Friday, December 30, 2005

Findings of Interest

1. Diving pioneer Norine Rouse Dies at 80
http://snipurl.com/l4xp

2. Just an honest healer, says indicted doctor
http://snipurl.com/l4xm

3. Malaria organism has a cloaking code
http://snipurl.com/l595

4. Mathematical model can help predict asthma risk
http://snipurl.com/l59b

5. Mobilizing stem cells by using HBO
http://snipurl.com/l598

Thursday, December 22, 2005

UnderwaterTimes.com's Top 10 Underwater Stories for 2005

Happy Holidays!

During 2005, UnderwaterTimes.com published links to over 3,000 stories, marking another year as the world's leading underwater news portal. As part of our year-end celebration, we've just re-read every one of those stories to come up with our annual top ten stories list.

You can read UnderwaterTimes.com's Top 10 Underwater Stories for 2005 at: http://www.underwatertimes.com/news.php?article_id=84012791056

Jeff Dudas
Founder and Editor
www.underwatertimes.com

Wednesday, December 21, 2005

Top Thirty Sites Visited on Scubadoc's Diving Medicine Online

http://www.scuba-doc.com/
This is the home page for Scubadoc's Diving Medicine Online. It contains links in drop down windows to the entire web site and offers easy and intuitive access to the large volume of information available about diving injuries and physiology. There is extensive information about assessment for fitness to dive.

http://scuba-doc.com/scubaclinic/index.php
This site is the main page for our forum/board for asking and answering questions about diving medicine. Answers are provided by a highly qualified cadre of moderators who give up to date advice and information on a broad range of subjects.

http://www.scuba-doc.com/seasnks.htm
This page provides easy to read information about the poisonous sea snake of the Indo-Pacific. It contains links and photos of the air breathing reptile. Visited frequently by school kids foe homework.

http://www.scuba-doc.com/entprobs.html
ENT difficulties are probably the most frequently seen of all diving maladies. Visited often, this page gives basic information about diving problems associated with the ears, sinuses and nose.

http://www.scuba-doc.com/pfo.htm
Patent foramen ovale is being studied for it's probable role in causing unexpected decompression illness.

http://www.scuba-doc.com/moray.htm
A web page about the moray eel with a photo. Visited often by school children for class homework.

http://www.scuba-doc.com/LTE.htm
An extensive web page with in-depth information about the possible results of a lifetime of diving. An article written for Medscape.

http://www.scuba-doc.com/shrks.htm
A page about shark injuries and management.

http://www.scuba-doc.com/DCSPartI.html
Part I of a two part article about decompression illness written for Medscape.

http://scuba-doc.com/Q&A.html
Questions from divers with answers.

http://www.scuba-doc.com/antcoag.htm
A web page with information about risks of diving while on anticoagulants.

http://www.scuba-doc.com/otherderms.htm
Skin problems and diving.

http://www.scuba-doc.com/dvacc.htm
Dive Accident Management

http://scuba-doc.com/ExAbs.html
Article about exercises for development of the abdominal muscles written by Dr. Jolie Bookspan.

http://www.scuba-doc.com/n2narc.htm
Nitrogen narcosis

http://www.scuba-doc.com/travexer.htm
Exercises for the travelor in his/her hotel room.

http://www.scuba-doc.com/gasesprbs.html
Index page for diving injuries involving gases; such as oxygen toxicity, nitrogen narcosis, decompression sickness, etc.

http://www.scuba-doc.com/mvp.htm
An article about mitral valve prolapse and diving.

http://www.scuba-doc.com/diveye.htm
Extensive material about diving and the eye.

http://www.scuba-doc.com/latenthypoxia.html
Shallow water blackout.

http://www.scuba-doc.com/moresea.htm
Sea sickness

http://www.scuba-doc.com/physics.htm
Some simplified information about the physics and diving.

http://www.scuba-doc.com/marij.html
Marijuana and diving.

http://www.scuba-doc.com/spntpnu.htm
Spontaneous pneumothorax and risks for diving

http://scuba-doc.com/nomobkpain.html
Article by Jolie Bookspan, PhD, about ways to relieve back problems.

http://www.scuba-doc.com/endmet.html
Endocrine difficulties and diving - including diabetes.

http://www.scuba-doc.com/asthma.htm
Information about asthma and diving

http://www.scuba-doc.com/hzrdmrnlf.html
Marine Life that is hazardous to divers. Injuries and management.

http://www.scuba-doc.com/Midearbt.html
Middle ear barotrauma, probably the most frequent of diving maladies.

http://www.scuba-doc.com/boxjel.html
Box jellyfish and dangers. Photo.

2006 Winter Symposium Hyperbaric Medicine and Wound Management

January 29, 30, 31st, 2006
Copper Mountain Resort, Copper Mountain, Colorado
(20 hours CME)

We have extended the pre-registration discount to December 30th, 2005

We are still accepting Abstract Presentations (due January 7th, 2006)

Useful Links

Conference Homepage

Conference Flier (pdf)

Conference Registration

Hotel Registration

Conference Agenda

Call for Abstracts (due by Jan 7th, 2006)

Hope to see you there!

Sincerely,

James Holm, MD
Program Director

DAN Link to Espacio Profundo: the Best of Two Worlds

From Dan Leigh, DAN

Espacio Profundo, the Mexican dive magazine, has joined in a partnership
with DAN's Alert Diver to provide DAN members residing in Latin America a combination of these two great publications.

Previously, DAN Members in Latin America only had the option to receive the
Alert Diver magazine in English. To better benefit Spanish-speaking members,
DAN sought a way to provide the Alert Diver content in their own language.

