Atypical distally distributed cutis marmorata decompression sickness associated with unconventional use of thermal protection in a diver with persistent foramen ovale.

Cutis marmorata is a mottled, marbling, livedoid rash caused by vascular inflammation and congestion in cutaneous decompression sickness. It may occur during or after ascent due to the formation of bubbles from dissolved nitrogen accumulated throughout the dive. It is strongly associated with the presence of right to left shunts, particularly persistent (patent) foramen ovale (PFO). We report a case of cutis marmorata decompression sickness of an unusual pattern associated with unconventional use of thermal protection (a 'shorty' wetsuit worn over full suit) by a diver with a PFO. The patient also had neurological manifestations of decompression sickness. The distal lower limb pattern of involvement favours the hypothesis that cutis marmorata in humans is likely to be due to bubbles in the skin itself and/or adjacent tissues rather than cerebrally mediated.

Recurrent dysbarism presenting with amnesia and hypoaesthesia in a professional breath-hold diver.

Dysbarism is a medical condition arising from change in ambient pressure which outpace the rate at which the body adapts to it. We report a case of recurrent dysbarism consistent with possible decompression illness presenting with amnesia, hypoaesthesia and other neurological manifestations in a professional breath-hold diver treated successfully with hyperbaric oxygen and fluid resuscitation.

Acute Effects on the Human Peripheral Blood Transcriptome of Decompression Sickness Secondary to Scuba Diving.

Decompression sickness (DCS) develops due to inert gas bubble formation in bodily tissues and in the circulation, leading to a wide range of potentially serious clinical manifestations. Its pathophysiology remains incompletely understood. In this study, we aim to explore changes in the human leukocyte transcriptome in divers with DCS compared to closely matched unaffected controls after uneventful diving. Cases (n = 7) were divers developing the typical cutis marmorata rash after diving with a confirmed clinical diagnosis of DCS. Controls (n = 6) were healthy divers who surfaced from a ≥25 msw dive without decompression violation or evidence of DCS. Blood was sampled at two separate time points-within 8 h of dive completion and 40-44 h later. Transcriptome analysis by RNA-Sequencing followed by bioinformatic analysis was carried out to identify differentially expressed genes and relate their function to biological pathways. In DCS cases, we identified enrichment of transcripts involved in acute inflammation, activation of innate immunity and free radical scavenging pathways, with specific upregulation of transcripts related to neutrophil function and degranulation. DCS-induced transcriptomic events were reversed at the second time point following exposure to hyperbaric oxygen. The observed changes are consistent with findings from animal models of DCS and highlight a continuum between the responses elicited by uneventful diving and diving complicated by DCS. This study sheds light on the inflammatory pathophysiology of DCS and the associated immune response. Such data may potentially be valuable in the search for novel treatments targeting this disease.

Echocardiography - techniques and pitfalls whilst diagnosing persistent (patent) foramen ovale as a risk factor in divers with a history of decompression sickness.

The case of a diver with a history of decompression sickness (DCS) after recreational scuba diving is presented. Cutis marmorata, a subtype of cutaneous DCS, has been consistently associated with the presence of a persistent (patent) foramen ovale (PFO) as a risk factor. Diagnostic uncertainty arose when transthoracic echocardiography with antecubital injection of agitated saline bubbles (ASBs) did not show any significant shunt, but the presence of a large Eustachian valve was counteracted by intra-femoral injection of ASBs, showing a large PFO with spontaneous shunting. The importance of proper echocardiography techniques prior to resorting to intra-femoral injection of ASBs to counteract the haemodynamic effects of the Eustachian valve is emphasised.

Hyperbaric oxygen therapy awareness within a doctor population.

Hyperbaric medicine is a relatively young specialty that remains in the blind spot of most doctors' awareness. This study endeavors to identify the level of awareness of the indications for hyperbaric oxygen (HBO2) therapy among a doctor population in a developed country and factors which may improve referral rates. An anonymized questionnaire was distributed to doctors licensed to practice in Malta. Questions included physician specialty, demographics and previous exposure to diving and/or hyperbaric medicine. Moreover, two scoring systems were used to score subjects on HBO2-related topics. Binomial logistic regression models and generalized linear models were used in the statistical analysis. A total of 152 full replies were obtained and analyzed. Respondents who had visited a hyperbaric unit (HBU) (p=0.002) or attended a lecture on HBO2 (p=0.006) scored better than their counterparts, indicating better awareness of HBO2 indications and local chamber location. A previous HBU visit (p=0.001), being a hospital-based doctor (p=0.027) and a history of scuba diving (p=0.03) were associated with willingness to refer patients for HBO2 in the future. Encouraging visits to an HBU has been shown to be associated with multiple factors, which are expected to result in improved referral rates. Targeted educational sessions to doctors and medical students are likely to be beneficial in improving correct referral of patients for HBO2. The findings from this study may prove useful in improving appropriate referral rates of patients who may benefit from this useful treatment modality.

Bilateral Total Hip and Unilateral Knee Arthroplasties in a Young Adult with Arthropathy-Associated Intestinal Epithelial Dysplasia (Tufting Enteropathy).

Intestinal epithelial dysplasia (tufting enteropathy) is an uncommon congenital disorder. Furthermore, its association with chronic inflammatory arthropathy is rarely documented in the literature. Low prevalence rates of 1 in 100,000 live births in Western Europe exist, with higher rates in North Africa and Middle Eastern countries. Malta, being a small Mediterranean island at the cusp between Europe and North Africa, has an anecdotal sevenfold prevalence rate. This is the first documented case report of a patient with both intestinal epithelial dysplasia and severe bilateral hip and knee arthropathy that required simultaneous bilateral hip followed by, after a short interval, unilateral knee arthroplasties. Our aim is to highlight the rapid progression of associated arthropathy as well as the successful treatment with joint arthroplasties in such extreme cases. Surgical treatment may be a necessity despite best medical efforts to halt the disease.