urine) and biopsy for histologic analysis.

Patients in the treatment-group (A) started HBO2 within 6 weeks from baseline (40 treatments within 60 calendar-days, 2.4-2.5 ATA, 100% oxygen for 90 min.). Patients in the control-group (B) received no treatment. At visit 2, 6-8 months after baseline, all measurements were repeated for both groups. Visit 2 defines the end of the main study. Patients in group B were offered HBO2 after completion of the main study. Patients will be followed-up for 5 years with annual registration of EPIC and SF-36 scores. The study is independently monitored. Analysis of predefined outcome-measures will be performed according to a statistic analysis plan.

Results: The listed numbers are preliminary. The study started 2012-09-01 and closed 2017-01-01. 209 patients have been referred to the participating centers, 119 screened for inclusion and 91 subjects included of which 12 have been excluded after randomization. By April 12th 2018, 79 patients were still included, 75 had finished visit 2. The last visit of the last subject is expected due in June 2018 and analysis and publication will be advanced thereafter.

Summary/Conclusions: This randomized and controlled trial on HBO2 for bladder LRTI with a significant number of patients is nearly completed and results expected within one year.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 152 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

PLENARY: HBO2 AND DFU 4:30 PM – 5:30 PM

4:30 – 5:00 Dirk Ubbink, MD "The effectiveness and costs of hyperbaric oxygen therapy for diabetic ischemic ulcers: Results of the DAMOCLES multicenter trial"

This trial was conducted in 9 hyperbaric centers and 25 referring hospitals to find out whether additional HBO2 would benefit patients with diabetes and ischemic leg ulcers. We randomized 120 diabetic patients with an ischemic wound to standard care without (SC) or with HBO2 (SC+ HBO2). Primary outcomes were limb salvage and wound healing, amputation-free survival (AFS), and direct and indirect medical costs. Limb salvage was achieved in 47 patients in the SC group vs. 53 patients in the SC+ HBO2 group. After 12 months, 28 index wounds were healed in the SC group vs. 30 in the SC+ HBO2 group. AFS was achieved in 41 patients in the SC group and 49 patients in the SC+ HBO2 group. In the SC+ HBO2 group 21 patients (35%) were unable to complete the HBO2-protocol as planned. Those who did had significantly fewer major amputations and higher AFS. Overall costs were slightly higher in the SC+ HBO2-group.

5:00 – 5:30 Michael Strauss, MD "The Long Beach Wound Score as a validated tool for comparative effectiveness research of wounds and objectifying the indications for hyperbaric oxygen"

The Long Beach Wound Score (LBWS) is a validated wound scoring system that is user-friendly, intuitively obvious and applicable for all wounds - not just diabetic foot ulcers. Five assessments, each graded from 2-points (best possible) to 0- points using objective criteria to grade each, are summated to generate 0 to 10- point scores. The scores then quantify three wound categories; "Healthy" 7.5 to 10 points, "Problem" 3.5 to 7 points and "End-stage" 0 to 3 points. The assessments include: 1) Appearance of the wound base, 2) Size--including undermining, 3) Depth--to wound base or bottom of a tract, 4) Infection and 5) Perfusion. For wounds in the "Healthy" category only simple wound care and, occasionally, biologics are needed for management. Deep infection, deformity, and/or ischemia are invariable present in the "Problem" wound category. These require debridements and antibiotics plus revascularization and/or hyperbaric oxygen (HBO2). Juxta-wound transcutaneous oxygen measurements in room air and with HBO2 objectify when this modality is indicated for wound management. Wounds in the "End-stage" category require amputation or revascularization if salvage is indicated. The decision for amputation versus salvage in a "Transition" zone (LBWS in the 2.5 to 4 point range) require information about the patients' wellness and goals, both quantified by 0 to 10 scores as intuitively obvious and easy to use as the LBWS. With 24 billion dollars a year being spent in the USA for management of chronic wounds, comparative effectiveness research (CER) is needed to evaluate the effectiveness, cost benefits, and convenience of wound care. The essential consideration for CER is using a wound scoring system that objectifies the evaluation so "like can be compared with like." The LBWS is the reliable (similar scores by two or more observers) and validated tool that meets this requirement. With the LBWS the UHMS has the potential to establish a registry, document the effectiveness of interventions and become the "go to" source for payers to justify authorizations for wound management including HBO2 treatments. ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 153 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 154 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

SATURDAY, JUNE 30

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 155 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 156 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

PLENARY: EMERGING INDICATIONS FOR HYPERBARIC OXYGEN THERAPY 8:00 AM – 10:00 AM

8:00 – 8:30 Enrico Camporesi, MD "Aseptic Bone Necrosis and Hyperbaric Oxygen Therapy"

Osteonecrosis of the knee (ONK) is a form of aseptic necrosis resulting from ischemia to subchondral bone tissue. Typically, common surgical treatments are invasive and palliative or time-limited. Hyperbaric oxygen (HBO2) therapy may provide a non-invasive alternative by improving oxygenation and reperfusion of ischemic areas, both for distal femoral condyli, as recently described, or for a similar malady of the femoral head, previously published. We recently described 37 ONK patients (29 male, 8 female; mean age ±1 SD: 54±14). 83.7% of patients presented with Aglietti stage I-II; 16.3% presented with Aglietti stage III. Patients were treated with HBO2 once a day, five days a week, at 2.5 ATA with 100% inspired oxygen by mask for an average of 67.9±15 sessions. Magnetic resonance imaging was performed before HBO2, within one year after completion of HBO2, and in 14 patients, 7 years after treatment. Oxford Knee Scores (OKS), an index of functionality, where 60 is normal, were recorded before HBO2 and at the end of each HBO2 treatment cycle. After the 30 sessions of HBO2, 86% of patients experienced improvement in their OKS, 11% worsened, and 3% did not change. All patients improved in OKS after 50 sessions. MRI evaluation 1 year after HBO2 completion showed that edema at the femoral condyle had resolved in all but one patient. MRI at 7 year after completing therapy were all normal. In conclusion, HBO2 is beneficial in ONK. Patients experienced improvements in pain and mobility as demonstrated by improvement in OKS. Radiographic improvements were also seen upon post treatment follow-up. Aglietti staging for the entire sample saw an aggregate decrease (p < 0.01) from 1.7 ± 0.7 to 0.3 ± 0.6.

8:30 – 9:00 Gerardo Bosco, MD "Hyperbaric pre-conditioning"

Pre-conditioning (PC) has been described as the hyperbaric oxygen (HBO2) experience before a critical event, with the aim to prevent a specific clinical condition, and its development as a valuable complement both in diving medicine (Bosco, 2010) as well as prior to ischemic or inflammatory situations. PC is a preventive treatment that triggers endogenous cascades, which can protect from stress-activated and stress-reactive responses. A possible mechanism of HBO2-PC mediating beneficial effects has been described as attenuation of the production of proinflammatory cytokines in response to an inflammatory stimulus such as surgery and modulation of the immune response. HBO2-PC protocols are performed at 2.0–2.5 atmospheres absolute (ATA), and usually only applied for one or a few days. The physical adaptations in response to alterations in atmospheric oxygen appear to extend not only to survival, but also a pre-conditioned state.

Similar to ischemic and stress pre-conditioning, many different paradigms have been used to ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 157 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY demonstrate that either rapid or delayed tolerance is affected by the HBO2 therapy. Irrespective of the cause of injury, inflammatory cytokines released after the primary event trigger leukocyte activation and free radical release, causing secondary damage and extension of injury. Thus, modulating inflammatory molecules has the potential benefit of limiting leukocyte-mediated extension of injury. Many studies demonstrated a protective mechanism of HBO2-PC in the injured brain, heart, or liver. Previous data by Yang and colleagues on animals demonstrated that HBO2 inhibits TNF-α production during intestinal, brain and muscle ischemia-reperfusion and it has a beneficial effect, mediated by decreased production of IL-6, IL-1β, dopamine and lactate (Bosco, 2007; Yang, 2001;2006;2010). Studies on animals showed that HBO2-PC can protect the brain from ischemia-reperfusion injury and that Sirt1 is a potential molecular target for therapeutic approaches (Ding, 2017). In man, HBO2-PC induces endogenous cardioprotection subsequent to ischemic reperfusion injury (Allen, 2014). Additionally, clinical HBO2-PC showed effects before surgery. A single preoperative hyperbaric oxygen treatment on the day before surgery may reduce the complication rate in pancreatic resection (Bosco, 2014). In liver surgery, studies demonstrated to increase the number of new cells and the density of microcirculation in the regenerating liver after HBO2-PC (Theodoraki, 2011). Furthermore, hyperbaric oxygen preconditioning improves postoperative dysfunctions by reducing oxidant stress and inflammation (Gao, 2017). A recent experimental paper has identified an important mechanism involved in triggering the beneficial effect of HBO2-PC, as the intracellular induction of heme-oxygenase-1 in hepatic IR injury. Moreover, in dive medicine HBO2-PC reduced bubble formation and platelets activation; HBO2-PC might enhance lymphocyte antioxidant activity and reduce reactive oxygen species levels. Pre-breathing oxygen in water may also preserve calcium homeostasis, suggesting a protective role in the physiological lymphocyte cell functions (Bosco, 2010; Morabito, 2011). Whether the various pre-conditioning protocols contribute to the different results, they should be investigated in further studies and applied to diverse surgical procedures, especially major surgeries leading to postoperative ICU admission. Therefore, HBO2-PC is an encouraging and feasible therapeutic strategy for protecting organs from the subsequent lethal stimulus.