As of January 2006, Espacio Profundo becomes the "official magazine of
Divers Alert Network in Latin America." It includes additional pages from
DAN and dive safety information from DAN's award-winning magazine, Alert
Diver. This partnership will provide those members the latest in Alert Diver
feature articles in Spanish, and the beautiful photography and captivating
stories found in Espacio Profundo.

For those members in the affected regions who prefer to read Alert Diver in
English, DAN has given them the ability to access Alert Diver online at no
additional charge.

Also as of January 2006, DAN Business Members in Spanish-speaking Latin
America started receiving both the Alert Diver in English and the new
version of Espacio Profundo in Spanish. Since Business Members often deal
with English-speaking customers who also read Alert Diver, it will benefit
them to have both copies.

Espacio Profundo has also agreed to help DAN and dive safety grow in Latin
America by giving their several thousand subscribers in Latin America the
opportunity to convert to DAN membership. And when they convert, they have
the option to choose DAN's worldwide dive insurance.

DAN Members in Brazil will continue to receive the printed English version
of Alert Diver. Eventually, DAN hopes to provide a Portuguese-language
diving publication to Brazilian-based members.

Letter from Don Chandler, Exe. Dir. UHMS

To all--

Forwarded to see if any of you out there can help Dr. Weisher.

If you can help, please contact him directly, but I would appreciate a Cc if you use email.

Don
--------------------------------------------------------------------------------
From: Dr. David Weisher [mailto:DWeisher@srmedicalcenter.org]
Sent: Wednesday, December 21, 2005 9:43 AM
To: Don Chandler

I'm looking for a used transcutaneous O2 machine for our hyperbaric program here in St. Thomas USVI. I would greatly app. if you could help me.

David D. Weisher MD
office 340 775 4666

dweisher@rlshospital.org

Monday, December 19, 2005

Medical Malpractice Insurance and the UHMS (a letter from Don Chandler)

To all--

First, please accept my thanks to all of you who responded. As promised, the below represents the response I received to my inquiry about whether there were companies that listed Undersea and Hyperbaric Medicine as a specialty they cover. Here's the summary. Hopefully it will be helpful to those who are searching for medical malpractice insurers.

The Doctors Company in California has had 22 years of experience in dealing with physicians who practice HBOT. See note below for address and phone number.
One of our members answers "no" to the usual questions such as whether he does surgery, delivers babies, gives electroshock, etc. (which he doesn't) and when the company asks what he does, he replies that he practices hyperbaric medicine. His company then insures him at the same premium as for a psychoanalyst.
In Florida, one of our members is covered by MagMutual Insurance Co. He operates 6 Sechrist monoplace chambers. Another member who also uses MagMutual reported that the company recognizes HBOT as low risk and classify it under primary care.
One medical malpractice company lists one of our members as "Preventive Medicine/Hyperbaric."
In the Netherlands Antilles all personnel, including volunteers who are involved in HBOT, are protected by law of the Netherlands Antilles and liability is covered by FATUM/VVAA Liability Insurance for Professionals. FATUM is/was the daughter of ING, which is available in the U.S.
One member reports that he lists UHMS as the group he belongs to. His company states that they cover other hyperbaric centers.
In Switzerland, one of our members reports that he has liability insurance that will cover any type of medical treatment he may offer to his patients. HBO is a treatment like any other one and is covered. The name of his company is AXA, but in Switzerland , any company will cover that.
It is reported that The Doctors Company has been excellent to work with and covers hyperbaric medicine (also see note above). The company address is: 185 Greenwood Road, Napa, CA 94558 Tel 707.226.0100 Attn: Eileen Reis, Agent 707.226.0224.
COPIC is reported to be a proprietary provider in Colorado and lists HBOT practitioners separately under Hyperbaric Medicine and has done so for several years. The rates from COPIC are reportedly about the same as a primary care physician who does not do obstetrics. One of our members who has used both Doctors and COPIC noted that he puts the insurance under one of his primary boards (IM was cheaper than EM) and he told them he did wound care and HBOT as well.
In Hong Kong, a member reports that his medical practice insurance is covered by Medical Protection Society (UK based). It covers hyperbaric medicine practice at a higher rate. Medical Protection website is: www.medicalprotection.org/medical/united_kingdom/default.aspx
One of our members in Arizona reported that Evanston is covering Wound Care/Hyperbaric Medicine Practice on the malpractice policy for Paradise Valley Emergency Physicians.
Peterson and Floyd is a company that has been used in years past for HBOT malpractice insurance.
Medical Protective is a company that has insured one of our members for a long time. To his knowledge, they insure him at the lowest level of Internal Medicine. Another member who insures with Medical Protective Corporation has done so for 20 years and reports they specifically cover him for Undersea and Hyperbaric Medicine (that is all he does).
One email I got read, "Try CNA."
In California one of our members reports that CAP-MPT offers Undersea and Hyperbaric Medicine malpractice insurance.
CPPRRG in central Pennsylvania offered one of our members a rider for Undersea and Hyperbaric Medicine, but at a separate cost. He didn't take it because the amount of HBOT he does is slim.
In Texas it is reported that TMLT recognizes Hyperbaric Medicine when insuring. One of our members who uses TMLT stated that it is offered in Texas only and the rates are very reasonable and are probably in the lowest 10% of physician malpractice insurance rates.
One of our Internist members from New York reports that any Internist pays the same rate and is covered for HBOT. The only exception for Internal Medicine is L heart catheterization...so, if you are an Internist, you are covered for every aspect of your practice, including HBOT. The name of this member's company is Medical Liability Mutual Insurance Company.
A member who practices in Florida reported that he works with a large group of physicians, each with his/her own malpractice coverage. The carriers in Florida have just added Undersea and Hyperbaric Medicine to the original coverage without increasing their individual coverage.
It is reported that ProNational recognizes Hyperbaric Medicine as a specialty.
In Canada, the Canadian Medical Protective Association, a member owned malpractice insurance plan, recognizes hyperbaric and diving medicine under the category of occupational medicine.
There you have it...this is all I have at the moment. Again, thank you to each of you who responded with information about this important topic. We now have a file here in the UHMS home office with information about medical malpractice insurance for practitioners of Undersea and Hyperbaric Medicine. Because I did not receive telephone numbers or addresses for most of the companies listed above (I didn't ask for them), I suggest that a Google search will produce any information you might need concerning any of the companies listed.

