Thursday, March 30, 2006

Wait after general anesthesia before diving?

How long should a patient that was under general anesthesia (knocked out) wait before diving?

To some extent, the ability to dive will depend on the diagnosis for which the anesthetic was given and the disability from the surgical procedure will determine when to dive. If one were being put to sleep for some non-debilitating diagnosis (such as dental), my guess would be that there should be no diving for at least 24 hours. Longer periods of diving cessation may be recommended depending on the procedure performed and the presence of complications.

There have been reported long term effects of a general anesthetic decreasing the cognition patients lasting up to 3-4 months postoperatively. This is seen mostly in the elderly (over 60). Studies on rats fail to show any reduction in longevity. However, there are no studies that I can find concerning how soon the patient recovers completely from the blunted sensorium that occurs with every general anesthetic. This would be highly variable and would depend on the length of the operation, intraoperative medications and recovery room problems

Another variable would be the type of preanesthetic medication given and the type of inhalation anesthetic chosen for the procedure. Whether or not becoming saturated with nitrogen (as occurs with most deep dives) would increase the residual effects of the anesthetic is not known, at least I cannot find any studies on this particular situation.

A good thing to do would be to take the recommendations of the US Department of Transportation for driving after an anesthetic and substitute the word dive for drive. These recommendations can be seen at this web site: .

Dr.Richard Moon, Duke Anesthesiologist, says that diving should be safe after 48 hours provided the patient is not taking any sedatives (including opiate analgesics). The cause of postoperative cognitive effects is not known, but could be due to the inflammatory response rather than the anesthesia per se.

However, the major determinant is not the anesthetic, but rather the reason for the anesthetic. Diving is a bad idea immediately after surgery irrespective of the anesthetic.

Another anesthesiologist says "all of the modern anesthetics are relatively insoluble and one would expect them to be largely eliminated within minutes after their cessation. This might not be the case with some of the older anesthetics such as diethyl ether which is roughly ten times more soluable in blood. In that case, if diving soon after an anesthetic - one could imagine a diver at depth becoming re-anesthetized. This would likely be facilitated by any concomitant narcotic usage as well."

So, to summarize - return to diving depends mainly on the type of surgery, the restrictions placed on the patient from the surgical procedure, medications required by the diver and there probably should be a wait between 24-48 hours after the procedure.

Underwater Forensics Research Seminar

Underwater Forensics Research Seminar
Speaker; Mack S. House Jr. Author: “Underwater Forensics Research/Commercial Scientific Diving”
Holliday Inn Express
Albemarle, NC April 8, 2006 From: 8:00 a.m. to 5:30 p.m.
Registration ends April 5,2006
Reservations: Veronica Porras

This seminar is designed to provide informational needs of medical and law enforcement, community through understanding the importance of crime scene investigation of the underwater victim. A model for preparing law enforcement, rescue squads, medical personnel and related fields to meet the needs of community and those directly involved in the recovery process. The importance of human anatomy and post mortem changes will also be provided.

Seminar highlights:
Overview of Underwater Forensics and Safe Diving Practices
Drowning and interpretation of different terminology
Post mortem anatomical changes in a fluid medium (photographs are used in this section)
Preparing reports and documentation of evidence
Authorized “chain of custody” and the importance of HIPAA
The importance of “Debriefing” and psychological considerations

Learning objectives:
The attendee will be able to understand the importance Underwater Forensics and its application in crime scene investigation, human anatomy, preparing court ready reports and documentation protocols.
The attendee will be able to understand the anatomical changes that occur and the importance of crime scene technique.
The attendee will be able to discuss and articulate a model for preparing law enforcement personnel and medical professionals to address the complex needs of this application in crime scene investigation.

Who Should Attend?
This one-day seminar is designed for law enforcement, medical professionals, psychologists, pathologists, counselors, social workers, nurses, case managers, attorneys and related personnel who are or may be involved in this specialized field of crime scene investigation..

Registration includes:
Continental Breakfast
Certificate of attendance

Wednesday, March 29, 2006

Problems, Divers With Disabilities

We get fairly frequent requests for information concerning diving with various disabling conditions and have generally applied the knowledge known to exist for all divers to the limitations of the particular disability involved. This has in most cases been satisfactory but occasionally we run into a wall of lack of pertinent information, such as the effect of pressure on electronic implants and pumps. Cheng and Diamond published a review of potential problems that they recognized as being important to divers with disabilities in the American Journal of Physical Medicine and Rehabilitation in May of 2005 and the article is paraphrased below.

Cheng J, Diamond M.
SCUBA diving for individuals with disabilities.
Am J Phys Med Rehabil. 2005 May;84(5):369-75. Review.

Potential Medical Problems in Divers with Disabilities

Osteoporosis and Fractures
Immobilization and paralysis can place some people with disabilities are at risk for osteoporosis.8,9 Divers at risk for pathologic fractures should seek dive boats with access platforms near water level for easier transfers in and out of the water. It would be rare for dive boats to have lifts that are commonly found in accessible pools. Many neurologic disorders have loss of sensation and fractures may go unrecognized. Unexplained lower limb swelling or redness should be evaluated for possible pathologic fracture.

Medical Implants
Questions are posed concerning the integrity of medical appliances when exposed to the increased barometric pressures associated with SCUBA diving. Many individuals with disabilities such as spina bifida have connections between the brain anf the abdominal cavity (ventriculoperitoneal shunts) for the treatment of hydrocephalus (excessive fluid on the brain). Huang et al.10 subjected four ventriculoperitoneal shunts to one and four atmosphere absolute in a hyperbaric chamber and found that all shunts performed according to manufacturers’ specifications. They reasoned that any increase in pressure will compress all fluid-filled compartments. Therefore, there would be no significant change in gradient between intracranial and intraperitoneal pressures. Preliminary studies have been carried out for cochlear implants in a hyperbaric chamber, illustrating that the implantable components of various cochlear implants can withstand pressures of up to six atmospheres without damage or failure of critical seals.11

Intrathecal baclofen pumps are increasingly being utilized in the management of spasticity and dystonia. Akman et al.12 described a case of retrograde leakage of cerebrospinal fluid (CSF) into the infusion pump reservoir of an intrathecal baclofen pump (Medtronic SynchroMed, Medtronic, Minneapolis, MN) during hyperbaric oxygen therapy. Medtronic does not recommend exposing their intrathecal baclofen pumps to pressures of 2 atmospheres absolute (SynchroMed II Technical Manual, Medtronic).

Thermal Regulation
There is an inability to maintain heat regulation in many disabling conditions. For individuals with this deficit, diving should be undertaken in warm water regions and neoprene wetsuits should be utilized. Deeper diving will cause increased compression of the air in neoprene wetsuits. Because a large component of the insulating quality of wetsuits is provided by the air trapped in the material, compression of these garments will decrease their insulating capabilities.13 When diving to greater depths, the need for increased thermal protection should be anticipated due to the compression of neoprene and the much colder water. Peripheral vasoconstriction, as an adaptation to minimize the strain caused by loss of body heat, may compromise circulation to the limbs and may need to be minimized.13 This vasoconstriction may decrease already decreased circulation to the limbs of some individuals with paraplegia. For example, Boot et al.14 found that individuals with spina bifida and spinal cord injury have peripheral arterial vasculature that was of smaller diameter, lower flow, and higher shear stress when compared with controls. These changes may compromise optimal regulation of the peripheral vasculature. For individuals with spinal cord injury at the neurologic level of T6 and above, exposure to cold water may increase sympathetic nervous system activity, inducing or exacerbating autonomic dysreflexia. 15 Development of autonomic dysreflexia at greater depths may become life-threatening. The need for slow ascent and safety stops may prevent the individual from receiving needed medical care quickly. Individuals with spinal cord injury who are at risk for autonomic dysreflexia should be monitored for common symptoms such as headache, vision changes, and flushing.

Atrophy and Hypotrophy
It should be noted that due to atrophy and hypotrophy of the lower limbs associated with paraplegia and tetraplegia and other disorders, regular wetsuits may not fit properly and custom wetsuits may be necessary to ensure proper fit and optimal heat retention. Because of decreased muscle mass in the lower limbs there may be increased buoyancy and ankle weights may be required to gain neutral buoyancy in the lower limbs. Due to increased buoyancy, this may be worsened when a full wetsuit is worn. 7

Cardiovascular Issues
Paraplegics and some amputees must rely on the upper limbs for propulsion and there are some physiologic factors that need to be considered when the upper limbs alone are used for propulsion. Activities performed with the upper limbs compared with the lower limbs require higher myocardial oxygen consumption at the same total oxygen consumption inducing more stress by upper limb propulsion underwater. Cardiac disorders are common with many neurologic and muscular conditions such as the muscular dystrophies/myopathies, Friedreich’s ataxia, and many syndromes. The shift of blood into the central circulation resulting from water immersion may aggravate congestive heart failure.17 There is also increased myocardial demand in diving due to increased exertion.13 In addition, immersion in cold water can also cause a significant increase in metabolic rate.15 Given these potential stresses on the cardiovascular system during diving, cardiac function should be evaluated carefully in those individuals who have documented cardiac disorders or conditions that predispose them to cardiac pathology. The use of webbed gloves can help facilitate propulsion with the upper limbs and disabled divers may also opt for the use of motorized propulsion devices that are available from several manufacturers and utilized by many nondisabled divers as well.