References

1. Ding P, Ren D, He S, He M, et al (2017). Sirt1 mediates improvement in cognitive defects induced by focal cerebral ischemia following hyperbaric oxygen preconditioning in rats. Physiological research, 66(6). 2. Yang ZJ, Bosco G, Montante A, Ou XL and Camporesi EM (2001) Hyperbaric O2 reduces intestinal ischemia- reperfusion-induced TNF-a production and lung neutrophil sequestration. Eur J Appl Physiol 85: 96-103 3. Yang Z, Nandi J, Wang G, Bosco G, et al. (2006) Hyperbaric Oxygenation ameliorates indomethacin- induced enteropaty in rats by modulating TNF-a and IL-1 b production. Dig Dis Sci 34(1-2):70-6. 4. Bosco G, Zj Yang, J Nandi, Jp Wang, et al. (2007) Effects of hyperbaric oxygen on glucose, lactate, glycerol and antioxidant enzymes in the skeletal muscle of rats during ischemia and reperfusion. Clin Exp Pharmacol Physiol 34, 70-76. 5. Yang Zj, Bosco G, Xie Y, Chen Y, Camporesi EM. (2010) Hyperbaric oxygenation alleviates MCAO-induced brain injury and reduces hydroxyl radical formation and glutamate release. Eur J Appl Physiol. Feb;108(3):513-22. 6. Bosco G, Yang Zj, Di Tano G, Camporesi EM, et al. (2010) Effect of in-water versus normobaric oxygen pre- breathing on decompression-induced bubble formation and platelet activation. J Appl Physiol. May;108(5):1077-83. 7. Morabito C, Bosco G, Pilla R, Corona C, et al. (2011) Effect of pre-breathing oxygen at different depth on oxydative status and calcium concentration in lymphocytes of scuba divers. Acta Physiol (Oxf). May;202(1):69-78. 8. Bosco G, Casarotto A, Nasole E, Camporesi E, et al. (2014). Preconditioning with hyperbaric oxygen in pancreaticoduodenectomy: a randomized double-blind pilot study. Anticancer research, 34(6), 2899- 2906. 9. Theodoraki K, Tympa A, Karmaniolou I, Tsaroucha A, et al. (2011). Ischemia/reperfusion injury in liver resection: a review of preconditioning methods. Surgery Today, 41(5), 620. 10. Gao Z. X, Rao J, & Li Y. H. (2017). Hyperbaric oxygen preconditioning improves postoperative cognitive dysfunction by reducing oxidant stress and inflammation. Neural regeneration research, 12(2), 329.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 158 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

11. Allen M, Golembe E, Gorenstein S, Butler G. Protective effects of hyperbaric oxygen therapy (HBO2) in cardiac care-A proposal to conduct a study into the effects of hyperbaric pre-conditioning in elective coronary artery bypass graft surgery (CABG) Undersea Hyperb Med. 2014;42:107–114.

9:00 – 9:30 Shai Efrati, MD "Brain injury"

Objectives:  Basics pathophysiological cascade of non-recoverable brain injuries.  The neuroplasticity effect of hyperbaric oxygen therapy  Selecting the optimal candidate for the treatment

Clinical studies published in recent years present convincing evidences that hyperbaric oxygen (HBO2) therapy can be the coveted neurotherapeutic method for brain repair of neurological incidents like traumatic brain injury and stroke. This new understanding leads to a paradigm change in the way that we refer to chronic brain injuries; from now these should be thought of like other non-healing wounds in other parts of the body. The classical candidate for HBO2 is a patient with unrecovered brain injury where tissue hypoxia is the limiting factor for the regeneration process. In this patient, HBO2 may induce neuroplasticity in the stunned regions where there is a brain anatomy/physiology mismatch (as for example PET/MRI). In this lecture we will discuss the multifaceted role HBO2 can play in neurotherapeutics based on recent persuasive evidence demonstrating HBO2 efficacy in brain repair as well as a new understanding of brain energy management and response to brain damage. We will also discuss how to select suitable candidates and how to choose the optimal HBO2 protocol for the selected candidate

9:30 – 10:00 PANEL DISCUSSION

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 159 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 160 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY SESSION E HBO2 OPERTIONS, CHAMBERS, AND EQUIPMENT Moderators:

SATURDAY, JUNE 30

Oral Presentations: 10:30 AM – 11:30 AM

Poster Presentations: Poster Session: 11:30 AM – 12:00 PM

Moderators: Gus Gustavson, RN Kaye Moseley, RRT

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 161 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 162 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

E 1 Saturday, June 30 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 11:30-12:00 RESIDENT COMPETITION: No

Preprogrammed bailout and surface decompression schedules for multiplace treament profiles Raleigh GW Center for Comprehensive Wound Care and Hyperbaric Oxygen Therapy, Aurora St. Luke’s Medical Center, Milwaukee, WI Presenting Author: Greg Raleigh, CHT [email protected]

Background: There is not an accepted standard for computing chamber attendant decompression requirements. Most decompression tables are not optimal for computing decompression obligations for non-standard dives such as stepped dive profiles. When medical emergencies or mechanical problems necessitate immediate egress, decompression solutions must be readily available to prevent injury to the chamber attendant. Emergency bailout and surface decompression are seldom used low-frequency / high-risk procedures that must be performed during stress situations.

Method: The hyperbaric team at St. Luke’s Medical Center, utilized a Decompression Computation and Analysis Program (DCAP) to generate and analyze all treatment profiles and their associated decompression. The algorithm parameters were adjusted to obtain schedules that were minimally more conservative than the DCIEM decompression schedules.

Results: Each treatment profile was analyzed at five-minute intervals to determine emergency bailout and surface decompression solutions. All treatment profiles and their associated decompressions were compiled into a chamber operator handbook in an easy to read format.

Summary: A computer Decompression Computation and Analysis Program (DCAP) was used to formulate emergency bailout schedules and surface decompression schedules for all of the departments treatment profiles. The treatment profiles and all of their associated decompression schedules were organized into a book for quick, easy access. Through preplanning, organization and staff training it is possible to respond rapidly and appropriately when stressful emergency decompressions are necessary.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 163 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

E 2 Saturday, June 30 ORAL PRESENTATION TIME: 10:45-11:00 POSTER PRESENTATION TIME: 11:30-12:00 RESIDENT COMPETITION: Yes

Hyperbaric oxygen simulation education Arefieva CA, Duchnick J, Bermudez R, Witucki P, Shishlov K, Sadler C Division of Hyperbaric Medicine, Department of Emergency Medicine, University of California San Diego, 200 W Arbor Dr, San Diego, CA 92103 Presenting Author: Christa Arefieva [email protected] or [email protected]

Introduction/Background: Fortunately, the incidence of complications and critically ill patients in hyperbaric medicine is relatively low. However, this poses a challenge to those tasked with educating trainees, as well as maintaining the skills of staff. A hyperbaric medicine fellowship is only a year-long and it is conceivable that fellows may not be exposed to certain patient care situations or complications of hyperbaric medicine. Additional staff, including chamber operators and inside observers may also be unfamiliar or uncomfortable dealing with these situations. The purpose of hyperbaric simulation curriculum is to train healthcare providers in various roles in situations that rarely occur in hyperbaric medicine practice.

Materials and Methods: The need for a simulation curriculum in hyperbaric medicine has been identified by the occurrence of rare situations with which team members may not have regular or any experience. Two different simulation cases have been developed that involve caring for a patient with oxygen toxicity during hyperbaric treatment as well as an ICU patient. The cases outline events and critical actions, and are followed by debriefing.

Results: Simulation curriculum allows for training healthcare providers in situations that rarely occur in hyperbaric medicine practice as well as identifying content areas in which more education is needed. We present the development of a new curriculum for medical simulation training for the hyperbaric chamber. These simulations are also unique in that, unlike other medical training simulations that focus on a single role, these can be used to simultaneously train physicians as well as nurses, technicians and other team members.

Summary/Conclusions: A hyperbaric simulation curriculum is an achievable educational initiative that is able to train multiple team members at once in situations that they may not encounter on a regular basis. We believe that that this could be easily exported to other institutions for further education.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 164 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

E 3 Saturday, June 30 ORAL PRESENTATION TIME: 11:00-11:15 POSTER PRESENTATION TIME: 11:30-12:00 RESIDENT COMPETITION: Yes

Performance characteristics of high-frequency percussive ventilation (HFPV) under hyperbaric conditions Huang ET, Heltborg JL, Apsey RT, Ray K Legacy Emanuel Medical Center, Portland OR Presenting Author: Kristi Ray, MD [email protected]

Introduction: We tested the Bronchotron® Transport ventilator with a digital multimeter (Percussionaire Corporation, Sandpoint, Idaho) under hyperbaric conditions. This is a pneumatically powered, time- cycled, and pressure-limited high-frequency flow interrupter. Release volume is a product of pulsatile flow rate (PFR) over oscillatory CPAP (OCPAP) and the non-convective subtidal volumes produced by the percussive rate. A sliding Venturi valve (Phasitron®) regulator is driven by a 50 psi gas supply at a high- frequency rate from 200-800 beats/min superimposed on a conventional pressure controlled cycle1.

Methods: Following a modified Navy protocol2, we used a test lung with analytical software (Test Lung with PneuView3 Software, Michigan Instruments, Grand Rapids, Michigan) for data collection. Testing took place in a multiplace hyperbaric chamber at 0, 30, and 60 feet of seawater (fsw). The ventilator was maintained at a PFR/OCPAP ratio of 30/10, percussive rate of 500, and inspiratory and expiratory time of 2 seconds each.

Results: Parameter Test 1 Test 2 Test 3 Test 4 Test 5 Test 6 Airway resistance (cm H2O/L/sec) 20 20 20 50 50 50 Barometric pressure (fsw) 0 30 60 0 30 60 Respiratory Rate 15 16 15 15 17 15 Inspiratory Time 2 1.9 1.9 2 1.8 1.9 Expiratory Time 2 1.8 2 2 1.8 2.1 Peak Inspiratory Flow (L/min) 105 76 68 62 30 22 Pulsatile Flow Rate 26 22 22.5 18 15.2 13.6 Oscillatory CPAP 6 7 8 9 8.5 7 Release Volume (mL) 880 547 513 400 253 180 MAP (cm H2O) 17-18 17-19 19-20 17-18 18-19 18-20

Discussion: As barometric pressure increased, entrained flow through the Phasitron® decreased. This resulted in lower peak flow and release volume, as commonly seen in conventional ventilators used in hyperbaric environments. The mean airway pressure (MAP) remained stable throughout all test conditions, theoretically supporting adequate lung recruitment and gas exchange.

References 1. Salim A, Martin M. High-frequency percussive ventilation. Crit Care Med. 2005;33(3 Suppl):S241-245. 2. Stanga D, Beck G, Chimiak J. Evaluation of respiratory support devices for use in the hyperbaric chamber. Naval Sea Systems Command: Navy Experimental Diving Unit; November 2003. NEDU TR 03-18.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 165 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

E 4 Saturday, June 30 ORAL PRESENTATION TIME: 11:15-11:30 POSTER PRESENTATION TIME: 11:30-12:00 RESIDENT COMPETITION: No

Observations on O2% during air breathing periods using a non- rebreather face mask in a monoplace chamber Bell J1, Koumandakis G1, Churchill S1 , Weaver LK1,2 1Division of Hyperbaric Medicine Intermountain Medical Center, Murray, Utah, and Intermountain LDS Hospital, Salt Lake City, Utah; 2University of Utah School of Medicine, Salt Lake City, Utah Presenting Author: James Bell, CHT [email protected]

Introduction: We tested a non-rebreather reservoir (NRB) face mask delivering medical air (20.9% O2) in an oxygen-filled monoplace chamber and the impact on the chamber O2%.