Don

Sunday, December 18, 2005

UHMS ANNUAL SCIENTIFIC MEETING


2006 GENERAL INFORMATION

2006 REGISTRATION FORM: ONLINE WORD PDF

2006 PROGRAM

PRE & POST COURSE INFORMATION

HOW TO PREPARE FOR ACCREDITATION

ACCOMPANYING PERSON EVENTS

PLENARY SESSIONS

SPECIAL SEMINARS

2006 CALL FOR ABSTRACTS: Deadline for Submission: FEBRUARY 28, 2006

2006 CALL FOR OFFICER NOMINATIONS

2006 AWARD NOMINEES NEEDED

SPONSOR/EXHIBITOR INFORMATION

DISNEY PARK TICKETS & ALL ORLANDO ATTRACTIONS
(Special rate for UHMS attendees)


--------------------------------------------------------------------------------
ASSOCIATES/BNA ANNUAL SCIENTIFIC MEETING INFORMATION

CALL FOR NOMINATION FOR ASSOCIATE OFFICERS

ASSOCIATES/BNA CALL FOR ABSTRACTS: WORD PDF

ASSOCIATES/BNA PROGRAM (available soon)

PAUL C. BAKER AWARD: Nominees Needed - this award is award to an Associate Member (All UHMS members can nominate)

more information can be found on the Associates website: http://www.uhmsassociates.org/

Friday, December 16, 2005

Adventist Hospital in Portland Opens Special Wound Center

Adventist opens special wound center

Adventist Medical Center opened a new Wound Healing and Hyperbaric Medicine Center on Monday. (Dec. 13, 2005)

The center features two hyperbaric chambers in addition to an American Diabetes Association-recognized education center that will instruct diabetic patients on general diabetes control and wound care-related dietary issues.

Dr. Enoch Huang -- Oregon's only board-certified undersea and hyperbaric medicine physician -- will serve as medical director for the wound center. The center will contribute to the hyperbaric medicine community through its partnership with Praxis Clinical Services, an organization with 63 hyperbaric facilities across the country.

NDC Diving Incidents Report 2005

Dr. Omar Sanchez recommends a visit to the NDC Diving Incidents Report 2005 , from The British Sub-Aqua Club,
Available at: http://www.bsac.org/techserv/increp05/intro.htm

From Buenos Aires, Omar Sanchez, Wetdoc.

NDC Diving Incidents Report 2005

Compiled by Brian Cumming
DivingSafety & Incidents Advisor

Introduction

This section contains the 2005 Diving Incidents Report, produced by The British Sub-Aqua Club (BSAC) in the interest of promoting diving safety. It is important to note that it contains details of UK diving incidents occurring to divers of all affiliations, plus incidents occurring world-wide involving BSAC members.
Report Format
The majority of statistical information contained within this report is also shown in graphical form. Please note that all statistical information is generally produced from UK data only and does not include Overseas Incidents unless noted as ‘All Incidents’.

The contents of this report are split into an overview of the year, and then the details of nine incident categories plus some historical analyses. The various sections can be found as shown below;


i) Overview
ii) Fatalities
iii) Decompression Incidents
iv) Injury / illness
v) Boating & Surface Incidents
vi) Ascent Problems
vii) Technique Problems
viii) Equipment Problems
ix) Miscellaneous Incidents
x) Overseas Incidents
xi) Numerical & Statistical Analyses
xii) List of Abbreviations


Within each category the incidents are listed in the order of their occurrence, not necessarily that of Incident Reference. They are laid out in the following form:


MONTH/YR OF INCIDENT INCIDENT REF.
Brief Narrative of Incident....................................
..............................................................................

The nature of many diving incidents is such that there is usually more than one cause or effect. Where this is the case the incident has been classified under the more appropriate cause or effect. For instance an incident involving a fast ascent, causing decompression illness will be classified under 'Decompression Incidents'.

Brian Cumming,
BSAC Diving Incidents Advisor,
November 2005,

Undercurrent Subscriber Online Update (Reprinted with permission)

Undercurrent -- Consumer Reporting for The Serious Scuba Diver since 1975
www.undercurrent.org

December 15, 2005
--------------------------------------------------------------------------------

Diving News

Bold Divers Rescue Fifty Ton Whale: After a 50-ton humpback whale became entangled in crab pot lines 26 miles from San Francisco last Sunday, divers raced to the scene to cut it free. It was both a daring and miraculous rescue. Get the details here:http://sfgate.com/cgi-bin/article.cgi?f=/c/a/2005/12/14/MNGNKG7Q0V1.DTL

Grand Turk: During the last week of February, Holland America's 1848 passenger Noordam will be the first cruise ship to dock at Grand Turk's new port. That's close to half the island's population and about ten times more tourists than visit Grand Turk on any given day. If you're traveling to dive their fine wall after the ships arrive, tie down your dive boat reservations beforehand. No telling how the cruisers will affect dive reservations or reservations for lunch in the handful of small restaurants.