Venous Stasis
Levey et al. investigated the relationship of spina bifida and deep venous thrombosis and speculated that individuals with spina bifida may be at higher risk due to venous insufficiency and lower limb paresis.18 There is no direct evidence that SCUBA diving increases the risk of deep vein thrombosis. But, given the increase in prevalence of deep vein thrombosis in individuals with spina bifida, it would be prudent to monitor closely for signs and symptoms such as lower limb swelling and dyspnea that may suggest deep vein thrombosis or pulmonary embolus.

Decompression Sickness
The brain and spinal cord contain myelin, which is very susceptible to excess nitrogen supersaturation after ascent.17 Symptoms of air embolism affecting the brain or spinal cord include unconsciousness with stroke-like symptoms, paralysis, seizures, bowel/bladder dysfunction, sensory abnormalities, fatigue, personality change, poor concentration, irritability, and changes in vision.17 The cortical gray matter is more efficient at releasing nitrogen compared with the spinal cord.1,19 Therefore, the spinal cord is at particular risk for decompression sickness. Venous bubbles can cause thrombosis of the venous plexus surrounding the spinal cord, resulting in venous stasis and spinal cord ischemia.1 However, there is no direct evidence that individuals with spinal cord dysfunction or cortical neurologic disorders are at greater risk of decompression sickness of the brain or spinal cord. Boot et al.14 found that individuals with spina bifida had common femoral arteries that were smaller, with decreased blood flow, compared with normal controls. It is unknown if these arterial characteristics increase the risk of decompression sickness and there are currently no studies investigating the appropriateness of the use of current dive tables by the disabled population. Individuals with disabilities may be at increased risk in the context of decompression sickness because neurologic impairment caused by the decompression sickness can be confused with or masked by the neurologic signs and symptoms associated with the divers’ disease processes. Therefore, it is very important for the disabled diver and his or her dive companions to be familiar the signs and symptoms of decompression sickness and be able to contrast them with the disabled individual’s baseline state.

Many individuals with disabilities have seizure disorders related to their disease processes. Any seizure underwater would result in severe drowning risk and would also be a danger to that diver’s partner. Therefore, seizure disorder requiring ongoing medical management is a strict contraindication to SCUBA diving.17,20 Some certifying agencies, however, will allow divers who have been seizure-free without medications for 5 yrs to participate in their diving programs.

Pneumothorax can be spontaneous or result from trauma. Spontaneous pneumothorax can be associated with structural abnormalities and lung disease.21 It is a strict contraindication for SCUBA diving because the underlying cause may still be present at the time of diving.20 Many individuals who have disabilities resulting from traumatic events have had pneumothoraces. Traumatic pneumothorax, however, is not a contraindication provided that the injury is well healed.

Latex allergy is rare in the general population, with a prevalence of 1%.22 However, it is a concern for individuals with spina bifida and other disorders.22–25 Latex allergy is very common in these populations, with up to 60% of individuals with spina bifida having allergies to latex.25 It is an immunoglobulin E–mediated hypersensitivity reaction to natural rubber latex that can result in urticaria, rhinitis, bronchospasm, and anaphylaxis.23 Bernardini et al.25 found that 25% of subjects with spina bifida had latex sensitization, and only 33% of those individuals have had clinical reactions to latex. Although severe reactions are rare, such reactions at greater depths would present a life-threatening event. Therefore, previous screening is important. Individuals at risk for latex allergies, especially people with spina bifida, may wish to consult an allergist for skin prick or serum latex-specific immunoglobulin E antibody testing before considering SCUBA diving. Those individuals who are at risk may wish to have antihistamines and intramuscular epinephrine available in case of a serious reaction. It may also be prudent to contact the manufacturers of the equipment to be used to determine the precise material content to further decrease the risk. The majority of modern diving masks and snorkels are made from silicone. Also, there is usually no natural latex in neoprene wetsuits. However, certain seals and tubing may contain latex, as may seams in certain wetsuits. Latex seals are much more common in dry suits in which water-tight seals are required. Wetsuits manufactured from neoprene rarely have latex seals. Air tubing may contain natural latex, but the latex is usually vulcanized with other materials and therefore would not likely cause a hypersensitivity reaction. However, it may be best to contact individual manufacturers to confirm the latex content in their air hoses. Alternatively, silicone tubing can be utilized to further reduce the risk.

Many conditions resulting in paraplegia are also associated with sensory deficits. Because of insensate skin, these individuals are at risk for developing pressure ulcers and injuries from trauma. Muscle atrophy also results in decreased protection normally afforded by muscle mass and therefore increases the risk of pressure ulcers. In addition, these individuals are at risk for unrecognized burns from sun exposure. Wetsuits may provide a certain level of protection from skin injury. During the dive, they may protect from abrasions and lacerations while preventing sunburn while on the surface.

Bladder Management
Water immersion and cold exposure have been found to cause diuresis by increasing plasma volume and increasing the release of factors such as atrial natriuretic peptide.26,27 Changes in urine production can become a factor in individuals requiring catheterization because of a neurogenic bladder. Individuals whose bladder programs include clean intermittent catheterization may be required to catheterize more often to address the increased diuresis. This may be difficult given the limited space of a dive boat. It would be an important consideration to identify dive boats that have private spaces available for bladder management and a means of washing hands to maintain the aseptic nature of the procedure. Individuals who are on clean intermittent catheterization programs may regularly limit their intake of fluids to reduce the frequency of catheterizations throughout the day. While SCUBA diving, the sources of fluid loss as previously described and those associated with increased exertion and ambient temperature may predispose the diver to dehydration. In addition, wetsuits provide significant thermal protection while in the water. However, prolonged wetsuit wearing may result in hyperthermia, increased sweat production, and dehydration. 13 Therefore, careful monitoring of fluid intake and output balance and monitoring for symptoms of dehydration are very important in this population. Also, bladder distention can be of particular concern for spinal cord–injured patients with a neurologic level above T6 who are at risk for autonomic dysreflexia.

Ear Barotrauma
Problems associated with middle-ear spaces and paranasal sinuses are the largest source of morbidity among SCUBA divers.20 As a diver descends, external pressure increases and pushes on the tympanic membrane. This pressure needs to be equalized in the middle ear through the oropharynx via the eustachian tube.17 Equalization involves forcefully exhaling against closed (pinched off) nares. Inability to properly equalize will cause barotrauma and may result in pain, acute hemorrhagic otitis media, or tympanic membrane rupture. 17,20,28 Therefore, before diving, each individual should be evaluated for the ability to perform this maneuver independently or with the assistance of another diver.

Asthma affects 6–7% of the general population in the United States, often with childhood onset.17 Some have supported that any history of asthma is a strict contraindication.20 However, asthma varies greatly in severity and in its triggers across individuals. 3 Bove17 states that individuals with mild asthma should not be prohibited from diving. Neuman et al.3 suggests that individuals with normal airway function at rest with little airway reactivity to exercise or cold air inhalation may have risks of pulmonary barotrauma similar to nonasthmatic individuals. However, air-trapping at depth while breathing compressed air in individuals with asthma can lead to serious pulmonary barotrauma. 3,29 Therefore, subjects with a history of asthma should be screened carefully. Additional research may be helpful to better describe the risks for different asthma severities and triggers as opposed to using a history of asthma as a strict contraindication for diving.

Certifying bodies for recreational SCUBA diving such as the Professional Association of Diving Instructors and the National Association of Underwater Instructors have requirements for swimming and fitness. For example, Professional Association of Diving Instructors requires that an individual be able to tread water for 10 mins and swim for 200 meters independently, even though these skills are rarely needed in SCUBA diving. The authors advocate that for full certification, individuals with disabilities should be held to the same requirements and standards as their able-bodied peers. This is to ensure the highest level of safety for the disabled diver. In addition, an important component of SCUBA certification is the ability to perform skills necessary to assist a dive partner. Any disabled individual who is to be a candidate for full certification should be able to carry out these responsibilities. The Handicapped SCUBA Association has established a hierarchical certification structure based on each diver’s abilities. This system allows individuals with disabilities to participate in SCUBA diving at different levels of independence based on their level of function (Table 1).7

SCUBA diving is an adventurous sport that allows participants to explore a diverse, exciting marine environment. Guidelines have been established by SCUBA certification organizations to minimize injury and injuries often occur when these guidelines are violated. However, some individuals may experience injury even when diving conservatively. Mortality rates in recreational SCUBA diving are estimated to be one to nine in 100,000 divers.1,2,30 The authors advocate that SCUBA diving be made available to as many interested individuals as possible. It can be a great source of self discovery and a means of building confidence and independence. However, individuals with disabilities present with many medical conditions that need to be considered carefully by their physicians before certifying them as fit to dive. Recognizing and addressing risk factors can help to limit morbidity and mortality. Additional research into how the unique anatomy and physiology of individuals with disabilities interact with a hyperbaric, marine environment would help to better refine guidelines and allow safer diving in the least restrictive framework.

TABLE Levels of certification available from the Handicapped SCUBA Association
Level A
Able to provide equal assistance to a fellow diver in case of an emergency. Qualified to dive with another certified diver, including a level A diver.

Level B
Able to care for self in case of an emergency but cannot provide a fellow diver equal assistance in case of an emergency. Qualified to dive with two certified divers who may be level A.

Level C
Able to safely use SCUBA underwater but unable to effectively care for self or a fellow diver in case of an emergency. Must dive with two certified divers, one of whom has been trained by a nationally recognized diver training agency in diver rescue. In most cases, this would be an instructor, assistant instructor, or dive master.