Methods: A free-flow air-break assembly, with flow meter (Sechrist PN 100443), was installed on Sechrist 3600E chamber. An adult NRB mask (Hudson RCI, # 1061) was used to supply medical air to the occupant of the chamber. The flow meter was set to provide ≈15 liters per minute (lpm) and ≈30 lpm equivalent at 2.0 ATA and 2.4 ATA. Medical air was delivered to the NRB for 5-minute periods after the chamber atmosphere was >98% O2. The chamber was operated with a ventilation rate of 350 lpm. The chamber atmosphere was monitored at the chest level with a calibrated oxygen analyzer (Quantek Instruments, model 905P, range 0-100% oxygen, accuracy ±1%). A nasal cannula (Hudson RCI, # 1864) was used to monitor the inspired NRB O2%, at the chamber occupant’s face, with a calibrated oxygen analyzer (AMI, model 111, range 0-95% oxygen, accuracy ±1%)

Results: 2.0 ATA end of 5 min air breathing Medical air, lpm Chamber O2% O2% At NRB Time to return to >98% @ 350 lpm 22 96.8% 68 % 12 minutes 22 97.2 % 64.2 % 14 minutes 42 95% 34% 15 minutes 42 94.7% 35.3% 12 minutes 2.4 ATA end of 5 min air breathing Medical air, lpm Chamber O2% O2% At NRB Time to return to >98% @ 350 lpm 23 97.2% 69.8 % 9 minutes 23 97.1 65.6 % 10 minutes 45 95.3% 44.6% 14 minutes 45 93.8 % 51.4% 13 minutes

Conclusions: The NRB does not provide air (20.9% O2) during a 5-minute “air break.” After NRB use, the chamber O2 level is diminished, requiring 9-15 minutes to return to >98 O2%.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 166 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

E 5 Saturday, June 30 ORAL PRESENTATION TIME: 10:30-10:45 POSTER PRESENTATION TIME: 11:30-12:00 RESIDENT COMPETITION: No

Interim analysis of mucosal atomizer use to maintain myringotomy patency during elective hyperbaric treatments Walter J, Westgard B, Hendriksen S, Masters T, Logue C Hennepin County Medical Center, 701 Park Ave. Minneapolis, MN 55415 Presenting Author: Joe Walter, MD [email protected]

Introduction/ Background: The most common side effect of hyperbaric oxygen (HBO2) treatments is otic barotrauma. Historically patients who were unable to equalize were referred for pressure equalization tubes (PETs). Elective myringotomies are a relatively safe and more readily available alternative to PETs but have a higher failure rate over a course of HBO2. A possible solution to this issue is the use of a mucosal atomizer device (MAD) and syringe to maintain myringotomy pantency.

Materials and Methods: Patients who underwent elective bilateral myringotomies were randomized to use a MAD in one of their ears with the other ear acting as a self-control. This is done by gently insufflating 5 mL of air gently into the ear using a MAD.

Results: 1. 19 patients have been enrolled thus far with an enrollment goal of 90 patients. 2. 8/19 (42.1%) of atomized ears did better than controls. a. 2 patients underwent subsequent unilateral PETs, both of which were in non-atomized ears. b. 2 patients underwent repeat unilateral myringotomies of the control ear. 3. 2/19 (10.5%) of atomized ears did worse than controls. a. Both had repeat unilateral myringotomies of the atomized ear. 4. 9/19 (47%) had similar outcomes in both ears. a. 3 had subsequent bilateral PETs. b. 3 had repeat bilateral myringotomies. c. 3 had no issues with either ear.

Summary/Conclusions: Our interim analysis suggests that air insufflation with atomizer use may help maintain myringotomy patency. Further patient enrollment is ongoing.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 167 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

E 6 Saturday, June 30 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 11:30-12:00 RESIDENT COMPETITION: No

Multiplace hyperbaric chamber modifications for safe utilization of a non-hyperbaric rated cardiac monitor Bliss C, Mosteller J Legacy Emanuel 3001 N Gantenbein Ave Portland, OR 97227 Presenting Author: Chae Bliss, CHT [email protected]

Introduction: Cardiac monitoring is required when treating critical care patients in the hyperbaric chamber. We had limited budget to purchase new equipment and were given a surplus Philips Intellivue MP30 monitor to use in our facility. Ensuring that electronic equipment meets NFPA 99 standards for use in a hyperbaric environment is difficult; however, multiplace operations makes this task much easier with the versatility of through-hull penetrators.

Materials and Methods: Our first step was determining if the MP30 met NFPA 99 standards for battery operated devices. Unfortunately, the MP30 batteries failed the NFPA 99 standard as each of its 2 batteries exceeded 48W. We determined that the MP30 can utilize the Multi-Measurement Server (MMS) extension brick that meets NFPA standards because it does not contain batteries, the power output from the monitor to the bricks is no more than 5V, and the power supply comes from a through- hull penetrator cable. The MMS brick is mounted inside the chamber while the monitor is mounted outside of the chamber. For the inside chamber staff to see the monitor, the MP30 output was slaved to the television monitor located inside the chamber. While there is no sound, the screen can be monitored closely by the inside critical care team during a treatment.

Results: We successfully tested our setup and demonstrated that the MMS brick can simultaneously monitor 3-, 5- or 10-lead ECG, respiration, SpO2, non-invasive and invasive blood pressure monitoring, and temperature. This allows us to closely monitor a critical care patient during hyperbaric oxygen therapy while minimizing changes to patient care.

Conclusions: Through creative engineering we could utilize our existing equipment rather than purchasing a new monitor. We identified discrete barriers and solved each one to allow for our current equipment to be used.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 168 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

E 7 Saturday, June 30 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 11:30-12:00 RESIDENT COMPETITION: No

Leg ulcer characterization by photographic imaging pre and post hyperbaric oxygen treatment: Lessons learned with first 10 cases Maran CA1, Salles-Cunha SX2, Millazo PAA1, Farias PSR1, Castro IJL1, David JRN1, David RAR1 1Centro de Medicina Hiperbárica do Nordeste. Salvador, BA, Brazil; 2Consultant, Itanhaém, SP, Brazil Presenting Author: Cristiane Maran, MD [email protected]

Introduction/background. Hyperbaric oxygen (HBO2) treatment can improve healing of leg ulcers. HBO2 effectiveness still demands investigation. Characterization of tissue by ultrasonography (CATUS), a technique to quantitate image brightness, was adapted to photographic imaging of leg ulcers (p-CATIM). Lessons learned during the first 10 cases are described here in.

Methods. P-CATIM was applied to photos of leg ulcers of diabetic patients, pre and post 10-40 HBO2 sessions. Color photo was transformed into gray scale with 256 brightness levels. Re-scale to diminish variability was based on “black” and “white” bars of a sticker placed by the ulcer. Observed variables are listed in results.

Results. A reduction in open ulcer area was documented by pixel ratio between ulcer and “black” square (1 cm2 reference). B) Open ulcer brightness histograms were wide, showing peaks associated to “necrosis” or “granulation”. “Necrosis” had low 0-40 brightness and its pixel percentages decreased with HBO2. “Granulation” brightness varied from 40 to 150, depending on skin type. C) Skin brightness surrounding open ulcer differed but tended to “normal” skin with HBO2. D) “Normal” skin brightness varied individually. HBO2 decreased brightness variability and increased percentage of pixels tending to “normal” skin. E). Technical considerations: illumination, camera-ulcer distance and angulation, leg circumference effects, i.e. cylindrical leg exposed to straight light rays, are factors that need to be optimized and controlled during p-CATIM investigations.

Conclusions. P-CATIM quantitated leg ulcer conditions by a) area based on number of pixels, and b) distinct tissue brightness. Regions evaluated included a) open ulcer, b) surrounding region, and c) “normal” skin. Brightness levels were easily associated to “necrosis”, a low brightness condition that decreased with HBO2. “Normal” skin brightness and, more so “granulation” may require individual definition by an expert analyzing each photo. P-CATIM is a promising technique to quantitate HBO2 effectiveness and timing in ulcer healing.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 169 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

E 8 Saturday, June 30 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 11:30-12:00 RESIDENT COMPETITION: No

Responding to an active shooter: Learning from one facility’s experience Ptak J, Cormier J Center for Hyperbaric Medicine at DHMC, One Medical Center Dr., Lebanon, NH 03756 Presenting Author: Judy Ptak, RN/CHRN [email protected]

Introduction/Background: FEMA defines an active shooter as an individual actively engaged in killing or attempting to kill people in a confined and populated area. Active shooter events in healthcare facilities are a rare occurrence; however, FEMA has reported 6 of these events in healthcare facilities in the USA from 2000 to 2015. Active shooter situations present challenges that are unique from other medical emergency situations. The current response advocated by FEMA is “run, hide, fight”, which is very different from the way most health care providers respond to an emergency.

Materials and Methods: A hyperbaric facility with 2 monoplace chambers was actively treating 1 patient at 2.4 ATA when an active shooter was reported on campus via computer and audible alert. Previous training for an active shooter event consisted of one computer-based training module. For the next 4.5 hours the staff and patient were locked down in the hyperbaric room, managing issues that had not been previously considered, until the active shooter was located and apprehended by law enforcement.

Results: Staff debriefing post-event was held to identify what went well and opportunities for improvement. A number of issues that had not been considered or discussed during training were identified; including issues with communication, text messages from people inside and outside the institution, the inability to lock areas of the facility, use of cell phones to access police scanners, and the description provided of the active shooter.

Summary: Although rare, facilities should prepare for this low-frequency but high-impact event. There is no definitively correct response, and response will depend on many factors. Staff can be better prepared to deal with the situation through practice drills, detailed discussions about various situations and ongoing training.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 170 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

E 9 Saturday, June 30 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 11:30-12:00 RESIDENT COMPETITION: No

Use of high-frequency percussive ventilation (HFPV) in a patient with carbon monoxide poisoning Huang ET, Heltborg JL, Apsey RJ Legacy Emanuel Medical Center, Portland OR 97227 Presenting Author: Enoch Huang, MD [email protected]

Case Description: The patient is a 66-year-old female who was found unresponsive in a house fire. She had a Glasgow Coma Scale of 3 and was intubated less than an hour from when she was removed from the house. The carboxyhemoglobin (COHb) was 36.8% in the emergency department (ED). An initial arterial blood gas (ABG) was done in the ED on conventional mechanical ventilation (CMV). The patient was transferred to the burn center and placed on HFPV as part of the smoke inhalation protocol. We treated the patient with a USAF 66 fsw treatment table using our Bronchotron® Transport ventilator breathing 100% oxygen. We obtained ABGs before and during HBO2 therapy while on HFPV.