Equipment design problems: Do you have a complaint with your dive equipment that you wish could be addressed? For example, one diver with arthritic thumbs told us that he could not pop his low pressure hose leading to his BCD when it malfunctioned. Some have complained about straps on certain fin models. Others say that some computers or gauges are unreadable. What about products that don't live up to their hype ("no fog" masks, "dry" snorkels, etc.). Older divers have some problems that younger divers don't have; women have some problems that men don't have. Let us hear your complaint about specific gear, and what, if anything, you've been able to do about it (modifications, appeals to manufacturers, returns, trade-ins, etc.). Maybe we can help you find a solution. Email me at bendavison@aol.com, and include your full name and hometown.

Two We'll Miss: Popular and world-renowned underwater photographer Rick Frehsee died in late August from a heart attack. He was 63 years old. His photographs have appeared in Sport Diver, Skin Diver, and scores of nondiving publications. He taught underwater photography for Nikon for ten years. . . .Zak Jones, 30, who was technical diving with six colleagues from Fort Lauderdale's Pro Dive International, died Thanksgiving day. At 150 ft., his buddy saw him struggling as if he were entangled in his tank lines. When the partner reached Jones, he was unconscious with the regulator out of his mouth. Jones' buddy dumped the air out of Jones' BCD, sending him quickly to the surface. Jones never regained consciousness. Jones was course director at Pro Dive International.

Planning Your Air Travel: If you plan your own air travel to dive destinations (or anywhere for that matter), the website you need is Kayak.com. After rapidly searching more than a hundred travel web sites, from Expedia and Travelocity, to the airlines themselves, you get a list of flights you can organize by price, time of departure, seating class, etc.

Dive with Sylvia Earle: While it's short notice, the Oceanic Society still has spots left for its January 11-18 Belize trip with "her deepness." To celebrate the purchase of its 11-acre field station at Blackbird Caye on Turneffe Atoll, Sylvia Earle will lead divers and snorkelers along the coral reefs and in the mangroves in search of manatees. Presentations by Earle and other experts each evening. $2,295-$2,450. (800-326-7491; www.oceanicsociety.org).

Not Too Late to Give Your Buddy a Holiday Gift: Plenty of great diving books are available at www.undercurrent.org. Click on a book, you'll go to Amazon.com, where you can get low prices and guaranteed delivery before Christmas. All of our profit goes to saving coral reefs. . . . Or, give your dive buddy the all-new 2006 Travelin' Diver's Chapbook and nine issues of Undercurrent for $33. We'll send a diver's holiday card from you announcing the subscription. Sign up at www.undercurrent.org/UCnow/nl_subscribe.shtml.

Say No to DEET: Consumer Reports has found two new substances that work as well as DEET to keep mosquitoes at bay: the chemical picardin and oil of lemon eucalyptus. Picardin is formulated in Cutter Advanced, and oil of lemon eucalyptus is the basis for Repel Lemon Eucalyptus Spray. Details in the January 2006 issue of Undercurrent.

Cancun/Cozumel and Wilma: the Washington Post on December 9 has an interesting update: www.washingtonpost.com/wp-dyn/content/article/2005/12/09/AR2005120900567.html

Note: Our travel writers never announce their purpose, are unknown to the destination, and receive no complimentary services or compensation from the dive operators or resort.

Ben Davison, editor/publisher
editor@undercurrent.org

Monday, December 12, 2005

Study: Patent Foramen Ovale Not a Risk Factor for Stroke ?

People and physicians interested in diving medicine are justifiably concerned by the presence of a patent foramen ovale, through which bubbles can flow from the right side of the heart into the left side during ascent from dives and causing unexpected decompression illness. There also have been associations drawn between stroke/TIAs and PFO. Here is a fairly large study of non-divers by the Mayo Clinic which fails to show a relationship between PFO and stroke.

*Note Dr. John Ross' letter below in which he notes that the study does not rule out a relationship.


See more about PFO on Scubadoc's Diving Medicine Online.

From Reuters Health Information as Printed in Medscape.

NEW YORK (Reuters Health) Dec 09 - Contrary to current thinking by some physicians, the findings from a new prospective study indicate that patent foramen ovale is not an independent risk factor for cerebrovascular events. Larger studies are needed to determine if this holds true with atrial septal aneurysm as well.

"We now see that a hole in the heart leading to stroke is not borne out in our study, the largest transesophageal echocardiogram-based study of the general population," study co-author Dr. Bijoy K. Khandheria, from the Mayo Clinic in Rochester, Minnesota, said in a statement. "Just because you have a hole, you don't automatically need to have it closed."

The findings, which appear in the Journal of the American College of Cardiology for December 9, are based on a study of 585 randomly selected subjects who lived in Olmsted County, Minnesota and were evaluated by transesophageal echocardiography and then followed for a median of 5.1 years.

Overall, 24.3% of subjects had a patent foramen ovale and 1.9% had an atrial septal aneurysm, the report indicates. The 11 subjects with atrial septal aneurysm included 6 with a patent foramen ovale and 5 without a patent foramen ovale.

During follow-up, stroke and other cerebrovascular events occurred in 41 subjects. As noted, patent foramen ovale was not an independent risk factor for such events. Atrial septal aneurysm, by contrast, raised the risk of cerebrovascular events nearly fourfold. However, possibly due to the small patient numbers, this association fell short of statistical significance.

"Our findings show that the hole is not always the guilty party in a stroke; it may be an innocent bystander," Dr. Khandheria concluded.

J Am Coll Cardiol 2005.

**********************************************************************************
December 12, 2005

Dr. Omar Sanchez has generously sent us the following information about PFO and Stroke that was featured in the New England Journal of Medicine. This would seem to refute somewhat the article from the Journal of the American College of Cardiology.