1. DeGorordo A, Vallejo-Manzur F, Chanin K, et al: Diving emergencies. Resuscitation 2003;59:171–80
2. Spira A: Diving and marine medicine review part II: Diving diseases. J Travel Med 1999;6:180–98
3. Neuman TS, Bove AA, O’Connor RD, et al: Asthma and diving. Ann Allergy 1994;73:344–50
4. Pelletier JP: Recognizing sport diving injuries. Dimens Crit Care Nurs 2002;21:26–7
5. Frankel H: Aqualung diving for the paralysed. Paraplegia 1975;13:128–32
6. Williamson JA, McDonald FW, Galligan EA, et al: Selection and training of disabled persons for scuba-diving: Medical and psychological aspects. Med J Aust 1984;141:414–8
7. Madorsky JG, Madorsky AG: Scuba diving: Taking the wheelchair out of wheelchair sports. Arch Phys Med Rehabil 1988;69(3 pt 1):215–8
8. Chan YY, Bishop NJ: Clinical management of childhood osteoporosis. Int J Clin Pract 2002;56:280–6
9. Apkon SD: Osteoporosis in children who have disabilities. Phys Med Rehabil Clin N Am 2002;13:839–55
10. Huang ET, Hardy KR, Stubbs JM, et al: Ventriculo-peritoneal shunt performance under hyperbaric conditions. Undersea Hyperb Med 2000;27:191–4
11. Backous DD, Dunford RG, Segel P, et al: Effects of hyperbaric exposure on the integrity of the internal components of commercially available cochlear implant systems. Otol Neurotol 2002;23:463–7; discussion, 467
12. Akman MN, Loubser PG, Fife CE, et al: Hyperbaric oxygen therapy: Implications for spinal cord injury patients with intrathecal baclofen infusion pumps. Case report. Paraplegia 1994;32:281–4
13. Doubt TJ: Cardiovascular and thermal responses to SCUBA diving. Med Sci Sports Exerc 1996;28:581–6
14. Boot CR, van Langen H, Hopman MT: Arterial vascular properties in individuals with spina bifida. Spinal Cord 2003;41:242–6
15. Sramek P, Simeckova M, Jansky L, et al: Human physiological responses to immersion into water of different temperatures. Eur J Appl Physiol 2000;81:436–42
16. Braddom R: Physical Medicine and Rehabilitation, ed 2. Philadelphia, WB Saunders, 2000
17. Bove AA: Medical aspects of sport diving. Med Sci Sports Exerc 1996;28:591–5
18. Levey EB, Kinsman KF, Kinsman SL: Deep venous thrombosis in individuals with spina bifida. Eur J Pediatr Surg 2002;12(suppl 1):S35–6
19. Barratt DM, Harch PG, Van Meter K: Decompression illness in divers: A review of the literature. Neurologist 2002;8: 186–202
20. Dembert ML, Keith JF III: Evaluating the potential pediatric scuba diver. Am J Dis Child 1986;140:1135–41
21. Noppen M: Management of primary spontaneous pneumothorax. Curr Opin Pulm Med 2003;9:272–5
22. Turjanmaa K, Makinen-Kiljunen S: Latex allergy: Prevalence, risk factors, and cross-reactivity. Methods 2002;27: 10–4
23. Mazon A, Nieto A, Linana JJ, et al: Latex sensitization in children with spina bifida: Follow-up comparative study after two years. Ann Allergy Asthma Immunol 2000;84: 207–10
24. Hochleitner BW, Menardi G, Haussler B, et al: Spina bifida as an independent risk factor for sensitization to latex. J Urol 2001;166:2370 –3; discussion, 2373–4
25. Bernardini R, Novembre E, Lombardi E, et al: Risk factors for latex allergy in patients with spina bifida and latex sensitization. Clin Exp Allergy 1999;29:681–6
26. Hope A, Aanderud L, Aakvaag A: Dehydration and body fluid-regulating hormones during sweating in warm (38 degrees C) fresh- and seawater immersion. J Appl Physiol 2001;91:1529–34
27. Nakamitsu S, Sagawa S, Miki K, et al: Effect of water temperature on diuresis-natriuresis: AVP, ANP, and urodilatin during immersion in men. J Appl Physiol 1994;77: 1919–25
28. Newton HB: Neurologic complications of scuba diving. Am Fam Physician 2001;63:2211–8
29. Orlowski JP: Adolescent drownings: Swimming, boating, diving, and scuba accidents. Pediatr Ann 1988;17:125– 8, 131–2
30. Morgan WP: Anxiety and panic

Hope this is helpful!


Tuesday, March 28, 2006

Certifying examination in Undersea and Hyperbaric Medicine

Lisa Wasdin with the UHMS sends the following information about the Board certification dates:

The American Board of Emergency Medicine (ABEM) and the American Board of Preventive Medicine (ABPM) will administer the Certifying examination in Undersea and Hyperbaric Medicine

ABPM EXAM DATES: October 2-6 and October 9-13

CHANGES for the 2006 Application Cycle:
* The exam will be offered over a two week period at Pearson Professional Centers. The dates for 2006 are: October 2-6 and October 9-13.

* The application deadline is still JUNE 1, but residency pathway applicants will now be allowed to complete requirements up to 15 business days prior to the first day of the examination. For example, a resident who will not complete the practicum year requirement until September 1, 2006 will be allowed to sit for the 2006 exam, rather than wait until 2007, as long as they submit the application by June 1 and all appropriate documentations by September 11.

* The Core examination has been reduced from 175 questions to 150 questions.

* The online application fee and examination fee can now be paid by credit card.

Guidelines for Recreational Diving with Diabetes - Summary Form

We have placed the following summary of guidelines for recreational diving with diabetes recommended by UHMS/DAN workshop on our web site at
(Proceedings of the UHMS/DAN 2005 June 19 Workshop. Durham, NC:Divers Alert Network; 2005.)

Table 1: Guidelines for Recreational Diving with Diabetes - Summary Form 1
Selection and Surveillance
• Age ≥18 years (16 years if in special training program)
• Delay diving after start/change in medication
- 3 months with oral hypoglycemic agents (OHA)
- 1 year after initiation of insulin therapy
• No episodes of hypoglycemia or hyperglycemia requiring intervention from a third party for at
least one year
• No history of hypoglycemia unawareness
• HbA1c ≤9% no more than one month prior to initial assessment and at each annual review
- values >9% indicate the need for further evaluation and possible modification of therapy
• No significant secondary complications from diabetes
• Physician/Diabetologist should carry out annual review and determine that diver has good
understanding of disease and effect of exercise
- in consultation with an expert in diving medicine, as required
• Evaluation for silent ischemia for candidates >40 years of age
- after initial evaluation, periodic surveillance for silent ischemia can be in accordance with
accepted local/national guidelines for the evaluation of diabetics
• Candidate documents intent to follow protocol for divers with diabetes and to cease diving and
seek medical review for any adverse events during diving possibly related to diabetes
Scope of Diving
• Diving should be planned to avoid
- depths >100 fsw (30 msw)
- durations >60 minutes
- compulsory decompression stops
- overhead environments (e.g., cave, wreck penetration)
- situations that may exacerbate hypoglycemia (e.g., prolonged cold and arduous dives)
• Dive buddy/leader informed of diver’s condition and steps to follow in case of problem
• Dive buddy should not have diabetes
Glucose Management on the Day of Diving
• General self-assessment of fitness to dive
• Blood glucose (BG) ≥150 mg·dL -1 (8.3 mmol·L -1 ), stable or rising, before entering the water
- complete a minimum of three pre-dive BG tests to evaluate trends
 60 minutes, 30 minutes and immediately prior to diving
- alterations in dosage of OHA or insulin on evening prior or day of diving may help
• Delay dive if BG
- <150 mg·dL -1 (8.3 mmol·L -1 )
- >300 mg·dL -1 (16.7 mmol·L -1 )
• Rescue medications
- carry readily accessible oral glucose during all dives
- have parenteral glucagon available at the surface
• If hypoglycemia noticed underwater, the diver should surface (with buddy), establish positive
buoyancy, ingest glucose and leave the water
• Check blood sugar frequently for 12-15 hours after diving
• Ensure adequate hydration on days of diving
• Log all dives (include BG test results and all information pertinent to diabetes management) 1 For full text see: Pollock NW, Uguccioni DM, Dear GdeL, eds. Diabetes and recreational diving:guidelines for the future. Proceedings of the UHMS/DAN 2005 June 19 Workshop. Durham, NC: Divers Alert Network; 2005.

Donna Uguccioni joins DAN's Renée Duncan and Betty Orr on the Women's Dive Hall of Fame

Donna Uguccioni, DAN dive physiologist and research coordinator, has been named to the Women's Dive Hall of Fame (WDHOF). She received the honor at Beneath the Sea 2006 at a meeting of the WDHOF.

Dan Orr, DAN President and CEO, commended the naming of Uguccioni. "Donna has been a major contributor to our research effort and certainly deserves the recognition as a member of the Women Divers Hall of Fame,” Orr said. “We, here at DAN, are all proud of her accomplishments."

A DAN Member since 1992, Uguccioni is the safety organization's dive physiologist and research coordinator. She has conducted research on women and diving for DAN; she has coordinated the DAN diabetes and diving project (1997-2000); she co-coordinated the DAN/UHMS Diabetes and Diving Workshop at UHMS (2005); she co-edited the DAN/UHMS Diabetes and Diving Workshop Proceedings (2005)).

Added Richard Vann, Ph.D., DAN Vice President for Research: “We are really pleased for Donna to receive this honor which she earned through her fine work in the office, in the field, and in the chamber, all toward improving the safety of all divers.”

She conducts the DAN Research Internship Program (2000-2006); contributes to and co-edits DAN Annual Diving Report (1995-2005); she coordinates Project Dive Exploration, which represents all DAN research efforts in the field, including studies of dive professionals, technical diving, seasickness and ear barotraumas.

