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ABSTRACT Cracchiolo AN, Palma DM, Saporito EFG, Palazzolo C, Mannino SM, Genco F, Vitale F, Profera L, Raineri SM, Accurso G. Safety Of Hyperbaric Oxygen Therapy In Patients Aged 75 And Older: A Multicenter Retrospective Study. Undersea Hyperb Med. 2025 Fourth Quarter; 52(4):495-506. Background: The increasing life expectancy presents new challenges in managing elderly patients requiring hyperbaric oxygen (HBO2) therapy. This retrospective study evaluates the safety and adherence to HBO2 guidelines in patients aged 75 years and older, focusing on side effects and adverse events. Methods: Data from 69 elderly patients treated between 2019 and 2023 at two Sicilian hyperbaric centres were analyzed. Demographics, indications for HBO2, comorbidities, treatment protocols, and side effects were collected. Pre-treatment evaluations included ENT checkups, ECG, chest X-rays, and laboratory tests. Patients underwent HBO2 sessions at 2.4–2.8 ATA, with clinical monitoring pre-and post-treatment. Results: 1,799 HBO2 sessions were performed in 69 patients (mean age 78 years; 59.4% male). The most common indications were progressive necrotizing infections (33.3%), sudden sensorineural hearing loss (17.3%), and chronic radiation-induced tissue injuries (14.5%). Side effects occurred in 14 patients (20.3%), primarily middle ear barotrauma (8.7%), sinus barotrauma (4.3%), confinement anxiety (4.3%), hypoglycemia (1.4%), and chest pain (1.4%). Most side effects were resolved with prompt care, and no life-threatening events were ..

ABSTRACT Kumar S, Kansal V, Chaundhry HBS, Bhutani S, Mohanty CS. Evaluation of the efficacy of modified low-dose HBO2 therapy. Undersea Hyperb Med. 2025 Fourth Quarter; 52(4):507-513. Background: The COVID-19 pandemic, being an airborne disease, posed a challenge in providing Hyperbaric Oxygen (HBO2) Therapy in multiplace chambers by increasing the risk of cross-infectivity while on air break inside the chamber. The standard regimen consisting of two air breaks was modified, anda new low-dose HBO2 therapy regimen with no air breaks was introduced to mitigate the risk of cross- infection. This study aimed to evaluate the efficacy of the modified HBO2 therapy regimen compared to the standard HBO2 therapy regimen for patients with soft tissue radiation injury. Methods: A retrospective observational study compared the modified low-dose HBO2 therapy regimen of 2.4 Atmosphere Absolute (ATA) for 60 minutes without air-break vis-a-vis the standard regimen of 2.4 ATA for 100 minutes with two air breaks of five minutes each. Patients with soft tissue radiation injury in the form of radiation cystitis and radiation proctitis were selected for comparison in the study. Data was retrieved from patients who underwent the standard and modified regimen during the COVID-19 pandemic. Late Effects Normal Tissue (LENT)/ Subjective Objective Management Analytic (SOMA) questionnaire-based scoring was compared for ..

ABSTRACT McCray P, Johnson-Arbor K. Dermatologic medical ozone therapy complications treated with hyperbaric oxygen. Undersea Hyperb Med. 2025 Fourth Quarter; 52(4):515-519. Introduction: Medical ozone therapy, which involves topical or systemic administration of ozone gas,is promoted as a treatment for various infections and inflammatory conditions, although evidence supporting its clinical effectiveness in humans is limited. Medical ozone administration is also associated with serious adverse effects, including gas embolus and fatality. We present the case of a patient who experienced dermatologic complications after receiving medical ozone therapy. The complications were managed with surgical intervention and hyperbaric oxygen therapy. Case Report: A 43-year-old female was administered medical ozone therapy injections to the temples and central forehead by a dermatologist to enhance hair growth and collagen formation. After the procedure, the patient experienced worsening alopecia and scarring in the treated areas. She eventually underwent surgical excision and closure that was performed by a plastic and reconstructive surgeon. Intraoperatively, she was noted to have significantly fibrotic, scarred, and poorly vascularized tissue, which raised concern for poor wound healing. Her plastic surgeon referred her for adjunctive hyperbaric medicine evaluation to treat presumed skin flap vascular compromise. She completed a course of forty hyperbaric oxygen treatments before returning to the plastic ..