"Dear Scubadoc.
About : - Patent Foramen Ovale Not a Risk Factor for Stroke.
Patent Foramen Ovale in Young Adults with Unexplained Stroke
J. R. Kizer and R. B. Devereux - Extract
The New England Journal of Medicine, Volume 353 - December 1, 2005 - Number 22

A 38-year-old man notes abrupt loss of vision in his right visual field while reading. He has no significant medical history and reports that he neither smokes nor uses alcohol or illicit drugs. Physical examination reveals right homonymous hemianopia but no other abnormalities. Magnetic resonance imaging reveals acute left occipital infarction and normal head and neck vessels. Transesophageal echocardiography shows a patent . . . [Full Text of this Article]

The Clinical Problem - Patent Foramen Ovale and the Risk of Stroke - Atrial Septal Aneurysm -

Strategies and Evidence - Evaluation - Treatment - Medical Therapy - Mechanical Closure - Areas of Uncertainty - Guidelines - Conclusions and Recommendations.
********************************************************************************

Dr. John Ross writes:


I read with interest the trial of pfo as a risk factor for stroke. The adjusted mean hazard ratio for an association was 1.4 (95% confidence interval 0.74-2.88). With this degree of variance, while the authors cannot say they have found an association, they can in no way rule one out. Bove's metanalysis of the relationship of PFO with decompression illness indicated that PFO more than doubled the risk. A similar relationship with stroke cannot be ruled out by this study.

Basically it is a numbers problem. I reckon that, in a balanced study design, 946 patients are required to have a 90% chance of detecting, as significant at the 5% level, an increase in the primary outcome measure (stroke) from 6% in the control group (no PFO) to 12% in the experimental group (PFO). That is 425 patients with PFO and 425 without. In terms of study design, you would identify the requisite number of PFO patients and then establish an age and gender matched control group. If a lesser increase of risk was though to be important, the numbers will be a lot higher.

This and other points are nicely highlighted by the editorial in the same edition of JACC.

Patent Foramen Ovale, Guilty But Only as a Gang Member and for a Lesser Crime * EDITORIAL
In Press, Corrected Proof, Available online 6 December 2005
Bernhard Meier

Regards

John Ross

Dr John A S Ross
Senior Lecturer, Hon. Consultant Department of Environmental and Occupational Medicine University of Aberdeen Medical School Aberdeen AB25 2ZP

FDA Warning to Asthmatics

We have many asthmatics who regularly visit our web site and who read our newsletters. Some are taking medication and continuing to dive, willing to accept the increased risks incurred. Recently, in mid November the FDA issued a warning about the dangers of taking certain asthma medications containing long acting beta agonists(LABA). Here is some information that might be helpful.

Asthma Drugs
On November 18, the Food and Drug Administration (FDA) issued a warning of the increased risk of severe asthma episodes, which could lead to death, when using an inhalation powder containing long-acting beta agonists (LABAs). The warning followed a 28-week clinical trial of the drugs, which showed an increase risk of fatal asthma events in patients taking a LABA.

Three asthma medications have been named in the public health advisory:

* Advair Diskus
* Foradil Aerolizer
* Serevent Diskus


The FDA says that even though LABAs decrease the number of asthma episodes, the drugs may increase the chances of a severe attack when they do occur.

The FDA has recommended that the drugs remain on the market, but has asked manufacturers to update the products labels to include the risk of severe, potentially life-threatening asthma episodes.

FDA Recommendations

The FDA has highlighted the following recommendations concerning the use of a LABA:

* LABAs should not be used as first-line therapy for asthma. These drugs should only be used in patients who have not responded to other asthma-controlling medications. Other medications that should be tried before LABAs include inhaled corticosteroids.
* If you are currently taking a LABA, the FDA recommends that you continue to take your prescribed medication until you speak with your doctor.
* Do not use a LABA to treat wheezing that is getting worse. Instead, call your doctor if your wheezing is getting worse while you are using a LABA.
* LABAs do not relieve sudden wheezing. Be sure to always have a short acting bronchodilator medicine to treat sudden wheezing.


The warning does not address the use of LABAs for exercise-induced wheezing or chronic obstructive pulmonary disease.

See also:
Asthma
COPD
Medications, Drugs and Beta Blockers

Saturday, December 10, 2005

Extensive infection and surgery of the ear and mastoids

Question from person with history of extensive infection and surgery of the ear and mastoids

About four years ago I under went an operation for purulent otitis nedia, conductive hearing loss, canal stenosis, foreign body in the middle ear and protympanum; all of which was done on the right ear. The actual operation was a tympanomastoidectomy with ossicular chain reconstruction using temporalis fascial athroplasty of incudomalleolar joint, canal plasty, removal of foreigh body in protympanum. My final audiogram and impedence test showed normal ear canal volum for both ears, negative middle ear pressure l., c/w eustachian tube dysfunction. The left ear was normal. I am interested in taking a commercial underwaater weilding course. However, I am not sure if the above procedure will keep me from doing this. Can you please tell me if this will keep me from diving? Is there any kind of equipment that can keep the pressure off of my ears and allow me to dive?

**********************************************************************************
The query was referred to Dr. Allen Dekelboum for reply.

Your request was referred to me for comment.

Thank you for your very complete history of your disease and surgery. If you have negative middle ear pressure in that ear with Eustachian tube obstruction, you will not be able to equalize adequately and would be a candidate for further damage to the operated ear. Without examining you, I cannot give you any advice about your entering a diving course. I would discuss this carefully with your surgeon, but from what you tell me, I think you should try a profession that would not require you to be under water, under pressure. The only suit that would keep you out of pressure would be a one atmosphere suit (JIM suit), not available except for very sophisticated research (very expensive).

Allen Dekelboum, M.D.