Uguccioni is a chamber, Doppler and TTE technician for DAN research projects at the Duke Center for Hyperbaric Medicine and Environmental Physiology.

At DAN, Uguccioni has also written or contributed to numerous abstracts and publications and she has contributed research-based articles to Alert Diver magazine. She becomes the third active staff member to be so named. Renée Duncan and Betty Orr also are members.

Her specialty dive certifications include PADI Advanced, Rescue and Dive Master; TDI Nitrox Diver; and NOAA/NURC Scientific Diver and Dive Master.

Her 10 First Aid certifications include N.C. EMT; PADI Medic First Aid; DAN Oxygen Provider, Oxygen Instructor and Instructor Trainer; NBMHMT Certified Hyperbaric Technician; and International Board Undersea Medicine Diving Medical Technician.

Her professional memberships include:

* Undersea and Hyperbaric Medical Society (UHMS)
* Professional Association of Underwater Instructors (PADI)
* American Academy of Underwater Sciences (AAUS)
* Cambrian Foundation (scientific underwater exploration)
* Global Underwater Explorer's Club (underwater exploration)

Saturday, March 25, 2006

Costochondral Separation and Diving

March 25th, 2006
Costochondral Separation and Diving
From DivemedTFS Newsletter,December 30, 2001

Question from a reader:

After a dive I was removing my wet suit and twisted around to grab my zipper cord and had severe pain in the chest. I was given O2 on the boat with little relief and went to the doctor here in Samoa and was told not to worry. (We do not have a chamber here, but since the doctor told me not to worry, I basically tried to put it out my head).

The general pain to touch subsided after a couple of days, but an ache continued to bother me. The pain evolved into a strange combination of pains during the day. At night when I lay down, it eases up. Now, after three months of enduring all of this uneasiness in my chest, I am worried that the injury was actually related to the dive (not the act of taking off the wetsuit). I am currently feeling a general tightness around the upper right chest area, sometimes it feels like nerve pain stretching towards my shoulder from my chest, oftentimes, the pain extends to
my back and is quite uncomfortable beside and below my right shoulder blade. Massage
seems to help, but the pain soon returns.

I also sometimes have a strange tingling throughout the area below where the collarbone attaches to the chest, it feels like something is in my throat, sometimes almost a hot sensation with a taste. I have been on an acid inhibitor (nexium), so I don’t believe it is coming from my stomach. I have seen a doctor here in Samoa, but he doesn’t know much about dive medicine. I am a male, 41 years old and generally quite healthy and I stay in shape. This injury has become rather debilitating and I would like to try to do something about it. I would like some advice.
Thank you for your time.

Answers to questions are for information only, do not imply diagnosis or treatment and should always be used in conjunction with the advice of an examining physician.

What you are describing is probably ’sternocostal or costochondral separation’, an injury that is seen fairly frequently with trauma situations but not often associated with wet suit removal. It is not serious but is difficult to diagnose or see on x-ray or other diagnostic methods and often is a diagnosis of exclusion.

The fact that it is associated with movement and pressure seems to rule out serious internal problems such as pulmonary problems, but it would be wise to have yourself checked for coronary artery disease.

One would have to agree that it most likely is not related to your dives. The condition can cause prolonged severe pain as you have noted and can often last for months. Pain syndromes can also be markedly worsened by anxiety of the unknown and one would suspect that this is having a part to play in your situation.

Here is another letter about the same subject:
I recently suffered chest pain in my right side after crashing on roller skates with my daughter (long story, but I had to prevent the 4-year-old from getting squashed). I landed on my right side with right arm stretched over my shoulder. Later in the evening (not immediately), I began to experience muscular-type pain at the interior edge of my ribcage, approximately 2″ below the sternum. I went to the doctor, and chest xrays were negative for cracks/fractures. 600mg of Ibuprofen taken a few times a day helps, but after a couple of days without, the pain begins to return. The pain is low grade with occasional sharp pain, no coughing, voice changes or shortness of breath. The injury appeared to get better, but my weight training seemed to aggrevate it. Therefore, I have rested it for over a month, but the low grade pain lingers.

While this has not impacted normal life, I have not been able to lift weights/exercise for our dive team. I’m still in good shape, but do not want to get too far gone before resuming. Based upon what I’ve read, I believe I either have a bruise, rib separation, or perhaps a cartilege stretch/tear.
I would very much appreciate information or websites that might contain information on such injuries so I might be able to accelerate the rehab. I’ve heard soft tissue rib injuries are some of the worst for rehab, but I’m willing to help the process in anyway possible. I’ve also wondered if an MRI might help diagnose the problem, or if that would even affect the recommendations.

From your history provided this sounds like a costochondral separation, although an undisplaced rib fracture is possible. Rib fractures can take a long time to clear up (four to six weeks) and costochondral separations can take twice as long. You might want to be sure that you don’t have some other internal injury, such as liver damage (right side). It would probably ease your mind - if not your pain - to see a physician and be sure.

Here are some links:

Friday, March 24, 2006

More water deaths

By Kevin Wadlow
Senior Staff Writer

Posted-Wednesday, March 22, 2006 9:10 AM EST

Coroner says reasons vary for recent spate

The number of visitors dying in Keys waters either while snorkeling or diving continues to rise this year.

Two people died while snorkeling off the Keys over the weekend, bringing to six the number of deaths on local waters in 2006 - a number higher than a typical annual total of such deaths.

Three of those deaths - none involving the use of scuba gear - occurred within the past eight days.

Friday, a 65-year-old man died while on a commercial snorkeling trip near Rock Key, off Key West.

The man, believed to be visiting from out of state, was found floating face-down during a morning reef trip. He was pulled out of the water by crew on a second dive boat. Despite rescue attempts on the six-mile trip to shore, he was pronounced dead on arrival.

The name of the victim and other details were not released pending completion of a U.S. Coast Guard investigation.

The next day, a deepwater spearfisherman died while free-diving to the Thunderbolt shipwreck off Marathon. Ivan Morffi, 29, of Miami was diving with friends when he disappeared. His body was recovered from the bottom, 120 feet down.

On March 15, a 47-year-old woman from Ohio died while diving off a Key Largo snorkel boat.

“Most people who go snorkeling are not at high risk for drowning,” said Dr. Michael Hunter, Monroe County's medical examiner.

In cases where a middle-aged visitor dies while on a snorkel trip, Hunter said, “Heart disease is often a contributing factor. Many of these people never knew they had heart disease, and the sudden increase in exertion put them at risk.”

The victim may die of a heart attack, or the incident could contribute to a drowning, he said.

“Water is unforgiving,” said Dr. Ernest Campbell of Ono Island, Ala., who runs a dive-medicine Web site, “People start having trouble, then they run short of breath and they can't do what they need to do to keep their heads above water.”

Snorkeling and diving are physical activities that can trigger a heart attack in people with pre-existing conditions or who are seriously out of shape, he said.

“It's not much different from somebody deciding to go out and run a mile,” Campbell said. “Your mind is making a commitment your body can't keep.”

Saturday's death of Morffi falls into a different category, Hunter said.

“These [free-divers] tend to be younger and physically fit with much more experience in the water,” he said. “But they may make repetitive dives to extreme depths.”

That can cause a buildup of carbon dioxide, which leads to oxygen deprivation - and possible blackouts. “If that happens, especially at depth, drowning follows,” he said.

To P or Not to P: Why Use a P Value, Anyway?

What is a P Value?

When doing a study, research problem or trying to decide if some finding is significant - statisticians use a method called the "P value". P is short for probability: the probability of getting something more extreme than your result, when there is no effect in the population. To get statistical significance, you assume there is no effect in the population. Then you see if the value you get for the effect in your sample is the sort of value you would expect for no effect in the population. If the value you get is unlikely for no effect, you conclude there is an effect, and you say the result is "statistically significant".

Andrew J. Vickers, PhD, in Medscape, has written an article that might be of interest to many physicians and people interested in trying to decide whether or not a particular study is of any true value. We hear a lot these days of "evidence based studies" with findings that are statistically significant and not "anecdotal". This might apply to the use of a treatment modality such as hyperbaric oxygenation for conditions that might show a benefit for several patients but after rigorous statistical analysis - fail to have a significant "P value" and not really have a beneficial effect across the board.

Dr. Vickers writes humorously of his statistical obsessions in a manner to point out the ramifications of a statistically significant P value. The article is paraphrased below.

"Going home each night, he has a choice between a busy road or winding through the backstreets of Brooklyn. Being statistically obsessed, he records how long each route takes on a number of occasions and calculates means and standard deviations. He needs to know the quickest route and conducts a statistical analysis of his times: it turns out that the travel time for the busy road is shorter, but the difference between routes is not statistically significant (P = .4). Nonetheless, it would still seem sensible to take what is likely to be the quicker route home, even though it hasn't been proved that it will get him there fastest.

So, he now decides to get more information and spends 2 years randomly selecting a route home and recording times. After analyzing the data, there is strong evidence that going home via the busy road is faster (P = .0001), but not by much (it saves me 57.3 seconds on average). So he decides that, he'll wind along the backstreets, simply because it is a more pleasant journey and well worth the extra minute. Pragmatic?

If P values should determine our actions, as most think; in the case of a drug or hyperbaric clinical trial, for example, we say: "P < .05: Rx effective; P ≥ .05: Rx not effective." Yet, the bicycle trip home (above) shows the opposite: he chose the busy road when P was .4 but not when P was .0001. This suggests we need to think a little harder about what P values are and how we should use them.