ABSTRACT Clarke R. Transcutaneous Oximetry Optimizes Clinical Management and Cost-Effectiveness of Diabetic Foot Ulcers Treated with Hyperbaric Oxygen: A Review of Point-of-Care Vascular Screening Options. Undersea Hyperb Med. 2025 Fourth Quarter; 52(4):521-535. Hyperbaric oxygen therapy has been employed to treat diabetic foot ulcers for more than four decades. While supported by some high-quality evidence, there is sufficient conflicting data to render its use open to criticism. Even systematic and other reviews favorably disposed to this treatment adjunct invariably plead for better patient selection. Common among several causes of non-healing ulcers is persistent hypoxia. Transcutaneous oximetry uniquely measures tissue oxygen tension. Combination air and oxygen testing provides an evidence-based approach to hyperbaric patient selection through demonstration of locally reversible hypoxia. Transcutaneous oximetry differentiates hyperbaric responders from non- responders early in their treatment course by detecting neoangiogenesis, thereby providing a basis for continuing hyperbaric dosing only in those who benefit. Finally, such testing guides therapeutic endpoint determination, namely, normalized peri-ulcer oxygen tensions. This contrasts with continuing medically unnecessary and costly hyperbaric treatments until wound closure. Measurements of blood pressure and blood flow are imperfect surrogates for oxygen delivery. Recently introduced near-infrared spectroscopy and long-wave infrared thermography provide insights into tissue oxygen saturation and changes ..

ABSTRACT Voigt A, Laspro M, Thys E, Jethanamest D, Chiu ES. Systematic Review of Otologic Adverse Events in Hyperbaric Oxygen Therapy. Undersea Hyperb Med. 2025 Fourth Quarter; 52(4):537-547. Objectives: Hyperbaric Oxygen (HBO2) Therapy has been associated with some risks and adverse events. Previous studies examining otologic complications from HBO2 therapy vary in their reported incidence of adverse events. This study aims to systematically review the otologic complications associated with HBO2 therapy and investigate contributing risk and protective factors. Review Methods: A systematic review was conducted to identify studies reporting otologic adverse effects due to HBO2 therapy. Utilizing PRISMA 2020 guidelines, titles and abstracts were screened before conducting a full-text analysis. Studies reporting the incidence of otologic complications and studies reporting risk or protective factors for otologic complications were included. Results: A search for articles on HBO2 therapy otologic complications yielded 2,027 articles, of which 183 were relevant to the research question. Ultimately, 54 studies met the inclusion criteria. Fifteen percent of the 18,284 patients treated with HBO2 therapy experienced adverse events. Of the middle ear barotrauma (MEB) that occurred, 42.8% was mild, and 6.4% was severe. The major risk factors were increasing age, female sex, head and neck pathology, sensory neuropathy, and pre-treatment difficulty equalizing ear pressure. The main protective factor ..

ABSTRACT Zulfiqar A, Spindari K. Hyperbaric Oxygen Therapy Enhances Autologous Bone Graft Integration: A Meta-Analysis. Undersea Hyperb Med. 2025 Fourth Quarter; 52(4):549-564. Background: Autologous bone grafting is crucial in reconstructive surgeries, yet high-risk patients often face challenges in achieving robust graft integration. Hyperbaric Oxygen Therapy (HBO2) has been proposed to improve graft outcomes by enhancing osteogenesis and vascularization. This systematic review and meta-analysis evaluated HBO2’s efficacy in promoting autologous bone graft integration and identified contexts in which HBO2may be most beneficial. Methods: A systematic search identified 11 studies that met the inclusion criteria, of which seven provided quantitative data for meta-analysis. Random-effects models generated pooled Standardized Mean Differences (SMD) and assessed heterogeneity (I2). Subgroup analysis focused on orthopedic applications. Results: Compared to control groups, HBO2 demonstrated a moderate to strong effect on bone graft integration in the primary analysis (SMD: 1.476, 95% CI: 0.814–2.138). However, heterogeneity was substantial (I2 ≈ 77%), reflecting diverse protocols and patient populations. A subgroup of orthopedic studies showed a stronger, consistent effect (SMD: 1.995, 95% CI: 1.117–2.873) with low heterogeneity (I2 = 3.361%). Although observational data suggest potential benefits in maxillofacial grafts, many studies in this domain are small or lack controls. One cranial study reported a negative result, indicating possible variability ..

ABSTRACT Graffeo CS, Petitt MJ, Neubauer LE, Steckler GD, Knapp BJ. Reversal of a Globus Pallidus Injury in a Severe Carbon Monoxide Poisoned Patient. Undersea Hyperb Med. 2025 Fourth Quarter; 52(4):565- 569. Carbon monoxide (CO) is an important source of poisoning in the United States and accounts forover 50,000 emergency department (ED) visits annually. Of these, almost 15,000 cases are reported as intentional, with over 1,000 deaths annually reported in the USA.1 Unintentional deaths from carbon monoxide poisoning are commonly associated with the improper use of generators, heaters, or other sources of combustion, such as malfunctioning home appliances or vehicular exhaust [2,3]. We describe a case of severe intentional CO poisoning that had reversal of CT and MRI findings that were consistent with a globus pallidus injury and a favorable clinical outcome in an adult male treated with Hyperbaric Oxygen Therapy (HBO2). There are currently conflicting data and guideline recommendations regarding the utility of HBO2 in the management of CO.4 This case provides additional evidence for HBO2 treatment in a patient population whose clinical presentation and imaging findings are consistent with severe poisoning. Keywords: carbon monoxide; case reports; clinical toxicology; globus pallidus; hyperbaric oxygen therapy; treatment