Extensive infection and surgery of the ear and mastoids

Question from person with history of extensive infection and surgery of the ear and mastoids

About four years ago I under went an operation for purulent otitis nedia, conductive hearing loss, canal stenosis, foreign body in the middle ear and protympanum; all of which was done on the right ear. The actual operation was a tympanomastoidectomy with ossicular chain reconstruction using temporalis fascial athroplasty of incudomalleolar joint, canal plasty, removal of foreigh body in protympanum. My final audiogram and impedence test showed normal ear canal volum for both ears, negative middle ear pressure l., c/w eustachian tube dysfunction. The left ear was normal. I am interested in taking a commercial underwaater weilding course. However, I am not sure if the above procedure will keep me from doing this. Can you please tell me if this will keep me from diving? Is there any kind of equipment that can keep the pressure off of my ears and allow me to dive?

**********************************************************************************
The query was referred to Dr. Allen Dekelboum for reply.

Your request was referred to me for comment.

Thank you for your very complete history of your disease and surgery. If you have negative middle ear pressure in that ear with Eustachian tube obstruction, you will not be able to equalize adequately and would be a candidate for further damage to the operated ear. Without examining you, I cannot give you any advice about your entering a diving course. I would discuss this carefully with your surgeon, but from what you tell me, I think you should try a profession that would not require you to be under water, under pressure. The only suit that would keep you out of pressure would be a one atmosphere suit (JIM suit), not available except for very sophisticated research (very expensive).

Allen Dekelboum, M.D.

Whooshing Noise in Ear After Diving

Dear Scubadoc:

I am a newly certified diver. However, I have a problem with water in my ears. I went to see my doctor who is a scuba diver himself. He prescribed a strong anti-decongestant and said to take the pills all the way through our scuba diving trip to Raotan. We leave a week from today.

My problem is that I keep hearing a whoosing noise in my right ear. It has gotten a little better, but it is very annoying. My doctor said I am hearing the whooshing noise because my eustacian tube is blocked. I have heard the whooshing before taking up scuba diving but never realized what it was. (I do a lot of swimming.)

My question is, how long can I expect to hear the whooshing moise? What do you think is causing it? And I doomed to going to sleep the rest of my life with a little fan next to me to shut out the whooshing noise?

Thanks.

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Answer from Dr. Allen Dekelboum:

Your question was referred to me for comment.

The presence of the whooshing sound prior to diving and the fact that
it seems to be in rhythm with your pulse suggests that it has nothing
to do primarily with diving. The carotid artery runs very close to the
inner ear and when the ear is blocked to sounds from the outside, like
the fluid in your middle ear, you can hear your pulse clearly. This
can also occur when you lay on that ear at bedtime. It generally is of
no importance, but you should mention it to your doctor as there are
some other concerns that he/she might want to investigate. I would
also suggest that you see your doctor before leaving on the trip to be
certain all the fluid in your middle ear has resolved and that you are
able to equalize easily. I am attaching my tips for equalizing which
might make it easier for you to clear your ears while diving.

This advice is based solely on the information you have given me and
without examining you personally I cannot be certain of the diagnosis.
My recommendations are for information only and you should consult your
doctor for a diagnosis.

Allen Dekelboum, M.D.

Some ENT advice from Allen Dekelboum, MD: Hole in the Ear Drum and Diving

Hole in the Ear Drum

Hi Scubadoc,

My wife visited an Orintologist (Sp?) today (a none diver) and was told that she could never never ever dive again due to a rather large her ear drum. The doctor said that the danger of infection was too great. She also said that my wife who hears excellently needs to have an operation or she will have hearing problems with that ear in the future (my wife says NO OPERATION). The doc said the ear is very very dry (whatever that means). My wife has been diving (has her open water certification) and has found that she did not have problems with pain at less than 15 meters, but had pain after that. The doctor said that she would never be able to equalize the pressure because water would get into the inner ear.

She is very disappointed since we have just started the sport and is wondering if there are any possible ways that she can continue without damaging her hearing and maybe getting an infection in the inner ear. Is there any solution to this problem other than giving up diving? It is important to us as we do it together and it is not feasible for me to go off alone.

Thanks for your help.

Regards

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Answer:

Your request was referred to me for comment.

If your wife has a large perforation (hole) in her ear drum, then she should have some hearing loss. Since you did not say what was large in her ear drum, I assume it was a perforation. How long has the perforation been there and, if so, what was the cause of the perforation? Did it occur from one of her dives or has it been present for some time? If she has a perforation and it has been present for a long time, it will not close by itself and will require surgery to close it. The surgery is not major if that is the only problem. If the hole is not closed and she continues to dive, the risk of infection is very high and she could lose all her hearing in that ear or even worse. Pain is not acceptable in diving, even if it occurs after 15 meters.

I would strongly advise your wife not to dive with a perforation in her ear drum.

This advice was given based on the limited information you sent me, did not include an examination of the individual mentioned and is not to be considered a doctor/patient relationship.

Correspondence between the diver and Dr. Dekelboum:

Doctor Deckelboum,

Thank you again for your interest and assistance. My wife is supposed to get a hearing test as the ear specialist that checked her ear was one of her professors at the university who has a private practice but not the testing equipment. I do not believe it has actually been scheduled but she is waiting for notification as to when she can get tested.

She doesn't have any problem equalizing the good ear but has great difficulty equalizing the bad ear and when she dives without pain, she can only go down once because after surfacing the ear won't equalize again for several hours.

The perforation is at the bottom in the center of the ear drum and occurred when she was 8 years old and both ear drums ruptured as a result of an infection. She lived in a small Costa Rican town and only had access to the local doctor who worked for the socialized medicine plan run by the government which even today is generally poor to terrible in the smaller hospitals. The doctor would only treat one ear even though she had pain and drainage in the other. (There are some excellent doctors in Costa Rica but not working in the small towns for the social medicine plan and even the good doctors are hampered by a lack of equipment and trained technicians in the major hospitals. For example the waiting time to start radiation therapy for cancer patients is about 18 months!)