The most important thing to remember about P values is that they are used to test hypotheses. This sounds obvious, but it is all too easily forgotten. A good example is the widespread practice of citing P values for baseline differences between groups in a randomized trial. The hypothesis being tested here is whether there are real differences between groups. Yet we know that groups were randomly selected, so any differences in characteristics such as age or sex must be due to chance alone.

Science is often said to be about checking ideas, but in many cases this is not what we want to do at all. When he needed to get home quickly, he wasn't interested in proving which was the quickest way home, he just needed to figure out which route would do what he needed -to get him to an appointment on time (Pragmatism?). Moreover, even when we do want to test ideas, the conclusion is often an insufficient reason for action. He eventually proved that using the busy road was quickest but decided to choose a different route on the basis of considerations -- pleasure and quality of life -- that formed no part of the hypothesis test.

An even more difficult problem is when our P value is > .05, that is, when we have failed to prove our hypothesis. This is often interpreted as proof that our hypothesis is false. Using this interpretation might withhold beneficial therapy to many. Such an interpretation is not only incorrect, but Dr. Vickers feels that it can also be dangerous; he will discuss this in a future column."

Andrew J. Vickers, PhD, Assistant Attending Research Methodologist, Memorial Sloan-Kettering Cancer Center, New York, NY

Dr. Omar Sanchez, Buenos Aires physician, has the following quotation that seems apropos here:
“Statistics are like a bikini. What they reveal is suggestive, but what they conceal is vital.”

He also sends us a citation for an article in the Spectrum, a journal of the National Cancer Institute titled "What's the Rush? The Dissemination and Adoption of Preliminary Research Results";98/6/372

This article emphacizes the gamble of taking early returns from studies and applying the good results as a treatment modality.

Scubadoc's Diving Medicine Online to be translated and posted in Czech

We thought that you might be interested in the following request to translate portions of our web site into the Czech language.

Good morning,

My name is Jaroslav Malek and I am owner of diving shop and scuba divers school NAUI here in Prague, Czech republic. Because Your web pages are very nice and helpful and there are not such pages here in Czech, I would ask you, if is possible to translate documents and insert them to my web pages with reference to

I think it could be very helpful and interesting for divers here in our country.

Thank You very much.


Jaroslav Malek
Executive Head


Bludovicka 400 Prague Czech Republic
tel./fax: + 420 266 31 24 25
mobile: + 420 774 37 64 64


Good Morning Jaroslav:

Thank you very much for your kind remarks about my web site. Our raison d'etre has always been to provide free, accurate and up to date information about diving safety. Your offer to translate our material fits in nicely with our program.

We have had this done with several other languages, notably German, Italian, Portuguese and Spanish. One problem that we have encountered is the "meaning of syntax" being lost in translation. This is only to emphasize to you the need for accuracy in the translation . Of course, you may proceed with your offer without further ado.

Please provide proper attribution as to authorship and link to my web site at Let me know when you have placed a translation so that I can post this on my Ten Foot Stop blog at .

Best regards:

Ern Campbell, MD, FACS
Scubadoc's Diving Medicine Online


Thank You very much, I`ll do it so.

Have a nice day

Jaroslav Malek

Australian team to salvage old U.S. sub ‘Explorer’; 1st case of decompression sickness ?

March 24th, 2006

United Press International has an interesting story published on March 20, 2006 from Panama City, Panama.

“A team of Australians plan to salvage a U.S. submarine from the Civil War era 130 years after it was beached on a Panamanian island, a member of the team has said.

Built by Julius Kroehl in 1865 to counter the Confederate vessel Hunley, the hand-powered submarine was identified in 2002 by James Delgado, imminent marine archaelogist.

Believing the rusting hulk to be a WWII Japanese midget submarine, the Panamanians allowed the vessel to lie at the tide line, deteriorating. The 'Explorer', a 59-foot vessel, was built too late to play a decisive role in the Civil War and was sent to trawl for pearls in the Gulf of Panama. However, the sub was abandoned 11 days into its maiden voyage, after collecting 10 tons of pearl shell, when divers on board succumbed to decompression sickness.

James Delgado, Marine Archaelogist has an interesting article describing his investigation of the submarine in 2002-2004 at .

He is also quoted in this article at . He is quoted as stating that Kroehl possibly was the first reported case of decompression sickness.

Wednesday, March 22, 2006

Two Classified ads from the UHMS

Technical Director and Nurse Supervisor

The Mayo Clinic Section of Aerospace Medicine in Rochester , Minn. , will open a hyperbaric and altitude medicine program in Fall 2007 to provide hyperbaric oxygen therapy for patients and clinical research. The facility will include hypobaric capability to conduct altitude physiology and applied research for aerospace technology.

We are currently seeking a Technical Director and Nurse Supervisor for this new and exciting initiative.

The chamber will be a multiplace, triple lock 3/6 ATA rectangular system with two treatment compartments each accommodating 12 patients. It is being built by Fink Engineering of Cheltenham, Victoria, Australia. Medical Multiplex, Inc., of Louisville, Ky., has been enlisted to consult on operational planning and training.

Mayo Clinic, one of Fortune magazine’s “100 Best Companies to Work For,” offers an excellent salary and benefits package. To learn more about Mayo Clinic and Rochester , MN, visit For additional information regarding these opportunities, please contact:

Paul L. Claus, M.D., Medical Director
Mayo Clinic Hyperbaric & Altitude Medicine Program
Phone: 507-266-4602
Fax: 507-266-0909

Dr. Claus will be attending both the Hyperbaric Medicine 2006 Symposium ( March 23-25, 2006 ) in Columbia , South Carolina and the 2006 Annual UHMS Scientific meeting ( June 22-24, 2006 ) in Orlando Florida . Interested individuals attending those meetings may be reached through Medical Multiplex, Inc. representatives at their booth.

Mayo Clinic is an affirmative action and equal opportunity employer.


Hyperbaric Technician

Wound Care Ctr.

Provide direct care for patients and functions as the outside attendant as well as console operator for the monoplace hyperbaric chambers. Licensed Practical Nurse (LPN), Respiratory background or Emergency Technician/Paramedic. Certified in hyperbaric technology preferred, or ability to acquire such knowledge. At least one yr. exp. in pt. care environment and/or diving/medical hyperbaric exp. Working knowledge of various control systems of the chamber or ability to acquire such knowledge in a reasonable period of time. Please apply online, fax, or send cover letter & resume to:

Ohio Valley General Hospital
Attn: H.R.
25 Heckel Road
McKees Rocks, PA 15136
(412) 777-6218
Fax: (412) 777-6804

Interesting "Dive Away" to the Socorro Islands, a 2006 Live Aboard Diving and Diving Medicine Program

To: Diving Enthusiasts

Subject: "Dive Away" Socorro Islands, Mexico
2006 Live Aboard Diving and
Diving Medicine Program
April 22-30, 2006


We cordially invite you to join us for our 15th International Diving, Diving-Medicine Program. This year the course is being held aboard a state of the art live aboard diving vessel at the Socorro Islands and Isla Revillagigedos, off the coast of Mexico.

There are only a few more spots left available, so act now.
The Socorro Islands are a premier dive area in the same league as Palau, Cocos Islands, and the Galapagos. In fact, the islands are often times referred to as "The Galapagos of Mexico". The diving at Socorro Islands is famous for extraordinary interactions with gentle giant manta rays, with which you can anticipate having numerous close encounters!

The medicine program and related travel expenses qualifies as a medical education expense with 24 hours category 1 CME credit reviewed and approved by the Undersea and Hyperbaric Medical Society. Our faculty is second to none with Jeff Bozanic, PhD author of Mastering Rebreathers, Michael B. Strauss, MD co-author of Diving Science, Alan Lewis, MD fellowship trained in Undersea and Hyperbaric Medicine, and Arian Nachat, MD contributor to the newest edition of Auerbach’s Wilderness Medicine. In addition to a comprehensive diving medicine curriculum, special seminars will be given analyzing diving activities as seen in the entertainment media, Anarctic diving, and new developments in technology.

Our dive platform, the Nautilus Explorer, ranks with the top of the recreational diving fleet. The Nautilus Explorer is a ship custom designed for divers to the highest possible level of comfort and safety. There are much too many details about the ships features and amenities to be covered in a brief email. Please visit to take a visual tour of the ship and find lots more information.

For more information about this program, please open the attached brochure and registration form. If you would like a brochure and registration form mailed to you (should you be unable to bring-up this information on the PDF format attachments), please call (562) 933-6950 or

We look forward to having you attend this very exciting program.
Best wishes and safe diving,

The "Dive Team"
Long Beach Memorial Medical Center
Long Beach, CA
Jeff Bozanic, PhD Michael Strauss, MD
Alan Lewis, MD Arian Nachat, MD
Stuart Miller, MD

Monday, March 20, 2006

Woman: Toxin Still Powerful Years Later |


Dr. Omar Sanchez sends us a link about a woman who had ciguatera and who still is symptomatic years later. This can be read in the "ledger" at this address:

The following is information that we have on our web site about this toxin and the condition it can cause.

* The toxin, icthyosarcotoxin, is heat stable, lipid soluble and comes from the dinoflagellate Gambierdiscus toxicus. It is common in the tropics, concentrated up the food chain and is seen in eels, red snapper, amberjack and so forth.

* Symptoms: vary, the usual onset occurs in the first 12 hours and can last for ten to twelve days. The GI symptoms are followed by myalgias, arthralgias and paresthesias. There is the heat/cold reversal phenomenon and this is supposed to be diagnostic. Neurological symptoms may take months to resolve and occasionally may be permanent. Symptoms are aggravated by alcohol and by eating a fish only slightly affected.