Results: The patient was successfully treated and had no issues with ventilation during HBO2 therapy. The ventilator was maintained at a PFR/OCPAP ratio of 28/10, percussive rate of 500, and inspiratory and expiratory time of 2 seconds each.

Base Location Time pH pCO2 pO2 HCO3 Excess Initial ED on CMV 08:23 7.07 45 318 13 -17.3 Pre-HBO2 on HFPV 10:06 7.35 32 320 17 -7.2 66 fsw on HFPV 12:04 7.25 42 >700 18 -9.0 33 fsw on HFPV 13:10 7.33 39 >700 20 -5.4

Discussion: We were able to maintain oxygenation and ventilation using HFPV. HFPV can be successfully used in a hyperbaric environment.

References: 1. Salim A, Martin M. High-frequency percussive ventilation. Crit Care Med. 2005;33(3 Suppl):S241- 245.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 171 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

E 10 Saturday, June 30 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 11:30-12:00 RESIDENT COMPETITION: Yes

Continuous bladder irrigation in the monoplace hyperbaric chamber: A cautionary tale Cooper JS, Lagrange CA UNMC 981150 NMC Omaha NE 68198 Presenting Author: Jeffrey Cooper, MD [email protected]

Introduction: We previously published an article in this journal, presenting our method of performing continuous bladder irrigation (CBI) in a monoplace hyperbaric chamber using an IV pump to infuse saline into the chamber to a 3-way Foley catheter. However, the specter of causing iatrogenic rupture of the bladder was raised by our urologic colleagues after the following case at our institution.

Case Report: An 80-year-old female with severe hemorrhagic cystitis secondary to radiation therapy Was being treated with hyperbaric oxygen (HBO2) therapy as an outpatient shortly before admission and was to continue as an inpatient on CBI. CBI was set up in the HBO2 chamber on a pump as per our previous report. She received two HBO2 treatments with this set up. One day after her second treatment, she received an alum instillation on the inpatient floor which was mistakenly done on a pump leading to bladder rupture and cystectomy. Obviously, this rupture could have as easily occurred on the CBI pump.

Discussion: A normal urinary bladder can distend remarkably if outflow is obstructed but the ability of a pathologic bladder to tolerate pressure is markedly impaired. A literature review of 40 cases of spontaneous urinary bladder rupture was published as long ago as 1931. Spontaneous urinary bladder rupture associated with delayed effects of therapeutic radiation have been reported. How much more susceptible may a bladder with radiation cystitis be to rupture with pressures exceeding that done in passive (gravity-fed) continuous irrigation. Subsequently we have discontinued the use of our previously published CBI method. Either an arrangement of gravity fed CBI will be done in the chamber or HBO2 will be withheld until CBI is no longer required. Most CBI cases require several liters of saline instilled over a typical HBO2 treatment, making a gravity-fed system in a monoplace chamber cumbersome. Given that CBI is used short term for acute and relatively severe hemorrhagic cystitis and that HBO2 is used for chronic radiation cystitis over a period of weeks, a few days’ delay in HBO2 treatment is likely to cause little harm.

Conclusion: Due to the danger of bladder rupture while providing CBI with a pump, we retract our previously reported method and encourage the use of either a gravity-fed system or delay in HBO2 until CBI is no longer necessary.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 172 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

E 11 Saturday, June 30 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 11:30-12:00 RESIDENT COMPETITION: No

The use of indocyanine green fluorescence angiography to assess perfusion of chronic wounds undergoing hyperbaric oxygen therapy Kim DU1, Rao A1, Kaplan S1, Baksh F1, Caprioli R2, Haight J2, Ferguson RG3, Pliskin M3, Oropallo A4 1Dept. of Surgery, Comprehensive Wound Healing Center and Hyperbarics, Northwell Health, Lake Success, NY 11042; 2Dept. of Surgery/Podiatry Section, Northwell Health (LIJMC), New Hyde Park, NY 11040; 3Dept. of Surgery/Podiatry Section, Northwell Health (NSUH), Manhasset, NY 11030; 4Dept. of Vascular Surgery, Northwell Health, Manhasset, NY 11030 Presenting Author: Christina Delpin, MD [email protected]

Objective: The purpose of this study is to determine the utility of using indocyanine green fluorescence angiography (IGFA) in assessing perfusion of chronic wounds after hyperbaric oxygen (HBO2) therapy.

Method: From May 2016 to January 2018, 26 patients underwent both HBO2 and IGFA. Near-infrared charge-coupled camera measured the flow of intravenous indocyanine green into the wound. IGFA was done pre- HBO2, after approximately 10 HBO2 sessions, and upon completion HBO2. Ingress rate at baseline, mid-therapy and post- HBO2 values were compared using descriptive statistics.

Results: Total of 26 chronic wounds were identified. Baseline median ingress rate was 0.90 units/sec (IQR: 0.28 to 6.10). Median ingress rate after approximately of 10 HBO2 was 2.45 units/sec (IQR: 0.48 to 6.35). Finally, median ingress rate post- HBO2 was 3.70 units/sec (IQR: 0.30 to 9.90). Median increase in ingress and rate from baseline to mid- HBO2 0.30 units/sec (IQR: -0.25 to 3.10) and from mid to post- HBO2 was -0.40 units/sec (IQR: -1.50 to 2.60).

Conclusion: This preliminary study shows capability of IGFA to detect changes in blood flow to wounds following HBO2. Results support the use of IGFA to evaluate the effectiveness of HBO2 in enhancing perfusion to chronic wounds. Larger sample size may help clarify the benefit of IGFA to predict potential for wound healing.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 173 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

E 12 Saturday, June 30 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 11:30-12:00 RESIDENT COMPETITION: No

Utilization of fluorescence microangiography (LUNA) in a pediatric patient with acute compartment syndrome Walter J, Settypalli S, Westgard B, Hendriksen S, Masters T, Logue C HCMC, 701 Park Ave. Minneapolis, MN 55415 Presenting Author: Joe Walter, MD [email protected]

Introduction: Acute compartment syndrome is a critical condition commonly associated with significant trauma and crush injuries. It is rarely reported in pediatric patients. We report utilization of fluorescence microangiography to monitor tissue perfusion in the setting of compartment syndrome.

Case Report: A 5-year-old female presented to the emergency department after sustaining a crush injury to her left foot. Exam revealed marked edema and ecchymosis of the distal forefoot wand pain with dorsiflexion, plantarflexion. Capillary refill and protective sensation was absent. Imaging revealed subtle displaced fractures of the fourth and fifth middle phalanx. Adjunctive daily hyperbaric oxygen therapy was started. LUNA performed 17-hours post-injury demonstrated hypofluorescence to digits the distal digits. 26 hours post injury she developed compartment syndrome and had emergent fasciotomies with large hematoma evacuation and cauterization of bleeding vessels. Immediate visual improvement of digital perfusion was noticed. However the most distal aspects of digits four and five remained dusky with continued guarded prognosis. Serial fluorescence microangiography done 1-week and 7-weeks post-operatively demonstrated normal perfusion of the dorsal left foot and 1-3rd digits. Hypoperfusion of the 4th and 5th digit was noted and decision was made to allow auto-amputation. Follow up at 4 months revealed successful auto-amputation of 4-5th digit. Patient returned to her normal pre-injury activity level with no pain, sensory deficits or functional disability at 6 months.

Conclusions: LUNA is a useful imaging modality to assess tissue perfusion of affected extremity with real time visual images. Adjunctive HBO2 and monitoring with monitoring with LUNA may benefit patients with crush injury or compartment syndrome.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 174 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

E 13 Saturday, June 30 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 11:30-12:00 RESIDENT COMPETITION: No

Public awareness of carbon monoxide poisoning Gwilliam AM, Williams B, Stewart JR, Robins MS Intermountain Healthcare, Utah Valley Wound Care and Hyperbaric Medicine Center Presenting Author: Annette Gwilliam, RN/CHRN [email protected]

Introduction/Background: Carbon monoxide (CO) is present in the exhaust of machines burning carbon- based fuel. Mortality and morbidity from carbon monoxide poisoning is a substantial, often unrecognized, problem in the United States.

Public awareness of the dangers of CO poisoning is essential. The CDC has several ongoing projects including a national initiative to develop educational tools to increase knowledge, attitudes, and practices relative to CO poisoning. Their website has educational materials in 17 languages and a diagnostic training tool for healthcare professionals.

Methods: 1. Bethany and her 5-day-old baby, Jane, had CO exposure from a malfunctioning gas-powered furnace. The Taylors did not feel well and Jane was sleepy and not eating. After presenting to the ED, we treated them with hyperbaric oxygen (HBO2) therapy. Jane’s improvement was significant after just one treatment. She went from lethargic and no response to touch to nursing well and responding age appropriate. 2. Paramedics were called to an office building when employees became sick. Painters next door were using a gas-powered machine. Sally was the worst and was sent for treatment. Upon arrival, we learned of 4 others treated and released. We called them in and ALL had symptoms of CO poisoning. They were treated and improved significantly!

Results: Utah does not mandate that landlords install smoke detectors. During this legislation session, a bill was presented to change this. Bethany took Jane and testified to legislators that the law should change. The Taylor’s story was presented during local news (view using attached QR).

We also developed a program presented to 8 local fire departments. Paramedics are taught CO symptoms, possibly long-term effects/neurological sequalae. We also have a flier for public distribution (attached QR).

Summary/Conclusion: Education to first responders and the public on CO prevention and treatment is essential.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 175 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

E 14 Saturday, June 30 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 11:30-12:00 RESIDENT COMPETITION: No

Surviving an active shooter event Brown P Washington Hospital Wound Care Center, 39141 Civic Center Dr., #106, Fremont, Ca. 94538 Presenting Author: Paul Brown, CHT [email protected]

An active shooter event takes place every two to three weeks in the United Sates. The Federal Bureau of Investigation study from 2000 to 2016 shows there were 220 Active Shooter events which resulted in 1,486 casualties (661 people killed and 825 people wounded). Approximately 2.5% of these events occurred within the health care setting. On average, the event lasts twelve minutes, and one person is shot every fifteen seconds. 39% percent of these incidents are over within five minutes, and 60% end prior to the arrival of Law enforcement personnel.

Whether the shooter is a disgruntled employee, committing an act of domestic violence, or some type of terrorist, the apparent goal is to kill or injure as many people as possible in the shortest amount of time. As a 25 year veteran Police Officer with extensive training in responding to, and handling dynamic, rapidly evolving situations, my goal is to provide you with training that will enable you to survive an Active Shooter event.

Even though this topic is not directly related to hyperbaric medicine, surviving an active shooter event can be accomplished by having a plan in place and by exercising that plan. How do you train to survive an active shooter?