She might give the "Pro ear" a careful try if that is the only way she can continue diving. It is her decision, but obviously if you have recomnendations I will pressure her to: a) follow your advice and b) take any safety precautions that you might suggest. She is very hard headed (a typical Latin woman) and we are booked into Roatan Bay Islands in Honduras for 12 days of diving at Christmas which I doubt that she will be willing to just drop. If you could recommend some safety precautions to reduce the risk, I would greatly appreciate it so if she insists on diving it will be a bit less dangerous. I KNOW that I can't pressure her into the operation partly because of her studies and partially because she doesn't want to have it.

I really appreciate your assistance and advice.

Yours truly,

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Thank you for responding to my questions.

You state that your wife's hearing is unbelievable. That may be true, but has she had a hearing test that tests each ear separately? With a hole in her ear drum, she has to have a significant loss in that ear. Since she has had it from childhood and her hearing is good in the other ear, she has probably compensated well and functions at a normal level. Persons who are born deaf in one ear function quite well.

Yes, I am very familiar with the ProEar 2000. Although I have no financial relationship with the developers and manufacturers of the mask, I was fortunate to be able to test it when it first appeared. I used it on several dives and found that my ears were dry with it. But there have been many users who were unable to keep water out of their ears. While diving, if anyone bumps the mask, there is a risk of water entering the ear canal and getting into the middle ear. And the fit is not good for all people. The shape of your head plays a role in its effectiveness. It is not fool-proof and there is a risk in its use. I would be very cautious in using it for someone with a perforation. It is best used by those who have repeated external ear canal infections and have an intact ear drum.

I have another question for you. I am concerned about the reasons your wife has a perforation. When she dives, does she have pain in her good ear? Is she able to equalize that ear without difficulty? Certainly she might have no problem with her good ear, but most perforations occur because of infection in the middle ear, due to some obstruction with the Eustachian tube. She should have good function in her non-perforated ear and be able to equalize easily.

Allen Dekelboum, M.D.

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Dear Dr. Dekelboum,

Thank you very much for the information. I understand that without an examination it is not really possible to give a good assessment.

My wife has had the perforation since she was a child; however her hearing is unbelievable! I mean this seriously. She can her a pin drop on the second floor when she is on the first floor. We don't want to jeopardize her health, but she can't take time at present away from classes for surgery at the present time as she is in a 12 month a year dental school program with very little time even between semesters.

We were wondering about the feasiblity of her diving with a "Pro Ear Mask" made by IST which is supposed to prevent any water entering the ear and actually preclude a lot of pressure on the ear drum. Are you familiar with this particular mask and if so what are your thoughts on that?

I really appreciate your assistance and if you don't have time to respond it is certainly understandable. We live in Costa Rica and don't know of any ENT Specialists here that are divers - - there probably aren't any as the sport is pursued more by foreigners than locals.

If you can take the time to answer re the mask, it would be appreciated.

Thanks,

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The information you gave me suggests that the operation to repair the ear drum would be fairly easy for her with an excellent chance of repairing the ear drum. As a child, the treatment she had for one ear would have also treated the other. Perforations do occur even in the face of adequate treatment.

With a perforation of the ear drum, the injured ear does not have to equalize. There is a connection between the external ear and the middle ear and no equalization can occur because it is already equalized. I am more concerned about the pain she has. It is due to the water in her ear and I would again strongly advise that she not dive with a perforation in her ear drum. The mask might help, but there is no guarantee.

There is also the possibility that she does not have a perforation, but does have a very thin membrane that can sometimes look like a perforation. In that case she will have to equalize and if she is unable or has difficulty, then she does not have good function of her Eustachian tube and still should not dive.

Good luck.

Allen Dekelboum, M.D.

Hemochromatosis and Diving?

Question:

hello,

can you please provide advice regarding any precautions and/ or risks accociated with a person scuba diving who has hemochromatosis.

regards,

john

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Hello John:

Simply put, hemochromatosis is the condition caused by excessive iron stores in the body. The condition causes some symptoms, none of which are adverse to diving, unless in the last stages of the condition. (fatigue, joint pain, abdominal pain, or organ damage.)
More about hemochromatosis.

The treatment of the condition is 'phlebotomy' (blood donation), as often as twice weekly for the about the first year of treatment then periodically thereafter, depending on the rapidity of the rebuild of the red blood cells
(about 120 days in most individuals) and the serum ferritin (iron) and TIBC (iron binding capacity).

Phlebotomy can cause temporary decrease in blood volume, which is thought to increase the risk of decompression sickness. It generally takes about 24 hours for the actively hydrating individual to get his blood volume back to what it was before the donation - so one would be advised not to dive for about that period of time.

Also, some individuals have feelings of faintness, nausea and weakness after donating. Of course, if present, these would be inimical to the diver.

I hope this is helpful!

Ern Campbell, MD
Scubadoc's Diving Medicine
http://scuba-doc.com/

* A prominent diving medicine physician has the following comment that I feel is pertinent to a proper answer to this question:

"I would suggest that you ask your diver when responding to his question on hemochromatosis a) his age and b) whether the diagnosis of hemochromatosis is primary or secondary. If the disease is primary, there is a risk of malignant change. If the disease is secondary, then it could be due to a number of causes, such as excessive alcohol intake, in which case one would probably not wish to dive with him. There are also secondary problems of hemochromatosis, such as diabetes, pancreatitis etc which would require careful consideration."