* Treatment: nonspecific, primarily supportive. Suggested treatment has included calcium gluconate, corticosteroids, atropine, vitamin B, pyroxidine, amitriptyline and mannitol. Mannitol treatment is 250 cc 20% Mannitol (1mg/kg), this usually relieves the neurological symptoms in minutes and the rest of the symptoms in 3 days.


* There is now a product that tests fish for the toxin.
The Cigua-Check product has added some changes. These are highlighted below...

The company name has changed from Oceanit Test Systems to ToxiTec, Inc.
They offer only a three (3) test kit size, retail price is $24.99US
They now offer scientific and research test kits in sizes as low as 24 tests
They can customize a test kit for your specific needs.

Ciguatera References


There is an interesting web site that divers need to be aware of - the World Recreational Scuba Training Council. It provides a web page for downloads in .zip at


Other downloads include,,,,,,

Sunday, March 19, 2006

Obesity and Its Correlation With Scuba Diving

We occasionally (often) get questions that relate to the risks of diving and obesity. Let's face it, we actually have an epidemic of excess weight in our general population and this translates right over to divers and dive instructors. Here is a web site that associates one of the main risks of diving and obesity - respiratory problems. To my knowledge, there are no studies, however, that relate an increased risk of DCS with obesity.

Obesity and Its Correlation With Spirometric Variables

See also our web page about obesity and diving at:
Obesity and DCS
Describes the increased risks of diving with obesity. ... Obesity and Scuba Diving. Questions are often asked about diving while overweight, body mass index ... -

Wednesday, March 15, 2006

Interesting links on the Internet

As we update our Diving Medicine Online, answer questions and maintain our forum, 'Scuba Clinic', we run across many interesting web pages that we feel you might be interested in seeing. Here are a few that we have saved and present in no particular order.

Coagulation May Be Activated by Prolonged Air Travel

From Journal of Travel Medicine
Traveler's Thrombosis: A Systematic Review
Posted 06/30/2005

See also:

1. Travel Related Links and Diving
Web Site DIVING TRAVEL MEDICINE The recreational diver ... hazard of travel-related illness than ... related accidents. TRAVEL LINKS DocVikingo on Dive/Travel Insurance Traveler's Health

2. Air Travel and Oxygen
Problems With Gases Air Travel, Oxygen and the Diver Scubadoc's Diving ... the specialist. Air Travel, Oxygen and the Diver There ... with baggage. Air travel decreases the partial pressure

3. Travel Exercises
non-diving physician and the specialist. Web Diving Medicine Online Travel Exercises The exercises described below can be done in a hotel room, on a boat or just about anywhere

4. Boussuges A, et al.
Activation of coagulation in decompression illness.
Aviat Space Environ Med. 1998 Feb; 69(2): 129-132.

Medical Talks could appeal
Divernet News for divers

The Diving Medicine 2006 conference, to run on 23/24 March in Shrewsbury, could be of interest to sport and particularly technical divers.

Organised by the United Kingdom Sport Diving Medical Committee, the event covers such subjects as fitness for diving, heart PFOs, asthma, diabetes, DCI treatments, and the physiology and medicine of technical diving.

The venue is the Shropshire Education and Conference Centre. Full details,

IMAX Film gets up close to marine life - Divernet

Ghostly coral bleachings haunt the worlds reefs - Yahoo News

[Central nervous system involvement in patients with decompression illness]
Medline Abstract of an article

[Acute decompression illness following hyperbaric exposure: clinical features of central nervous system involvement] Medline Abstract of an article

Neurological manifestations in Japanese Ama divers.

See also:
1. Taravana

1. Chronic Neurological Adverse Effects of Diving
Relates studies showing changes in the neurological system in divers who had DCS and in long-term divers.References Scubadoc's Diving Medicine Online Comprehensive information

3. Long-term Effects of Sport Diving
article on some of the possible long-term effects of sports scuba diving. References ... linked. Osteonecrosis, neurological disturbances, systemic and ... a discussion of patent foramen ovale

Noise and Diving

Tuesday, March 14, 2006

Diving Medicine Courses from Scott Haldane Foundation, Netherlands

I don't know if you are interested in publishing it on your web site, but we have a yearly course programme in diving medicine (for 12 years now) which is growing every year. In 2006 we have 10 courses, 5 in the Netherlands and 5 abroad (Curacao, Philippines, Roatan (Honduras) 3x). Our website will be translated into English shortly. Just to keep you updated the course schedule for 2006 is/was:

21-28 Jan. Diving Medicine for ENT-specialsts, Negros Philippines

11 Mar. Refresher course Diving Medical Exam. (Zaandam The Netherlands)

1, 7, 8 Apr. Basis course Diving Medicine, (Amsterdam The Netherlands)

13-20 May.Advanced course Diving with Physical Restrictions, a Restriction for Diving?, Curaçao Dutch Antilles)

2 June. Advanced course decompression-recompression, (Zwolle, The Netherlands)

9 Sep. Refresher course Diving Medical Exam, (Rotterdam, The Netherlands)

22 Sep. Advanced course decompression-recompression, (Zwolle, The Netherlands)

11-18 Nov. Basis course Duikgeneeskunde, (Roatan, Honduras)

18-25 Nov Advanced Course Diving Accidents (Roatan, Honduras)

25 Nov - 2 Dec. Advanced Course Diving Accidents (Roatan, Honduras)

Warm regards from a freezing Netherlands

Drs. Jan-Jaap Brandt Corstius
directeur Scott Haldane Foundation
voor meer informatie zie ook onze website

5th International Symposium for Hyperbaric Oxygenation and the Recoverable Brain

We have received the following letter from Sharon Phillips:

Hello Ernest

We wanted to let you know about our 5th International Symposium for Hyperbaric Oxygenation and the Recoverable Brain, July 18-22 in Fort Lauderdale, Florida. We expect 400 delegates, 50 speakers from all over the world and about 40 exhibitors. Please check out our website – There are a couple of speakers from the UK, and we are looking to have a bigger audience this year from Britain.

We are honored to announce that the Welcoming Ceremony will be given by Professor Franz Gerstenbrand Founder of the World Federation of Neurology on Wednesday, July 19, 2006. Professor James Toole, M.D. Teagle Professor of Neurology and Public Health Sciences, Director, Stroke Research Center Bowman Gray School of Medicine will also give an introduction during the welcoming ceremony.

There are a couple of areas that your organization might be interested in:-

a) Becoming a conference delegate – check out our early bird special rate prior to May 1st.

b) Your organization might like to have a booth. We have excellent sponsorship opportunities this year.

c) Parents with children with cerebral palsy or other brain injuries might be interested in attending (We have a family pass)

d) To promote this event to parents or other colleagues, you might want to put our URL onto your website or include our event into your next newsletter or event calendar.

To register for this annual event, please go to

I look forward to hearing from you soon.

Kind regards.

Sharon Phillips

Director of Marketing
5th International Symposium
Tel: +1 954 575 4973
Fax: :+1 954 827 0723
Cell: +1 954 540 1896

Monday, March 13, 2006

Letter from Dan Leigh, Divers Alert Network, re SSS


We deeply regret that many DAN members and others in the diving community
were the focus of a broadcast email campaign by the SSS Network. The latest
statement from SSS is designed to intimidate and frighten DAN members, and
much of the information is untrue, misleading and contradicts previous
statements from chambers within the SSS Network. DAN and SSS are in dispute
over the excessive treatment charges, which DAN believes are not reasonable
and customary in comparison to other hyperbaric chambers and will damage the
diving industry long term if not addressed now. By refusing to accept DAN
insurance, SSS is attempting to place the burden of payment on the diver in
order to gain leverage to force DAN¹s insurer to accept higher treatment

We find it hard to believe that SSS facilities would be closing due to
insurance issues involving DAN¹s insurer. SSS has claimed that insurance
purchased through DAN represents only a small percentage of their business.
They have now stated that some of this is being driven by a slowdown in
diving travel, especially to dive locations that experienced hurricane and
tsunami damage. DAN has always supported remote facilities through our
Recompression Assistance Program (RCAP). This program is part of the
not-for-profit mission of DAN, and provides equipment to help chambers
remain fully operational so they can remain open and viable and assist
divers in need without having to resort to overcharging injured divers.

The recent SSS press release implies that there is something suspicious
about Accident & General Insurance, Ltd. (AGI), a wholly-owned subsidiary of
DAN that underwrites a portion of the diver accident insurance purchased
through DAN. On the contrary, DAN has referenced AGI in all of its
publications and presentations about DAN. Revenue generated by AGI supports
DAN¹s mission activities including medical services and research. No DAN
employees receive compensation from AGI.

DAN has worked hard to bring this dispute to an equitable resolution. A
court date is set for early May 2006. A mediation session is scheduled for
late March. The tactics employed by SSS are unfortunate choices in a
dispute that we choose to handle in a more professional manner. While SSS
keeps changing its position (see DAN website for a chronological records of
their statements), DAN has always maintained a consistent message and
approach to the issue:

A. DAN Members will be treated at all SSS recompression chambers
B. DAN Members with Dive Accident Insurance purchased through DAN are fully covered
C. In the event of a dive injury, call the DAN Emergency Hotline immediately
D. DAN will handle all the necessary matters and no DAN member will be out of pocket

DAN has been here to protect divers for over 25 years and during that time
we have been true to our mission to keep divers and our sport as safe as
possible. We will continue to do so. DAN is and will remain 'Your Dive
Safety Association'.

