Diving and Hyperbaric Medicine The Journal of the South Pacifi c Underwater Medicine Society and the European Underwater and Baromedical Society Volume 47 No. 1 March 2017 Liver injury in decompression illness Field study of deep stops in technical diving: no advantages? Otitis externa is common but mild in navy diver trainees An unusual presentation of cerebral DCI ECG changes in Turkish professional divers ECHM recommendations for hyperbaric oxygen treatment The Grattan Report: poor methods and erroneous conclusions Infusion devices for hyperbaric use Print Post Approved PP 100007612 ISSN 1833-3516, ABN 29 299 823 713 Diving and Hyperbaric Medicine Volume 47 No. 1 March 2017 PURPOSES OF THE SOCIETIES To promote and facilitate the study of all aspects of underwater and hyperbaric medicine To provide information on underwater and hyperbaric medicine To publish a journal and to convene members of each Society annually at a scientifi c conference SOUTH PACIFIC UNDERWATER EUROPEAN UNDERWATER AND MEDICINE SOCIETY BAROMEDICAL SOCIETY OFFICE HOLDERS OFFICE HOLDERS President President David Smart <[email protected]> Jacek Kot <[email protected]> Past President Vice President Michael Bennett <[email protected]> Ole Hyldegaard <[email protected]> Secretary Immediate Past President Douglas Falconer <[email protected]> Costantino Balestra <[email protected]> Treasurer Past President Peter Smith <[email protected]> Peter Germonpré <[email protected]> Education Offi cer Honorary Secretary David Wilkinson <[email protected]> Peter Germonpré <[email protected]> Chairman ANZHMG Member-at-Large 2016 John Orton <[email protected]> Bengusu Oroglu <[email protected]> Committee Members Member-at-Large 2015 Denise Blake <[email protected]> Karin Hasmiller <[email protected]> Simon Mitchell <[email protected]> Member-at-Large 2014 Jen Coleman <[email protected]> Robert van Hulst <[email protected]> Cathy Meehan <[email protected]> Liaison Offi cer Shirley Bowen <[email protected]> Phil Bryson <[email protected]> Webmaster Joel Hissink <[email protected]> ADMINISTRATION ADMINISTRATION Honorary Treasurer and Membership Secretary Membership Kathleen Pye <[email protected]> Steve Goble <[email protected]> MEMBERSHIP MEMBERSHIP For further information on EUBS and to complete a membership For further information on SPUMS and to complete a membership application, go to the Society’s website: <www.eubs.org> application, go to the Society’s website: <www.spums.org.au> The offi cial address for EUBS is: The offi cial address for SPUMS is: Kathleen Pye c/o Australian and New Zealand College of Anaesthetists, Chantrey, Hillside Road 630 St Kilda Road, Melbourne, Victoria 3004, Australia Stromness, Orkney KW16 3HR SPUMS is incorporated in Victoria A0020660B EUBS is a UK Registered Charity No. 264970 DIVING AND HYPERBARIC MEDICINE <www.dhmjournal.com> Editor: Editorial Board: Michael Davis <[email protected]> Michael Bennett, Australia PO Box 35 David Doolette, USA Tai Tapu 7645 Christopher Edge, United Kingdom New Zealand Ingrid Eftedal, Norway Phone: +64-(0)3-329-6857 Peter Germonpré, Belgium European (Deputy) Editor: Jane Heyworth, Australia Lesley Blogg <[email protected]> Jacek Kot, Poland Simon Mitchell, New Zealand Editorial Assistant: Claus-Martin Muth, Germany Nicky Telles <[email protected]> Neal Pollock, Canada Journal distribution: Monica Rocco, Italy Steve Goble <[email protected]> Martin Sayer, United Kingdom Erika Schagatay, Sweden Journal submissions: David Smart, Australia Submissions should be made at http://www.manuscriptmanager.com/dhm Robert van Hulst, The Netherlands Diving and Hyperbaric Medicine is published jointly by the South Pacifi c Underwater Medicine Society and the European Underwater and Baromedical Society (ISSN 1833-3516, ABN 29 299 823 713) Diving and Hyperbaric Medicine Volume 47 No. 1 March 2017 1 The hyperbaric community is partly to blame for these The Editor’s offering attacks on the ‘stuff of life’ in failing over decades to produce the necessary solid clinical evidence base for many of the The importance of the interaction between the vascular proposed applications for HBOT11 and by its over-use by endothelium and blood constituents in the evolution of ‘charlatans’. As a result HBOT is still regarded by many decompression illness (DCI) was first recognised many years clinicians as a ‘fringe medicine’ therapy. The hyperbaric ago. For instance in the 1990s, stripping of the surfactant medical community has much work still to do to establish lining of the vascular endothelium in the brain was proposed firmly the place of HBOT in modern medicine. as an important mechanism for vascular and other organ injury.1 Also stopping the adhesion of neutrophils to the References damaged vascular wall after gas embolism prevented subsequent local cerebral circulatory impairment.2 Since 1 Hills B. Surfactant update. SPUMS Journal. 