Great Opportunity to develop CO2 Sensor, letter from UHMS

From Don Chandler, UHMS Executive Director

To all--

I have attached an opportunity that Gene Smith, a friend of mine, who works in the headquarters of the NOAA Undersea Research Program made me aware of yesterday. He told me that anyone interested in developing a CO2 sensor for a closed circuit underwater breathing apparatus should respond. The successful respondent to this phase one could receive as much as $95,000 to develop a prototype sensor. He also said that if anyone who is interested but is unfamiliar with how to submit a SBIR (Small Business Initiative) proposal he/she should telephone the contacts listed on the grant announcement and they will help them. He also said he would be pleased to talk with any interested party and steer them in the right direction. Gene can be reached at 301-713-2427 extension 106.

Gene emphasized that even if someone has nothing more than an idea about how to put together a CO2 monitor for use with a closed circuit SCUBA, they should apply. Please make note of the short turn-around time requirement to get the proposal to NOAA...sorry, but I can't do anything about that.

I hope some of you will apply for this need to help advance undersea research/technology.

Don

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Here is the attachment.

Hello Colleague or interested party,
The point of this email is to distribute the following announcement of an SBIR opportunity:
NOAA SBIR 2006 Subtopic 8.1.4 R: A Carbon Dioxide Sensor suitable for use in a Closed Circuit Mixed Gas Rebreather.
Proposals must be submitted as directed by 4:00pm January 18, 2006; however, please read the solicitation carefully. Some information and preparation to file must be received before the proposal will be accepted. .
To obtain the information you need to submit; open the link below to the SBIR home page for the Department of Commerce.
Scroll down and Click on the line titled NOAA’s Solicitation FY 2006. Proposal instructions begin on page 20, and on the 54th page out of 97 you will find the subtopic repeated below: 8.1.4.R the request for proposals for a CO2 sensor for Closed Circuit Mixed Gas Rebreathers.

http://www.ago.noaa.gov/ad/sbirs/

8.1.4 R Subtopic: A Carbon Dioxide Sensor suitable for use in a Closed Circuit Mixed Gas Rebreather.
The NOAA undersea Research Program and the NOAA Dive Program together support more then 25,000 dives per year. An important objective of both programs is to extend the bottom time per dive and to extend the depth limit from 130 feet to 300 feet. This will considerably increase the undersea areas where self-contained wet diving scientist can take fine measurements and conduct experiments. An important part of this program is to introduce closed circuit mixed gas rebreathers (CCRs) into the NURP and NOAA dive programs.
Standard SCUBA is called open circuit because the diver’s breathing gas is exhaled into the water. As the diver’s depth increases the total amount of gas required to fill the lungs increases proportionately although the oxygen consumed remains constant. The closed circuit breathing apparatus recycles the divers exhaled breath while removing the carbon dioxide and replacing the consumed oxygen. This greatly reduces the amount of gas required for shallow and deep dives. The partial pressure of oxygen is sensed electronically and controlled to specified levels using a computer. This is the technology that has matured within the last few years and is now reliable enough to be considered for use by the scientific community.

One shortcoming of currently available systems is the lack of a reliable carbon dioxide sensor that will warn the diver when the carbon dioxide level is becoming too high. There are over 2,000 CCRs in use today and their users rely on manufacturers test results and their own experience to know how long a dive the carbon dioxide scrubber canister will support. The sensor must be contained within the breathing apparatus, detect carbon dioxide over the range of 0.5 to 5% surface equivalent, and operate to a minimum depth of 300 feet in gas mixtures of oxygen, nitrogen, helium, and water vapor.
The document you open through the web page should provide all the information you need to apply. If you have any questions please contact the offices listed in the solicitation.
Regards and please pass this to anyone you know that might be interested.

Regards,

Gene

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Friday, December 09, 2005

Diving Accident Claims Life of Beloved PADI Course Director Zak Jones

From the ProDive USA Website at http://www.prodiveusa.com/

Zak Jones
1975 - 2005


(Ft. Lauderdale, FL) Zak Jones, one of the most popular and most loved young professionals in the dive industry died recently during a recreational, non-training, staff dive with his buddies at Pro Dive International where he recently began working as a PADI Course Director. Zak and other Pro-Dive staff members were on a traditional, Thanksgiving Day dive, enjoying what Zak enjoyed most ‚ diving with those who loved diving as much as he did. Zak touched many people during his 12 years in the dive industry and he will be sorely missed.

Zak began his diving career in July 1992, the same year he received his first certification. At the time of his death, Zak held over 25 certifications, including instructor certifications from SSI, and IANTD. Zak was a PADI Course Director (Instructor Trainer). Over the years, Zak worked for several dive centers in Washington State, teaching, developing, marketing and selling dive related educational programs. He spent a year in Belize where he was general manager, director of education and course director at a dive center on Ambergris Cay. Zak recently joined Pro Dive International as a Course Director. Frank Gernert, CEO of Pro Dive said, "Zak was excited about the part he would play in the future of Pro Dive and we were ecstatic about the talent, energy and fun he brought to our family. We are deeply saddened by his untimely death and will honor him in life by remembering his positive attitude and by implementing several of the ideas and programs he had already begun here during his short tenure at Pro Dive."

An account has been set up to assist Zak's wife, Robyn, who has recently begun a new career after relocating to Ft. Lauderdale with Zak. Robyn is in need of financial assistance and Pro Dive now invites others to join them in contributing so that Robyn's basic needs can be met during this time of grief and adjustment. To contribute through PayPal, click the donation link below or you may send a check to: Robyn Woodman Jones, 1448 SW 10th Street, Ft. Lauderdale, FL 33312.

Zak's Pro Dive friends in Ft. Lauderdale have gathered to remember life with Zak, after which Robyn will leave for Seattle where a memorial service in Zak's honor is planned for Sunday, December 4, at the Seattle Aquarium.

Donation

For more information about this accident go to this web site:
http://www.cdnn.info/news/safety/s051207.html