The Wound Care Course

The Wound Care Course

April 7-9, 2006

Nix Hospital

San Antonio, Texas

This CME Activity is hosted by

International ATMO, Inc., 414 Navarro, Suite 502, San Antonio, Texas 78205

Phone: 210-614-3688, Fax: 210-223-4864, Email:




Nurses and Allied Health Professionals

Tuition includes all lectures, practical exercises, and course materials. Fees can be paid by cash, check, or credit card and should be received prior to course dates. Tuition includes a $50 non-refundable administrative fee.

Schedule / Topics


Introduction / PJ Sheffield

Physiology of Wound Healing / R Wolcott

Biofilms / R Wolcott

Infection and Infection Control / R Wolcott

Nutrition / K Itz-Thompson



Obstacles to Wound Healing Pathophysiology / J Shah

Arterial Insufficiency Ulcers / J Shah

Psychosocial Issues / Otis-Sullivan

The Diabetic Foot / JM Smith

Assessing the Wounded Patient / CE Fife

Lunch (Lunch Provided)

Managing the Wounded Patient / CE Fife

Advanced Therapeutics / CE Fife

Pressure Ulcers / DL Krasner

Dressings / DL Krasner

Hands-on Sessions



Unusual Leg Ulcers / J Shah

Putting It All Together Interactive Q&A Session / J Shah

Pain Control / DL Krasner

Prevention/ Keeping the Patient Healed / DL Krasner

Documentation/Clinical Research / DL Krasner





Caroline E. Fife, MD

Medical Director, Center For Hyperbaric Med

Memorial Hermann Hospital

Associate Professor of Anesthesiology

UT Health Science Center

Houston, Texas

Diane Krasner, PhD, RN, CWOCN, CWS

Skin & Wound Consultant

York, Pennsylvania

Sheree Otis-Sullivan, BSN

Staff Nurse

Nix Wound Care & Hyperbaric Medicine Center

San Antonio, Texas

Jayesh B. Shah, MD, CWS

Medical Director, Wound Care Center

Southwest General Hospital

San Antonio, Texas

Deborah Sheffield, MSN, APRN, CHRN, CHT


San Antonio, Texas

Aimee Dennis Wauters, MS, RD

Clinical Dietician

UT Health Science Center San Antonio

San Antonio, Texas

Randall D. Wolcott, M.D.

Medical Director

Southwest Regional Wound Care Center

Lubbock, Texas


For a brochure, click here: WCC Brochure.doc

‘Practical Approaches to Wound Healing’



May 11-12, 2006 August 28-29, 2006

Palmetto Health Richland

Two Medical Park

Lower Level Conference Center

Columbia, South Carolina


This activity is for Physicians, Nurses, Physical Therapists, Wound Specialists and other interested Clinicians.

After attending this activity, participants should be able to:

Discuss the physiology of tissue injury and wound repair.
Describe wound assessment and documentation.
Select and use basic and advanced wound care products/technologies.
Describe wound bed preparation including debridement, diagnosis of infection, and use of topical antimicrobials.
Recognize proper care of atypical wounds.
Identify differential diagnosis and management of arterial, venous and diabetic wounds.
Recognize the role of adjunctive therapies including support surfaces, offloading, nutrition, medications, etc.
Identify appropriate surgical management of chronic wounds.
Make decisions regarding fundamentals of billing for wound care products and services.
For additional information and registration options please visit our website at

Tuesday, March 07, 2006

Sleeping With The Fishes, an Interview with Patrick Musimu

Sleeping with the fishes
Brendan O'Brien explores the murky and lung-busting world of free diving with the sport's greatest exponent, Patrick Musimu.

For further reading on our web site go to:

Shallow Water Blackout
Discusses free diving, shallow water blackout (latent hypoxia) ... Hyperventilation is used by free divers to reduce the concentration of CO2 and extend the ...

Breathhold Diving:Taravana
Free diving onloads N2, to a small degree, more or less depending upon the depth and time at depth of the dives and this time should be taken into ...

Breath-hold Diving:Taravana
Free diving onloads N2, to a small degree, more or less depending upon the depth and time at depth of ... The free divers work to depths 150 fsw or more. ...

FAQ - Physics and Gases
Free diving - how long on average do the divers hold their breath for and ... The same things happen to the free diver that happens to the scuba diver or ...

Board Preparation: Problems With Gases
This might account for the increased performance trained free divers notice ... The use of hyperventilation in preparation for freediving is controversial. ...

Monday, March 06, 2006

Legal Aspects of Wound care and Hyperbaric Medicine, 2005

CME/CEU Two DVD Set Legal Aspects of Wound Care - $75.00

The Order Form is Located At Aspects Order Form.pdf

or call

International ATMO Education Department


International ATMO

For other courses or products visit our web site at

Undercurrent Online Update

Undercurrent -- Consumer Reporting for
The Serious Scuba Diver since 1975
Reprinted with permission

March 6, 2006

Dive News

Just How is Post Hurricane Cozumel Diving?: It was a rough year for Cozumel. Emily struck in July, then in October Wilma, one of the most intense Atlantic hurricanes in recorded history, visited. Topside the island has rebounded remarkably. You can generally expect to stay and play at your favorite establishments and submerge with your favorite dive operators. But, divers want to know what it's like underwater, so Undercurrent's Doc Vikingo visited in February to update our readers. His full report will be in our April issue. To give you a heads up, he says: "Even to a 32-year Cozumel veteran some sites were unrecognizable. Despite contrary reports, the underwater environment has been significantly rearranged and changed forever. The reefs, where not entirely covered in sand or denuded of delicate marine growth (e.g., Chun Chacaab shallows, Dalila, La Francesa), are silted to varying degrees. While some mid level sites like Palancar Gardens and the upper reaches of the Santa Rosa Wall fared better, choking silt on corals and sponges can still be seen. Not surprisingly, the deepest reefs survived best (e.g., Maracaibo Deep, Columbia Deep), but here massive hunks of reef have tumbled off in some sections. On the bright side, many delightful new swim throughs, caverns and holes have been created. These strikingly beautiful alterations in underwater structure put a fresh face on Cozumel scuba. The fish and reef creature life also has been altered, yet there remains much to see." When you go, choose the good operations we report on in Undercurrent with a thorough knowledge of the reefs, tanks and rules that allow you to dive relatively deep for extended times, and a willingness to visit the least damaged sites.

Saving Reefs the Painless Way: From your travels, I'll bet you have brought home foreign currency that only gathers dust. Why not get a tax deduction and save a reef with it? Undercurrent is a nonprofit 501 (c) 3 organization and we are raising money for reef preservation in Belize and Fiji. If you send me those foreign bills, I will exchange them for dollars, send you a receipt for your tax deduction, and direct ALL the money to one of two projects:

Belize: In southern Belize's 133-island Port Honduras Marine Reserve, poachers are taking manatees and other marine species, especially at night when stealth fishermen slip in. The underfunded park rangers want to repair and outfit their sailboat _ so silent at night _ for overnight patrols to prevent gill-netters from illegally fishing these breeding grounds and capture them. Your money will help them do it . . . Fiji: At the southern tip of Taveuni, virgin reefs and rain forest are under the control of Vuna Village chiefs, who need money to help their people. Outsiders want to pay to fish the reefs and cut the trees, but the villagers have struck an agreement with our partner, Seacology, to establish two marine protected areas and protect a forest preserve (silt from logging destroys reefs) in return for a much-needed school house. Your contribution will help ensure that it is completed and the reefs and forest are protected.

Send your foreign currency (we'll even take your personal check) to Undercurrent, c/o Ben Davison, POB 3120, Sausalito, CA 94966. I will send you a receipt for your tax-deductible contribution and ALL OF YOUR MONEY will go directly to these projects. If divers don't save the reefs, who will?

Jury Says Dive Shop Owner Murdered His Wife Underwater: A Providence RI civil trial jury has unanimously awarded the parents of Shelley Tyre, the deceased wife of David Swain, more than $3.5 in compensatory and punitive damages for her death. During the trial, they heard lawyers for the plaintiff describe how in the British Virgins in 1999, Swain had killed her in 80 feet of water by turning off her air and holding her down. His reason: to inherit her property. Swainn, who has never been criminally charged with her death, says he may appeal. The complete story will be in the April issue of Undercurrent.

DAN Insurance Update: The disagreement we reported earlier between the SSS Recompression chamber network and Divers Alert Network (DAN) has resulted in three of the network's chambers refusing to accept DAN America insurance. The three, all owned by SSS founder Mauricio Moreno, are in Cabo San Lucas, Nassau, and Cancun. Nine other chambers affiliated with SSS are still accepting DAN America coverage _ at least for now. A DAN spokesman has assured Undercurrent that if the chambers do not accept the insurance, DAN will reimburse policy holders according to their agreement. Nonetheless, it would be prudent for DAN-insured divers to carry credit cards with high enough limits to cover typical chamber treatments, which can run to $15,000 or more. More on DAN's lawsuit in the April issue of Undercurrent.

Been Diving in the Past Six Months? We're already at work on the 2007 Travelin' Diver's Chapbook and would like your report on your dive trips. You can complete an online form at Or, you can email the report to me at Be sure to include your name and home town. Or you can fill out the form in the March issue, which will be mailed this week. The Chapbook is only as good as the reports from the readers, so get yours in now. Thanks.

Divers and Internet Purchases. We're working on a story about Internet purchases, how divers fare, and the long range consequence for local dive stores. We need your help. Have you ever bought dive gear over the Internet? Did you check out the product at a dive shop before ordering? If you returned anything, how was it handled? How did you have the equipment serviced after your purchase? Have you had any warranty issues? Generally good or bad experience? Please provide the specific URL of website, and when you made the purchase. And email your comments to Thanks.