1994;24:122-6. then, many papers have established the important role of 2 Helps SC, Gorman DF. Air embolism of the brain in rabbits the local and circulatory nitric oxide and pro-inflammatory pre-treated with mechlorethamine. Stroke. 1991;22:351-4. systems and the potential role of circulating microparticles in 3 Peng B, Chen M-M, Jiang Z-L, Li X, Wang G-H, Xu L-H. Preventive effect of rosiglitazone on liver injury in a mouse the development of the injury from circulating gas bubbles. model of decompression sickness. Diving Hyperb Med. 2017;47:17-23. Most readers probably think of DCI largely in terms of 4 Goumas K, Poulou A, Tyrmpas I, Dandakis D, Bartzokis central nervous system symptoms and joint pain. However, S, Tsamouri M, Barbati K, Soutos D. Acute ischemic DCI is a multi-organ injury, and the study in this issue on colitis during scuba diving: report of a unique case. World J liver injury in rats using a pressure profile known to produce Gastroenterol. 2008;14:3262-5. Published online [2008 May severe DCI demonstrates this.3 There are also clinical reports 28]. doi: 10.3748/wjg.14.3262. of gastrointestinal tract involvement4 and renal failure,5 and 5 Viecelli A, Jamboti J, Waring A, Banham N, Ferrari P. Acute the acute lung injury, colloquially known as the “chokes”, has kidney injury due to decompression illness. Clin Kidney J. 2014;7:380-2. doi: https://doi.org/10.1093/ckj/sfu048. been recognised for many decades. Likewise, the diversity of 6 Azzopardi CP, Matity L, Muscat S. Anton’s syndrome as a CNS symptoms with which DCI may present is epitomised presentation of decompression illness. Diving Hyperb Med. 6 by the unusual case report of visual anosognosia. 2017;47:59-61. 7 Spisni E, Marabotti C, De Fazio L, Valerii MC, Cavazza The validation of decompression tables is a complicated, E, Brambilla S, Hoxha K, L’Abbate A, Longobardi P. A time consuming and expensive undertaking requiring comparative evaluation of two decompression procedures for large numbers of dives with different depth/time profiles. technical diving using inflammatory responses: compartmental In practice, particularly in technical diving using multiple versus ratio deco. Diving Hyperb Med. 2017;47:9-16. gas mixtures, decompression protocols are largely based 8 Mutluoglu M, Uzun G, Bennett M, Germonpré, P Smart D, on modelling and/or a fair amount of trial and error. Mathiu D. Poorly designed research does not help clarify the role of hyperbaric oxygen in the treatment of chronic diabetic Since the vascular pathophysiology and inflammatory foot ulcers. Diving Hyperb Med. 2016;46:133-4. response following diving can be measured, the concept 9 Grattan Institute. [cited 2017 February 26]. Available from: of using biological ‘markers’ to estimate 'decompression https://grattan.edu.au/about-us/. stress' is explored in the paper on two different types of 10 Duckett S, Breadon P, Romanes D, Fennessy P, Nolan J. decompression protocols for a standard deep trimix dive.7 Questionable care: stopping ineffective treatments. Report No.: 2015-7. ISBN: 978-1-925015-73-7. Melbourne, VIC: Hyperbaric oxygen treatment (HBOT) is under threat in a Grattan Institute; 2015. [cited 2015 Oct 30]. Available from: number of countries around the world, and poorly performed https://grattan.edu.au/report/questionable-care-avoiding- clinical research, such as that to which readers’ attention ineffective-treatment/. 11 Mathieu D, Marroni A, Kot J. Tenth European Consensus was drawn in a September 2016 editorial,8 does not help. In Conference on Hyperbaric Medicine: recommendations for this issue, a highly critical analysis is presented of a report, accepted and non-accepted clinical indications and practice of focusing predominantly on HBOT, from the Grattan Institute hyperbaric oxygen therapy. Diving Hyperb Med. 2017;47:24-32. in Australia.9 The Grattan Institute is an organisation “dedicated to developing high quality public policy for Michael Davis Australia’s future”. They claim to be “independent”, [email protected] “rigorous in obtaining the best available evidence” and “practical in articulating what governments should do to Key words improve the lives of all Australians”. However, the Institute’s Decompression illness; Hyperbaric medicine; Evidence; General interest; Editorials report entitled “Questionable care: stopping ineffective treatments”10 is a classic example of the presentation and interpretation of “alternative facts” (Conway K, “Meet the Front page photo by Dr Andrew Fock at Truk Lagoon (with