The natural reaction when faced with a life threatening event is to be startled, express fear, anxiety, disbelief, and even denial. Planning ahead and practicing that plan can mean the difference between life and death. Numerous organizations have various acronyms for how to respond to different events (RACE/PASS). Under stress, the easier the plan the easier it is to execute it. The plan I like the best is, Run. Hide. Fight. At the first indication, run away. If you are unable to run, hide. At the last resort FIGHT. Never give up.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 176 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

E 15 Saturday, June 30 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 11:30-12:00 RESIDENT COMPETITION: No

Compartment syndrome of the forearm related to carbon monoxide intoxication Kim GW Soonchunhyang University, College of Medicine, Republic of Korea Presenting Author: Gi Woon Kim, MD [email protected]

Introduction: Carbon monoxide (CO) poisoning is one of the most common forms of intoxication around the world. One of the complications associated with CO exposure is direct toxicity to the skeletal muscles. Though compartment syndrome induced by CO intoxication is rare, it is a well-known complication. In this study, we present a case of CO poisoning concerning a patient who developed compartment syndrome in his forearm.

Case report: A 22-year-old man was found unconscious in a motel where a beehive briquette had burned. He was later diagnosed with rhabdomyolysis associated with CO poisoning. After he regained consciousness, he experienced difficulty in moving his left arm, with sensory impairment in the same arm. He was diagnosed with compartment syndrome, and an emergency fasciotomy was performed. One month later, electromyography was performed which revealed in left median, ulnar, radial and musculocutaneous nerve palsy.

Discussion: Carbon monoxide has 200 times more affinity to hemoglobin than oxygen, but hemoglobin cannot carry oxygen to the tissues when it is affected by CO poisoning. This causes hypoxia in the tissue with adverse effects due to free carbon monoxide in the plasma [5]. As a result, carbon monoxide has a direct toxic effect on skeletal muscles. Compartment syndrome induced by CO intoxication is rare but is a well-known complication [2].

Conclusion: Side effects of CO poisoning can be prevalent, especially for those who are unconscious since they cannot express pain, numbness, and motor weakness. It is important not to overlook compartment syndrome, to double-check whether there is swelling, change in skin color, or skin firmness in extremities, and to observe the patient closely.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 177 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

PLENARY: New Pearls of Wisdom in the Diving and Hyperbaric Medicine Literature 1:00 PM – 2:00 PM

1:00 – 1:30 Brian Keuski, MD; Fellow, Duke Hyperbarics "Diving medicine literature update"

Take a whirlwind tour through the last 12 months of diving medicine literature. Major topics include: decompression illness, fitness to dive issues, immersion pulmonary edema, and diving physiology.

1:30 – 2:00 Lince Varughese, MD; Fellow, LSU Hyperbarics "Hyperbaric medicine literature update"

Dr. Varughese will give a brief update on key articles in recent hyperbaric medicine literature; novel ideas and newfound wisdom.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 178 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY SESSION F TOP CASE REPORTS Moderators:

SATURDAY, JUNE 30

Oral Presentations: 2:00 PM – 3:00 PM

Poster Presentations: Poster Session: 3:30 PM – 4:00 PM

Moderators: Davut Savaser, MD Heather Murphy-Lavoie, MD

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 179 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 180 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

F 1 Saturday, June 30 ORAL PRESENTATION TIME: 2:00-2:10 POSTER PRESENTATION TIME: 3:30-4:00 RESIDENT COMPETITION: No

Case series of central retinal artery occlusion followed with bedside ultrasound Hendriksen SM, Masters TC, Westgard BC, Walter JW, Logue CJ Hennepin Healthcare 701 Park Avenue South, Minneapolis, MN 55415 Presenting Author: Stephen Hendriksen, MD [email protected]

Introduction/Background: Central retinal artery occlusion (CRAO) presents with sudden, unilateral, painless vision loss and is an indication for hyperbaric oxygen therapy. Bedside ultrasound may be helpful in the initial diagnosis of CRAO but it is unclear how measured velocity in the central retinal artery changes over time. Ultrasound is also more available than fluorescein angiography, the accepted gold standard for evaluating retinal circulation. The purpose of this study was to follow patients with bedside ultrasound to see how the measured flow changed from the presentation to the end of the hyperbaric oxygen treatment course.

Materials/Methods: A retrospective chart review was conducted to include all CRAO cases from January 2017 to December 2017 that were evaluated for CRAO with a bedside ultrasound at presentation and near the end of their hyperbaric treatment course and had appropriate images measuring central retinal artery flow in the affected eye and the control eye. An ophthalmologist confirmed all cases of CRAO at presentation.

Results: 6 cases of CRAO with appropriate images were documented. All patients had objective findings of decreased blood flow within the central retinal artery that was detectable by ultrasound at presentation. Five of the six patients had measurable improvement in visual acuity at the end of the treatment course. Improvement in visual acuity did not correlate with improvement in measured velocity at the end of the treatment course.

Summary/Conclusions: Bedside ultrasound may be helpful in the initial diagnosis of central retinal artery occlusion. It may not be helpful in determining clinical outcome or length of hyperbaric oxygen treatment.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 181 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

F 2 Saturday, June 30 ORAL PRESENTATION TIME: 2:10-2:20 POSTER PRESENTATION TIME: 3:30-4:00 RESIDENT COMPETITION: No

AGE during controlled ascent training in a Navy Diver trainee: A case report with video registration of the accident Wingelaar TT, van Ooij, PJ, Koch D Royal Netherlands Navy Diving Medical Center, PO Box 10000, 1780 CA Den Helder, the Netherlands Presenting Author: Thijs Wingelaar, MD [email protected]

Introduction: Pulmonary barotrauma (PBT) with subsequent arterial gas embolism (AGE) is a rare but serious complication during ascent training. In order to prevent alveolar rupture, divers are instructed to exhale during ascents to compensate for the volume expansion of air.

Methods: The Royal Netherlands Navy Diving School trains ascents in a controlled environment: starting in a shallow pool (3 MSW) and later in the course in a deeper pool (9 MSW). During this training two instructors are in the pool ensure the trainee exhales and ascents at a safe rate. Video registration from multiple angels helps to give detailed feedback to the divers afterwards.

Results: In February 2018 a diver trainee from the Royal Netherlands Marine Corps performed an ascent as a part of his training. During this procedure he held his breath from 9 to 5 MSW, at which point an instructor corrected him and the diver started to exhale. Within seconds after surfacing the right leg of the diver became paralyzed, and he became paraplegic and lost eyesight minutes later. After a few minutes of 100% normobaric oxygen most of his symptoms subsided, except the paresthesia of his right leg. A CT-scan of his thorax showed mediastinal emphysema and a small pneumothorax. Treatment with an US NAVY table 6 was started within two hours after surfacing. At completion of recompression therapy all symptoms had disappeared. The diver is planned to resume the diving course upcoming September.

Conclusion: Failing to exhale during ascent training for 4 MSW (0.4 ATA) can cause PBT and subsequent AGE in healthy divers. Neurologic complaints can start within seconds after surfacing. Normobaric 100% oxygen gives quick relief of symptoms, but hyperbaric oxygen therapy is necessary for complete resolution. To our knowledge this is the first video registration of an AGE and the following paralysis during ascent training.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 182 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

F 3 Saturday, June 30 ORAL PRESENTATION TIME: 2:20-2:30 POSTER PRESENTATION TIME: 3:30-4:00 RESIDENT COMPETITION: Yes

Reversal of central pontine myelinolysis symptoms with hyperbaric oxygen therapy Bensusan AB, Staab P, LeGros TL, Murphy-Lavoie H LSU Undersea and Hyperbaric Medicine Fellowship, 1816 Industrial Blvd, Harvey, LA 70058 Presenting Author: Ariana P Bensusan, DO [email protected]

Introduction: Central pontine myelinolysis, or osmotic demyelination syndrome, is caused by destruction of the myelin sheaths covering nerve cells in the brainstem so that signals from one neuron to another cannot be properly transmitted. Most commonly, CPM is caused by a rapid correction of prolonged hyponatremia. This osmotic fluctuation in sodium causes edema in brain tissue which can compress fibrous tracts leading to demyelination. Symptoms of CPM include spastic tetraparesis, emotional lability, and pseudobulbar palsy. Up to 50% of CPM cases can be fatal and there is currently no known cure with treatment focused mainly on relieving symptoms.

Case report: This is a case of a 42-year-old Puerto Rican gentleman who presented with tetraparesis, dysphagia, and dysarthria starting soon after a hospital admission on September 5, 2017. On admission for hallucinations, this patient was found to have a sodium of 105 which was corrected to 120 over the course of 24 hours. Neurologic status had initially begun to improve but then declined precipitously. With power loss to the hospital in Puerto Rico from hurricane Maria, the patient’s cousin working at West Jefferson had him flown to New Orleans and placed in inpatient rehabilitation on September 22, 2017. MRI of his brain showed findings consistent with pontine and extrapontine osmotic demyelination syndrome. The patient required a PEG tube for feedings and full assist in all activities of daily living. The patient was referred to West Jefferson Hyperbaric Department on October 4, 2017 and subsequently had 18 treatments of HBO2 at 1.5-2.0ATA for 70 minutes over approximately 4 weeks.

Results: At the completion of these treatments with continued inpatient rehabilitation, the patient’s symptoms were markedly improved with return of motor function to all four extremities, resolution of dysphagia, and return of speech.

Conclusion: While more evidence is necessary, hyperbaric oxygen therapy may be a beneficial adjunctive treatment moving forward in cases of central pontine myelinolysis.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 183 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

F 4 Saturday, June 30 ORAL PRESENTATION TIME: 2:30-2:40 POSTER PRESENTATION TIME: 3:30-4:00 RESIDENT COMPETITION: Yes

Taravana: A syndrome revisited: A case report Derksen BD, Savaser DJ University of California, San Diego (UCSD) Presenting Author: Brenna Derksen, MD [email protected]

Background/Introduction: Taravana, or Taravana syndrome, represents a form of decompression sickness. It is the result of breath-hold diving to deep depths (from 100 - 140 feet of sea water [fsw]), many times, in close succession. Taravana has been described in pearl divers of the Tuamotu Archipelago, shell divers in Japan, sponge divers in the Mediterranean, spear fishermen, and even submarine escape divers.

Materials/Methods: A 35-year-old male competitive freediver, working as a part-time freedive instructor, presented with fatigue, light-headedness, headache, nausea, left leg numbness and right wrist pain after a series of multiple breath-hold dives over the course of 2 days. The patient experienced confusion with simple tasks, such as putting his fins away at the dive shop. The patient’s symptoms, history, and time course suggested a diagnosis of Taravana.