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

Things That Go "Bump in The Water" for Divers: Pneumothorax

[Spontaneous, traumatic, iatrogenic, post-surgical]

Compiled by Ernest S Campbell, MD

There are three obvious reasons for not diving:

* Disorders that may lead to altered consciousness
* Disorders that inhibit the "natural evolution of Boyle's Law".
* Disorders that may lead to erratic and irresponsible behavior.


Any lung disease, procedure, or event that can result in air trapping is thought to be a contraindication to diving. That having been said, most diving medical people would say that spontaneous, traumatic and post-surgical pneumothoraces are felt to be disqualifying, due to the almost certain presence of 'air trapping', either from the underlying disease process or the surgical procedure. Once a person has a spontaneous pneumothorax, recurrences are likely.

Traumatic and iatrogenic pneumothoraces vary in degree, those due to blunt or penetrating trauma usually leave lacerations of the lung surface, often with significant radiographic changes that indicate scarring and air trapping. Such individuals should not be allowed to dive. In the event of isolated injury without significant scarring or air trapping, such as is seen with ice pick trauma, clean knife penetration, subclavian line placement, thoracentesis needle injury and some some mediastinal surgery, diving should be permitted, pending proper radiological evaluation to rule out air trapping.

There are really two dangers involved -arterial gas embolism, with the possibility of immediate death due to coronary or vertebrobasilar embolism, and tension pneumothorax--which severely complicates recompression treatment of AGE [arterial gas embolism]. A large pneumothorax requires the insertion of a needle for relief and a tube management if treated in the chamber.

There appears to be little evidence that the dangers of spontaneous pneumothorax present a threat over a lifetime; there have not been any fatalities reported attributed to an AGE due to a previous spontaneous pneumothorax or previous thoracic surgery [NOAA Statistics, 1972-1982].

Spontaneous pneumothorax is an inherited disease which leaves some people with weakened areas of the pleural lining of the lung, called blebs or blisters.These can occasionally burst and cause air to leak from the lung to the chest cavity, resulting in a pneumothorax ('air in the chest'). It is 'spontaneous' in the sense that there was no trauma or surgical cause of the ruptured bleb. It can occur when the individual is exercising, straining, or performing some other physical task, but most of the time it just happens. If one spontaneous pneumothorax has occurred, there is a 33% chance that another will occur within 2-3 years 30% will have a recurrence after 3 years, and there is a 60% long term risk for another pneumothorax.

When a lung collapses while diving, the air in the chest cavity is at the ambient pressure of the dive depth. Upon ascending, the air in the chest cavity expands, and further compresses the lung (tension pneumothorax). This is a life-threatening situation and is one of the main reasons that a history of spontaneous pneumothorax is an absolute contra-indication to diving since most divers and dive boats are not prepared to provide first aid to a diver with pneumothorax. One of the symptoms of a small pneumothorax is a voice change after a dive. This would raise a warning flag about further diving as there might be a small pneumothorax which in itself is not harmful, but which will cause a serious problem if the diver does another dive.

Gas embolism, with air getting into the arterial circulation, is another thing that can happen, often with brain and cardiac symptoms.

Surgical procedures called pleurodesis (scarring the lung surface) and pleurectomy (excision of the pleura, a thin covering of the lungs) are commonly performed for recurrent collapsed lungs. There is a recurrence rate of 8 percent following pleurodesis. Recurrence is rare following pleurectomy. Even if recurrence of collapsed lung does not occur, the underlying cystic lung disease of the other lung remains, with the inherent danger now being pulmonary barotrauma with air embolism.

The following are absolute contraindications to diving:

---Diving within three months after any type of collapsed lung.
---Spontaneous collapsed lung in beginners.
---Expert divers with recurrent collapsed lung after pleurectomy.

If you feel that you will continue to dive regardless of the risk, Spiral CT scans and pulmonary functios of your lungs should be performed so as to detail the degree of risk involved. Best advice here would be not to dive until you have been cleared by your chest specialist.

(Developed from material provided by Maurizio Schiavon, MD, Consultant to Diving Medicine Online)

More at:

1. Reducing the Risk of Pulmonary Barotrauma
Lists diseases that cause spontaneous pneumothorax, ways to avoid barotrauma to the lungs and lists some references and abstracts about spiral CT scans.

2. Pulmonary Problems, Marfan's and Scuba Diving
Describes the problems that would face a diver with Marfan's Syndrome

3. Web Links to Pulmonary barotrauma
Extensive list of links to pulmonary barotrauma

Asia Dive Expo Returns to Singapore

Asia Dive Expo is Asia's largest and longest running exhibition for the dive industry and related businesses. Returning to Singapore in 2006, ADEX brings you 11 years of successful marketing for businesses that want to talk to the buyers and consumers that count. Firmly established as ‘THE’ premier platform to do business if you are in the dive industry, Asia Dive Expo is the only true International dive show which brings together the very best in the dive industry.

For more information, please log on to

Weena Lim

weena & associates
m: 97222774

Friday, March 03, 2006

First Patient Enrolled in St. Jude Medical's Migraine Headache Study; Clinical Trial

First Patient Enrolled in St. Jude Medical's Migraine Headache Study; Clinical Trial to Explore Link between Common Heart Defect and Migraine Headaches
St. Jude Medical, Inc. (NYSE:STJ) today announced the enrollment of the first patient in its ESCAPE (Effect of Septal Closure of Atrial PFO on Events of Migraine with Premere(TM)) migraine trial.

The first patient, a Virginia woman, will be one of over 500 patients to participate in the study, which received approval from the U.S. Food and Drug Administration (FDA) for an Investigational Device Exemption (IDE) in December 2005.

"Migraine is one of the 20 most disabling conditions that exists, according to the World Health Organization, and despite many good medications that help control the disease, millions of patients continue to suffer," said Dr. Neil Pugach, the first enrolling physician, a neurologist with the Brighton Research Group in Virginia Beach, Virginia. "Some patients struggle with the idea of having to take daily medications to treat their migraines, so it is exciting to think that an alternative treatment might prove successful."

"Patent foramen ovale (PFO) is a common heart defect without symptoms in most people," said Robert Sommer, M.D., Columbia Presbyterian Hospital, principal cardiology investigator for the trial. "However, PFOs have been linked to stroke and decompression illness (which may accompany activities like scuba diving), and it appears that PFOs may also play a prominent role in migraine headaches. The goal of this landmark trial is to determine if closing a PFO will help in reducing migraine attacks."

Migraine headaches are a neurological disorder characterized by chronic and disabling headaches. Approximately 10 percent of the population suffers from the disorder, and it has a prevalence rate estimated as high as 25 percent in young women.

"This trial will examine the benefit of treating a common heart defect - patent foramen ovale - in patients with migraine headaches," said David W. Dodick, M.D., Mayo Clinic College of Medicine, principal neurology investigator of the trial. "While the connection between a heart defect and head pain may seem counterintuitive, there is growing evidence that patients with migraines are more likely to have a PFO, and if repaired, it may lead to a reduction in migraine attacks. This is an exciting area of research into a chronic and disabling disease that affects millions of Americans, and I am enthusiastic about playing a role in this carefully controlled landmark U.S. study, which could answer these very important questions."

"Stroke prevention is an important aspect of PFO repair," said Dr. Sommer. "But migraine headaches are a part of daily life for nearly 30 million Americans. Current migraine therapies are difficult to take because of side effects, and the treatments are often ineffective. The catheter closure of a PFO is a simple 30-minute procedure that has been shown to eliminate migraine headaches in many stroke sufferers. If successful, this trial will have a major impact on the quality of life of millions of people."

The association between PFOs and migraine headaches was first observed by physicians who treated PFOs to remedy other medical conditions such as stroke; these physicians later noticed a reduced frequency in patients' migraine headaches. Additional informal studies have shown reduced pain - after PFO closure - for migraine patients. It is not clear why patients with a PFO would be more likely to have migraines, or why closing the PFO might decrease migraine attacks. Some physicians speculate that blood that crosses the PFO, without being filtered by the lungs, has substances that trigger migraines. More about this at .


Migraines and Diving

Patent Foramen Ovale There have been recent reports of an association between cerebral emboli, migraines with aura and right to left shunts (PFO). Philip Foster et al, ...

[PDF] Scubadoc's Ten Foot Stop Newsletter, Jan. 31, 2005 File Format: PDF/Adobe Acrobat - View as HTML
Migraine-PFO study. Migraine - New Study to Examine Possible Link With the Heart ... PFO Migraines ...

See also this 2005 report:
Migraine - New Study to Examine Possible Link With the Heart

LONDON, January 16 /PRNewswire/ -- Doctors have received approval to investigate the possible link between migraine headache and a common heart defect, called a patent foramen ovale (PFO)(1), which research indicates is prevalent in up to 25% of the general population or 15 million people in the UK. The prevalence of PFO in migraine with aura patients is 50%, or twice what would be expected in the general population.

PFO closure - currently used to treat certain types of stroke and decompression sickness - has been associated in some patients as a treatment, which eliminates or reduces the frequency and severity of migraine attacks. Now, the MIST ( (Migraine Intervention with STARFlex(R) Technology) trial(2) will seek to demonstrate the effectiveness of this simple, non-invasive PFO closure procedure in the treatment of certain patients who suffer from these severe migraine headaches.

People who experience migraine with aura(3) are invited to participate in the study. More information is available from the Migraine Action Association, telephone: 0870-050-5898 or with no obligation to sign up.