Results: Two days prior, the patient performed 40 breath-hold dives to depths ranging from 40-60 fsw over 6 hours (6-7 minute surface intervals between each dive). The next day, he performed 20 breath- hold dives, each to an average depth from 95-110 fsw, over 3 hours. The patient estimated his surface intervals between dives to be 2-5 minutes. Five hours after completion of his last deep dive, the patient manifested the above-mentioned symptoms. Evaluated in the ED, laboratory studies, EKG, CXR and CT head testing were normal. He was treated with a USN TT6 protocol without extensions and intravenous fluids with complete resolution of his right wrist pain, nausea and neurological symptoms, upon completion of therapy.

Summary/Discussion: The stress of multiple, deep and frequent breath-hold dives can induce Taravana (Tuamotu Polynesian for “to fall crazily”), a form of decompression sickness. Recognizing and treating this constellation of symptoms that may include vertigo, nausea, lethargy, joint pains and neurological findings is important. This is especially true where repetitive freediving (i.e. fishing, competitive sport or recreation) is common.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 184 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

F 5 Saturday, June 30 ORAL PRESENTATION TIME: 2:40-2:50 POSTER PRESENTATION TIME: 3:30-4:00 RESIDENT COMPETITION: No

Acute scalp necrosis successfully treated with hyperbaric oxygen therapy Johnson-Arbor K MedStar Georgetown University Hospital Presenting Author: Kelly Johnson-Arbor, MD [email protected]

Introduction: Acute peripheral arterial insufficiency (APAI) is a well-established indication for hyperbaric oxygen (HBO2) therapy. We present a rare case of acute arterial insufficiency which occurred after a cosmetic procedure.

Case Report: A 68-year-old female actress with no significant past medical history, sought care from a dermatologist for treatment of periorbital spider veins. The dermatologist performed sclerotherapy using 2 milliliters of 0.5% sodium tetradecyl sulfate solution which he injected into the veins. The patient experienced severe forehead pain immediately after the procedure, and over the next few days she developed full thickness necrosis of her right forehead and frontal scalp region, in the distribution of her right supraorbital artery. Plastic surgery consultation was obtained; the patient was advised that she may require extensive reconstruction, and she was referred for hyperbaric medicine consultation. She began HBO2 on postoperative day #8 and received a total of 30 treatments. By the of the HBO2 treatment course the necrotic tissue had sloughed off from the patient’s forehead, revealing new epithelium; unfortunately, the hair follicles were damaged as a consequence of the full thickness necrosis. The patient may require hair follicle micrografting in the future to restore her hairline, but she was able to avoid reconstruction of her forehead through use of HBO2.

Discussion: APAI is commonly considered to be a sequela of crush injury, compartment syndrome, or other traumatic ischemias. APAI may also occur during venous sclerotherapy, if inadvertent arterial injection is performed; aspiration prior to injection of the sclerosing agent can verify venous needle placement and may minimize the risk of this complication. When acute ischemia is identified, prompt initiation of HBO2 can restore oxygenation to ischemic tissues and optimize cosmetic outcome.

Conclusions: The use of HBO2 should be considered in patients with acute tissue necrosis after cosmetic surgical procedures.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 185 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

F 6 Saturday, June 30 ORAL PRESENTATION TIME: 2:50-3:00 POSTER PRESENTATION TIME: 3:30-4:00 RESIDENT COMPETITION: Yes

Delayed hyperbaric oxygen therapy for cerebral arterial gas embolism following scuba diving: A case report Brett KD, Boni B, Latham E, Hollidge M, Sadler C University of California, San Diego Presenting Author: Kaighley Brett, MD [email protected]

Introduction/Background: We present the case of a 42-year-old critically ill female from a cerebral arterial gas embolism (CAGE) while diving who encountered significant delay in treatment due to lack of availability of local hyperbaric oxygen (HBO2) therapy.

Materials and Methods (case description): A 42-year-old female suffered a severe case of CAGE while scuba diving in Maui, HI. She complained of shortness of breath and dizziness shortly after surfacing and then rapidly lost consciousness. She had a complicated hospital course, requiring intubation for persistent hypoxemia likely secondary to aspiration, markedly elevated creatine kinase, atrial fibrillation requiring cardioversion, and slow neurologic improvement.

Results (Discussion): Our case illustrates many of the complications that may occur when a patient suffers a severe cerebral AGE. These cases may occur in patients even without a history of rapid ascent or risk factors for pulmonary barotrauma, and it is imperative that they be recognized and treated as quickly as possible with HBO2. Unfortunately, our case also highlights the growing challenges in treating critically ill divers with the growing shortage of 24/7 hyperbaric chambers able to treat ICU level patients. The time and distance of medical evacuation not only negatively impacts the patient in terms of delay of treatment, but also places the patient and crew at risk during transport and incurs significant economic cost.

Summary Conclusions: Severe CAGE is a known complication of scuba diving and must be diagnosed and treated with HBO2 as soon as possible. The growing shortage of 24/7 emergency HBO2 chambers is a significant obstacle to treating these patients even in popular dive destinations in the United States.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 186 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

F 7 Saturday, June 30 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 3:30-4:00 RESIDENT COMPETITION: No

A case of trigeminal neuralgia treated with hyperbaric oxygen Huang ET Legacy Emanuel Medical Center Presenting Author: Enoch Huang, MD [email protected]

Introduction: Trigeminal neuralgia (TN) is a chronic pain disorder of the trigeminal nerve that can send disabling pain along the course of the nerve in the face. Attacks can be short and episodic, but can escalate to longer, more frequent attacks. Hyperbaric oxygen (HBO2) therapy has been theorized to decrease pain through antinociceptive neural nitric oxide (NO)-dependent release of opioid peptide, anti-inflammatory effects, as well as inhibition of neural and NMDA receptor activation and signaling after nerve injury. A 2012 sham-controlled, double-blinded study (n=42) showed that HBO2 (1.8 ATA x 10 days) decreased TN pain as assessed by a visual analog scale and reduced the daily dose of carbamazepine when compared to sham1.

Case Description: The patient is a 53-year-old male with severe TN. Medical management including opioids was unsuccessful. Microvascular decompression (MVD) did resolve his symptoms for about 10 months. The patient underwent stereotactic radiotherapy that eliminated all sensation on the right side of his face and remained asymptomatic from 2006 until 2010 when he developing severe TN symptoms on his left side. The patient has ruled out considering MVD or stereotactic radiotherapy again because he does not want to have complete anesthesia of both sides of his face.

Results: We used the McGill Pain Questionnaire (maximum of 78 points) to collect semi-quantitative data on the patient’s level of pain before (60 points), during (43 points), and after (30 points) a course of 10 HBO2 sessions provided at 2.2 ATA. The patient and his wife reported subjective improvement starting after the first few sessions.

Discussion: HBO2 is not used widely for chronic pain. This case study is consistent with previous published results. The potential for a placebo effect is quite high, and further large-scale randomized, sham-controlled studies are warranted.

1. Gu N, Niu JY, Liu WT, et al. Hyperbaric oxygen therapy attenuates neuropathic hyperalgesia in rats and idiopathic trigeminal neuralgia in patients. Eur J Pain. 2012;16(8):1094-1105.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 187 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

F 8 Saturday, June 30 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 3:30-4:00 RESIDENT COMPETITION: No

Cerebral AGE from upper endodoscopy Popa DA, Witucki P UCSD 200 W Arbor Dr MC 8676 San Diego, CA 92103 Presenting Author: Daniel Popa, MD [email protected]

Introduction: Arterial gas embolus (AGE) is a rare complication of esophagoduodenoscopy (EGD) that has been described in only a few case reports in the literature. The exact etiology remains unknown but many of the cases share some common characteristics.

Case Report: Here we report the case of a 52-year-old otherwise healthy male who underwent outpatient EGD for a sensation of retained food. During the procedure, he suffered a tonic clonic seizure, bradycardia, and hypoxia. Subsequent work-up showed pneumocephalus on CT brain imaging, and he was diagnosed with a cerebral AGE.

Materials and Methods: We performed a review of the patient’s chart and present the findings and the patient’s clinical course here. We also searched the literature and present a review of similar EGD AGE cases we were able to find.

Results: The patient was transferred emergently by helicopter to our facility for treatment of cerebral AGE with hyperbaric oxygen therapy. After multiple hyperbaric treatments while intubated, he was extubated and discharged with residual left hemiparesis which we considered a good outcome.

Summary/Conclusions: AGE during EGD is a rare complication of the EGD procedure but one of which hyperbaric physicians should be aware. Timely hyperbaric oxygen treatment can have a substantial mortality benefit.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 188 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

F 9 Saturday, June 30 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 3:30-4:00 RESIDENT COMPETITION: Yes

Hyperbaric oxygen for late sequelae of carbon monoxide poisoning enhances neurological recovery Keim LW, Koneru S, Ramos V, Murr N, Hoffnung DS, Murman DL, Cooper JS, Torres-Russotto D University of Nebraska Medical Center, 981150 Nebraska Medicine Omaha, NE 68198-8440 Presenting Author: Jeffrey Cooper, MD [email protected]

Introduction: Neuropsychiatric sequelae have been reported in 15-45% of survivors of carbon monoxide (CO) poisoning. Hyperbaric oxygen (HBO2) therapy reduces the incidence of cognitive and neurological a dysfunction. The efficacy of providing HBO2 beyond the first 1-2 days after initial insult is unknown. However, some evidence exists for the benefit of this treatment.

Case Report: We report on treating a patient 14 months after CO injury, who responded with markedly improved neurologic status.

Materials and Methods: A 27-year-old scholar was found comatose due to CO poisoning (carboxyhemoglobin = 31.7%). He received five acute HBO2 treatments. After discharge, he developed chorea, parkinsonism, dystonia, memory loss, slowed processing speed and verbal fluency, leaving him disabled. After the patient reached a clinical plateau, HBO2 was tried again at 90 minutes at 2.4 ATA plus air breaks. Neuropsychological testing was performed at baseline and after each 20 HBO2 cycle, 5 of which were performed during the period from 14-22 months after CO exposure.

Results: After the first 20 treatments, parkinsonism and dystonia improved. After 40 sessions, further improvements were seen on mental speed, verbal fluency, and fine motor movements. The outcome following 100 treatments was that the patient regained independence, including the ability to drive and to become gainfully employed.

Summary/Conclusions: Our case calls into question the concept that HBO2therapy has no role during the chronic phase of CO brain injury. Randomized clinical trials should be considered to evaluate the therapeutic efficacy of HBO2 in patients with neurological sequelae following CO injury.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 189 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

F 10 Saturday, June 30 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 3:30-4:00 RESIDENT COMPETITION: No

Facial baroparesis as a complication of HBO2: A previously unreported cause of a rare condition Sayers MP, Lopez E, Gutfreund Y Jackson Memorial Hospital, 1611 NW 12th Ave, Miami FL 33136 Presenting Author: Martin P Sayers, MD [email protected]

Introduction: A 65-year-old female undergoing HBO2 for osteoradionecrosis of the jaw had received 10 pre-operative hyperbaric oxygen sessions, underwent transoral mandibular resection, and resumed post-operative therapy at 2.4 ATA x 90 min with 2 air breaks. The patient did have tympanostomy tubes in place.

Case Description: During session 20 the patient described pain of her right ear upon ascent which resolved quickly with decongestant spray. Initial otoscopy revealed tympanostomy tube in place and normal appearing right TM. During subsequent observation, she developed right facial paresis. Subsequent otoscopic examination revealed bulging right tympanic membrane with hemotympanum. The tympanostomy tube appeared clogged, suggesting occlusion and inability to assist in equalization.

Given her acute onset of right sided facial paresis, she was evaluated by ENT, who referred her to the Emergency Department for CT temporal bone, which revealed fluid in the middle ear cavity, but no other finding to explain an isolated facial nerve palsy. CT brain was negative for acute intracranial pathology.

During ED course, her facial paresis resolved, and the patient was discharged with no further facial paresis.

Discussion: Facial baroparesis is a decompression-related neuropraxia isolated to the facial nerve, which has typically been described in association with ascent after SCUBA diving and aircraft ascent. The suggested pathophysiology is due to compression induced ischemic neuropraxia of the facial nerve within the facial canal as it transits in close proximity to the middle ear, with the facial canal being exposed to middle ear pressure due to bony dehiscences in the facial canal wall present in over half of the population. Previously, facial baroparesis has never been described in association with therapeutic hyperbaric oxygen treatment. Here, we present a case of hyperbaric oxygen therapy related facial baroparesis, which per the authors' literature review has not previously been described.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 190 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

F 11 Saturday, June 30 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 3:30-4:00 RESIDENT COMPETITION: No

Cerebral arterial gas embolism in a scuba instructor: An interesting cause Garcia E, Galicia P, Villanueva V Cozumel International Hospital Presenting Author: Eduardo Garcia, MD [email protected]

Introduction: Arterial gas embolism is a potential serious problem during scuba diving. It has been identified in submarine escape training, in scuba divers breathe holding during ascent and in people who dive with pulmonary pathology.

Material and Methods: We report a case of a Mexican dive instructor who suffered a loss of consciousness and subsequent neurological deficit after an uneventful air dive using an open circuit. He was diagnosed with cerebral arterial gas embolism secondary to pulmonary barotrauma due to lung cavitations from tuberculosis.

Conclusions: Cerebral arterial gas embolism (CAGE) occurs when gas bubbles obstruct cerebral arterial circulation. It has been attributed to breath holding and pulmonary barotrauma on ascent, but has also been seen during normal ascent in divers with lung pathology. Clinical manifestations of CAGE include loss of consciousness, confusion, and focal neurological deficits. Brain imaging is often normal, even with severe neurological abnormalities. The diagnosis is made on the basis of clinical criteria. In this case, the sudden onset of neurological symptoms after diving, merited differential diagnosis with CAGE.

Tuberculosis is a persistent and growing disease worldwide, found more frequently in certain areas of the world. Pulmonary changes can lead to cavitations, a contraindication to scuba diving. An index of suspicion of TB as a cause of a right upper lobe infiltrate in an injured diver allows for appropriate investigations and protective measures of health workers who are in contact with infected persons.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 191 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

F 12 Saturday, June 30 ORAL PRESENTATION TIME: POSTER PRESENTATION TIME: RESIDENT COMPETITION:

WITHDRAWN

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 192 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

F 13 Saturday, June 30 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 3:30-4:00 RESIDENT COMPETITION: No

Hypoglycemia after scuba diving with insulin pump Gomez-Castillo JD, Contreras U, Reyes-Silva KN Costamed Cozumel / Calle 1 Sur 101 , Cozumel QR Mexico Presenting Author: Jorge Dario Gomez Castillo, MD [email protected]

Introduction: Insulin-requiring diabetes mellitus is relative contraindication for diving. An episode of hypoglycemia and consequent alteration of consciousness while diving may be fatal to the diver. Some individuals with IRDM diving under closely controlled conditions may dive safely, while diving with an insulin pump is not recommended even if it is waterproof.

Case Report: We present a case of a scuba diver, 56-year-old male patient that was diving with an insulin pump and presented neurological disorders, disorientation and stupor after dive. Patient noticed that the insulin pump cartridge that should have lasted for 48 hours after changing it that morning, was empty. That is why he requested and received help from boat staff with oral glucose as first aid and decided to seek medical help. At admission to our hospital in the triage area his blood glucose was 85mg/dl and 10 minutes later a follow-up test capillary glucometry was indicated 44mg/dl. He was admitted in the ER department and administered a single dose of 50cc of Dextrose 50%, But his central glucose was still dropping (39 mg/dl). His treatment continued with glucose infusion at 1000cc of glucose 10% for 18 hours before if was safe again to restart his insulin pump. The patient was without neurological impairment and his last capillary glucose was 202 mg/dl. The patient decided voluntary discharge 24 hours later, without known further complications.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 193 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

F 14 Saturday, June 30 ORAL PRESENTATION TIME: n/a POSTER PRESENTATION TIME: 3:30-4:00 RESIDENT COMPETITION: No

Lyme disease developing during hyperbaric oxygen treatments Ptak J, Reetz S, Buckey J Center for Hyperbaric Medicine, DHMC, One Medical Center Drive, Lebanon, NH 03756 Presenting Author: Judy Ptak, RN/CHRN [email protected]

Introduction/Background: Hyperbaric oxygen (HBO2) treatments have been recommended to treat Lyme disease (LD). One presumed mechanism is that hyperbaric oxygen prevents the growth of, or is toxic to, the Borrelia burgdorferi bacterium that causes the disease. This suggests that developing LD while undergoing HBO2 should be unusual. We report the case of a 77 year old man who developed LD while receiving HBO2 for radiation cystitis.

th Materials and Methods: When the patient arrived for his 28 HBO2 treatment (he had started HBO2 38 days previously) he reported he had developed a rash in his axilla, around the spot where he had removed an attached tick 10 days prior. He had a classic erythema migrans rash. The state he lives in is classified by the CDC as a high incidence state for LD.

Results: He was seen by his primary care provider who diagnosed LD and initiated treatment with doxycycline. The LD resolved without further incident.

Summary: The typical incubation period for LD is 7 to 10 days and may range from 3 to 30 days after a tick bite. In this case the patient clearly had his tick bite and developed the signs of LD while he was undergoing HBO2. Although this is just a single case, it does not suggest that HBO2 can prevent LD.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 194 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

F 15 Saturday, June 30 ORAL PRESENTATION TIME: POSTER PRESENTATION TIME: RESIDENT COMPETITION: No

WITHDRAWN

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 195 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

PLENARY: CLINICAL AND METABOLIC ASPECTS IN BREATH-HOLD DIVING 4:00 PM – 5:00 PM

4:00 – 4:20 Gerardo Bosco, MD "Adaptive mechanisms in breath-hold divers"

The human body faces extreme physiological challenges while immersed with voluntary breath-holding. Breath-hold diving is potentially associated to extreme environmental factors such as increased hydrostatic pressure, hypoxia, hypercapnia, hypothermia and strenuous exercise. Physiological adaptations can depend among the time of breath suspension and the depth of diving. While descending chest squeeze and blood redistribution occur. Indeed, blood as being an incompressible fluid from peripheral circulation is shifted to the chest. The intrathoracic blood volume increases. Moreover, face immersion results in induced bradycardia, due to the diving reflex. Conversely, breath-holding at rest, out of water, induces non- significant changes in heart rate. Breath-hold swimming, even on the surface, instead causes pronounced bradycardia. During deep diving a higher O2 consumption and a fall in alveolar and blood O2 content was observed. Consequently, alveolar CO2 pressure increases due to chest compression while descending.

It was supposed that the maximum reachable depth in breath-hold diving was determined by the relationship between total lung capacity and residual volume. Craig suggested a compensatory physiologic mechanism to explain why thoracic implosion does not occur and hypothesized that a certain amount of blood was diverted from the peripheral circulation into the chest. Intrathoracic pressure in such a condition represented the elastic behavior of the chest wall when exposed to high hydrostatic pressure. The increased hydrostatic pressure at depth reduces pulmonary gas volumes and consequently increases intrathoracic blood volume, with enlargement of the right heart chambers and pressures. On the contrary, the left sections of the heart do not undergo any enlargement, and do not show any sign of pressure increase. The systolic stroke volume is the consequence of Starling’s law: the blood shift stretches the heart and increases the intracardiac volume. This certainly means that, although rarely exploited in nature, anaerobic metabolic reserve represents a resource for survival of the animal. The same can be said for high-altitude hypoxic environments.

Another consideration is the “graded response” to breath-hold diving in relation to the level of physiological stress and to the control by the central nervous system. The diving response is a strategic adaptation to hostile environmental conditions common to many animals but human breath-hold divers require knowledge for the safe and health of participants.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 196 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

4:20 – 4:40 Peter Lindholm, MD "Pulmonary pathophysiology in deep breath-hold diving"

Deep breath-hold diving may expose the lungs to the limits of known human physiology. We will discuss barotrauma of descent with pulmonary edema, glossopharyngeal hyperinsufflation and arterial gas embolism.

4:40 – 5:00 Alessandro Marroni, MD "Breaking news on breath-hold diving research"

Recent data from field research on pathophysiology of breath-hold diving will be presented, with a particular focus on breath-hold diving- induced pulmonary edema, Taravana, epidemiology, mechanisms, pathogenetic hypotheses and data on genetic predisposing factors.

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 197 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY AUTHOR INDEX

A Caprioli R: E 11 Efrati S: D 5, D 9 Abou-samra A: B 3 Carden CR: A 12, A 14 Eldridge MW: A 3, A 5 Aguiñaga S: C 18 Cascio M: D 11 Elmarsafi T: D 7 Akira K: A 8 Castro IJL: D 25, E 7 Endo B: C 12, C 13 Annis H: B 9 Catalogna M: D 5 Ennis WJ: D 12 Apsey RJ: E 9 Cha YS: C 21 Enomoto M: B 2 Apsey RT: E 3 Chang S: B 1 Enten G: B 3, B 5, B 6 Chin W: C 7, C 10, C 12, C 13, Arefieva CA: E 2 Esquivel-Garcia B: C 22 C 18 Evangelista J: D 17 Ari C: B 9 Choi SC: C 21 Arieli Y: A 15 Churchill S: D 1, D 4, D 11, E 4 F Armour D: D 8 Cialoni D: A 9 Fang XH: B 8 B Cianci PE: D 16 Farias PSR: D 25, E 7 Baksh F: E 11 Clemency BM: A 12, A 14 Feldmeier JJ: D 2 Balestra C: A 9, A 13 Contreras U: F 13 Fellows A: A 4 Barton G: A 3 Cook T: C 28 Ferguson RG: E 11 Baynosa RC: B 8 Cooper JS: C 6, F 9, E 10 Fishlev G: D 9 Bechor Y: D 5, D 9 Cooter M: A 4 Fitzpatrick DT: C 19 Bell J: E 4 Copel L: D 9 Fix SM: B 1 Bennett CM: C 5, C 20 Cormier J: E 8 Francis A: B 8 Bensusan AB: F 3 Costello PJ: D 16 Fraser KN: A 6 Bergan J: D 9 Covington DB: C 30 Freiberger JJ: B 11, B 13, C 31 Bermudez R: E 2 Cross CL: B 8 Fujii T: A 10 Bernasek T: B 5 D Furue Y: C 15 Bhopale VM: A 2, A 6 D’Agostino DP: B 9, B 11, B 13 G Bliss C: E 6 Dapena JC: D 18 Galicia P: C 14, F 14 Boes T: C 23, C 24, D 10, D 28 Daphna S: D 5 Galovich J: C 7 Boni B: F 6 David JRN: D 25, E 7 Garbino A: C 1, C 19 Borden MA: B 1 David RAR: D 25, E 7 Garcia E: C 14, F 11 Borges HL: D 23, D 24, F 15 Dayton PA: A 13, B 1 Gesell LB: D 2 Bosco G: B 3, B 5, B 6 Deal DD: A 4 Goldman JJ: B 8 Botros M: D 15 DeCato TW: B 4 Gomez-Castillo JD: C 22, F 13 Bouak F: A 1 Denoble PJ: A 9, C 5, C 20 Gordon HM: D 12 Brailsford JB: D 12 Derksen BD: F 4 Goto T: C 15 Braun R: A 3 Derrick BJ: B 11, B 13, C 31 Grier JW: C 20 Brett KD: A 6, F 6 Deru K: D1, D 4, D 6, D 11 Gupta A: D 6 Brito T: D 27 Dituri J: B 9 Gutfreund Y: F 10 Brown P: E 14 Do R: C 27 Gwilliam AM: D 11, E 13 Buckey JC: A 4, D 29, F 14 Doyle G: B 8 H Bueller B: D 30 DuBose KJ: D 2 Hadanny A: D 5, D 9 Buzzacott P: A 9, C 5, C 20 Duchnick J: E 2 Haight J: E 11 C E Handrahan D: D 1 Camporesi E: B 3, B 5, B 6 Edelson CJ: A 9 Hardwick R: C 19

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 198 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

Hardy K: B 10 Kim H: C 21 Marx RE: D 2 Hart BB: D 6 Kleban SR: B 8 Masaki H: A 8 Hatch JL: C 6 Knaus DA: A 4 Masters TC: E 5, E 12, F 1 Hayes WA: C 8 Koca E: B 15 McNicoll CF: B 8 Hazen K: C 31 Koch D: F 2 Medak A: C 12, C 13 Hebert D: D 3, D 4, D 6 Kojima A: C 3 Mehta A: B 8 Hegewald MJ: B 4 Kojima Y: C 3 Meir O: D 9 Heltborg JL: E 3 Koneru S: F 9 Michael M: D 13 Heltborg JL: E 9 Koumandakis G: E 4 Mihai A: B 12 Hendriksen SM: E 5, E 12, F 1 Kuchibhatla M: B 11, B 13 Millazo PAA: D 25, E 7 Henning WH: C 29 L Miller SS: D 22 Hensel JSE: A 13 Lagrange CA: E 10 Mirasoglu B: B 15 Hess HH: A 12, A 14 Lambert DK: B 10 Miyata K: C 15 Hess HW: A 11 Lambrechts K: A 9 Moon H: D 15, D 22 Heyboer M: B 12, C 23, C 24, Moon RE: A 4, B 11, B 13, C 31, Lang E: D 9 D 10, D 28 D 2 High R: C 6 Latham E: F 6 Morgan M: B 12, C 23, C 24, Hoffnung DS: F 9 Le DQ: A 13 D 28 Mosteller J: E 6 Hollidge M: F 6 Le PNJ: D 2 Motoyama T: C 15 Horie M: B 2 LeDez KM: C 28, D 2 Mrakic-Sposta S: B 3 Hostler D: A 11, A 12, A 14 Lee Y: D 26 Mulatya C: D 3 Huang ET: D 2, E 3, E 9, F 7 Lee YH: C 21 Huchim-Lara O: C 7, C 10, C 12, LeGros TL: F 3 Mullokandov M: A 15 C 13, C 18 Lev R: D 5 Murad MH: D 2 J Liboff A: A 15 Murman DL: F 9 Jang DH: B 10 Lik U: C 7 Murphy-Lavoie H: F 3 Johnson-Arbor K: C 16, D 7, Lindblad AS: D 3, D 4 Murr N: F 9 D 19, D 20, D 21, F 5 Linden RO: C 28 N Jones MW: C 29 Logue CJ: E 5, E 12, F 1 Nagayoshi I: C 15 Jones R: C 9 Lopez E: F 10 Nail S: D 11 K Lu LQ: B 14, C 27, D 15, D 22 Nakhaima S: B 8 Kaplan S: E 11 M Naoki Y: A 8 Kasoji SK: B 1Rivera JN: B 1 MacLaughlin KJ: A 3 Natoli MJ: A 4, B 11, B 13 Kawaguchi H: C 3 Magari PJ: A 4 Niizeki Y: C 3 Kawashima M: C 15 Malacrida S: B 3 Nishi R: A 1 Kawashima M: C 15 Manelli D: B 5 Norton M: C 26 Kazuyoshi Y: A 8 Mangar D: B 5 Nugent NZ: A 6 Keim LW: F 9 Mansouri J: D 2 O Kelly MP: B 10 Maran CA: D 25, E 7 Ofir D: A 15 Keuski BM: B 11, B 13, C 31 Mariani P: C 23, C 24, D 28 Oh SH: C 21 Khatri UG: B 10 Markovitz G: C 7 Oliveira N: D 23, D 24, F 15 Kim DU: E 11 Marroni A: A 9 Oropallo A: E 11 Kim GW: C 21, E 15 Marshall C: A 4 Oscarsson N: D 30

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 199 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

Owen E: D 14 Santiago W: C 23, C 24, D 28 V Oyaizu T: B 2 Santos PE: D 23, D 24, F 15 van Hulst RA: A 1 P Sasaki T: C 15 van Ooij PJ: A 1, F 2 Papadopoulou V: A 9, A 13, B 1 Savaser DJ: F 4 Vann RD: A 4 Paz MA: D 23, D 24, F 15 Sayers MP: F 10 Velds H: B 1 Pendergast DR: A 11 Schinazi EA: B 11, B13 Vezzani G: B 3, B 5, B 6 Perdrizet G: D 14 Schlader ZJ: A 11, A 12, C 11 Vifayarangan A: D 6 Phalke N: B 8 Seargent S: D 10 Villanueva V: C 14, F 11 Pieri M: A 9 Seeman-Lodding H: D 30 Settypalli S: E 12 W Pitkin AD: C 30 Walker JM: C 20, D 3 Sevick JR: A 4 Pittman T: D 7 Walker SC: C 1, C 19 Shah JB: D 2 Pliskin M: E 11 Walter JW: E 5, E 12, F 1 Shahbuddin Z: C 31 Pollack R: D 11 Walters E: D 7 Sharma D: C 23, C 24, D 28 Popa DA: C 12, C 13, F 8 Wang WZ: B 8 Shishlov K: E 2 Preston-Hsu E: D 8 Watanabe Y: C 15 Siegel M: D 18 Ptak J: D 29, E 8, F 14 Waterman M: C 9 Slagle C: B 1 Weaver LK: B 4, C 25, C 26, Q Smerdon GR: C 9 Quirk B: B 9 D 1, D 3, D 4, D 6, D 11, E 4 Sobakin AS: A 3, A 5 Weis TW: A 4, C 31 R St Leger Dowse M: C 9 Westgard BC: E 5, E 12, F 1 Rajpal N: D 7 Staab P: F 3 Whelan HT: B 9 Raleigh GW: E 1 Stansbery RL: A 11 Wieland AM: C 6 Ramachandran M: C 10, C 12, Stewart JR: E 13 Wilbur JC: A 4 C 13 Stooks JJ: A 12, A 14 Ramos V: F 9 Williams B: E 13 Strauss MB: B 14, C 27, D 15, Williams S: C 4 Ramsey M: A 4 D 22 Williams SJ: B 8 Rao A: E 11 Stump DA: A 4 Wilson EL: B 4 Rao N: B 5 Subbotina N: D 27 Wilson SH: D 3, D 4, D 6 Ray K: C 4, C 19, E 3 Suzuki S: C 3 Wingelaar TT: F 2 Reetz S: D 29 T Reetz S: F 14 Witucki P: E 2, F 8 Tailor Y: D 8 Renaldo C: B 9 Wojcik S: D 10 Takao K: C 15 Reyes-Silva KN: F 13 Tamura H: C 15 Y Richardson C: B 11, B 13 Yagishita K: B 2, B 3 Tang M-X: A 13 Rizzato A: B 3, B 6 Yamaguchi T: C 15 Thom SR: A 2, A 6 Robins MS: D 11, E 13 Yamamoto N: A 7, B 2 Tomoye EO: B 11, B 13, C 31 Rovig J: B 8 Yang M: A 2, A 6 Toni JP: D 23, D 24, F 15 Russo LN: A 11, A 12, A 14 Yanir Y: A 15 Torres-Russotto D: F 9 S Toshihiro K: A 8 Z Sackett JR: C 11 Tremblay R: D 13 Zacher JE: C 28 Sadler C: E 2, F 6 U Zisman A: D 9 Salles-Cunha SX: D 25, E 7 Uchida D: C 26 Sanders RW: C 1, C 4, C 19

ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 200 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

2019 UHMS ANNUAL SCIENTIFIC MEETING June 27-29: Wyndham Grand Rio Mar Beach Resort & Spa, PR* *UHMS recommends that you not make your flight arrangements until 90-120 days before the meeting

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ANNUAL SCIENTIFIC MEETING PROGRAM AND ABSTRACTS ** JUNE 28-30, 2018 203 UNDERSEA AND HYPERBARIC MEDICAL SOCIETY

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