ABSTRACT Luhulla K, Martin Q, Bhoke A, Mahfudh S, Nkya A, Magohe A, Yonazi M, Buckey JC. Case Report: Complete Coverage Of Chronic Sickle Cell Leg Ulcer Using Hyperbaric Oxygen Therapy Combined With Skin Grafting. Undersea Hyperb Med. 2025 Fourth Quarter; 52(4):571-575. Introduction: A chronic leg ulcer is a serious complication of sickle cell anemia. The ulcers are treatment- resistant, recur frequently, and are associated with more severe disease. Treatment options for chronic leg ulcers in patients with sickle cell disease are limited. Hyperbaric oxygen (HBO2) therapy is a promising therapy for the management of sickle cell chronic leg ulcers as it relieves hypoxia, promotes angiogenesis, and reduces wound inflammation. Case: A 35-year-old male with sickle cell anemia with a chronic leg ulcer for one year, despite regular wound dressing and antibiotics, was then successfully managed through HBO2 therapy followed by skin grafting. Conclusion: HBO2 therapy was effective in this case and has also shown effectiveness as an adjunct therapy in the management of sickle cell-related chronic leg ulcers in other case reports. This supports the need for further research in this area. Keywords: chronic leg ulcer; hyperbaric oxygen therapy; sickle cell anemia

ABSTRACT Plogmark O, Hjelte C, Olsson M, Ekström M, Frånberg O. Decompression at 1.3 versus 1.6 bar and Nitrogen Elimination and Venous Gas Emboli: A Randomized Controlled Trial. Undersea Hyperb Med. 2025 Fourth Quarter; 52(4):577-585. Introduction: The optimal depth for decompression stops is unclear. We hypothesize that a decompression stop at 1.3 bar, compared with 1.6 bar, decreases post-dive whole-body nitrogen washout volumes and venous gas emboli (VGE). Methods: In this randomized crossover trial, divers performed wet air dives of 40 minutes at 3.4 bar (340 kPa) with a seven-minute-long decompression stop at either 1.3 bar (Deco 1.3) or 1.6 bar (Deco 1.6) in randomized order. The primary outcome was the difference in post-dive whole body nitrogen washout volume, analyzed using multilevel linear regression. The secondary outcome was the difference in peak VGE detected by cardiac two-dimensional ultrasound, graded using the Eftedal-Brubakk scale, and analyzed with Wilcoxon matched-pairs signed-rank tests. Results: Sixteen divers completed both Deco 1.3 and Deco 1.6. Post-dive whole body nitrogen washout volumes were measured in eight of the 16 participants and were lower with Deco 1.3 than Deco 1.6 (696 ml [95% confidence interval [CI], 601 to 790] versus 1068 ml [95% CI, 962 to 1174]), mean difference of 373 ml (95% ..

ABSTRACT Ekman L, Sjöblom C, Ekström M, Frånberg O. Increased ventilatory response to carbon dioxide after dive training. Undersea Hyperb Med. 2025 Fourth Quarter; 52(4):587-597. Introduction: Divers are reported to have a lower ventilatory response to elevated levels of carbon dioxide (CO2) than non-divers. Hypoventilation with CO2 retention during diving is potentially dangerous. It is unknown if CO2 retention is largely inherited or develops during diving training. We aimed to investigate if a military dive training course would influence the ventilatory response to CO2. Methods: Novice rebreather Divers with Amphibious Rangers as controls were tested at baseline, after12 weeks of water exercise training, and after 15 weeks of diving: participants rebreathed in a Douglas bag filled with an initial 100% oxygen, resulting in increasing levels of inspiratory CO2 (iCO2). The test was performed until symptom-limitation or an expiratory CO2 of 8.0 kPa. To decrease conscious control of breathing, participants were distracted with a memory game during the test. Differences between groups and over time were analyzed using independent and paired t-tests. Results: Ten Divers and six Amphibious Rangers completed baseline testing and eight Divers completed all tests. Divers had a statistically significant higher Minute Ventilation (V’E) after dive training, compared to after water exercise training and baseline, at all levels ..

ABSTRACT Rosenberg M, Ezra R, Arieli R, Barash U. Synergistic Neuroprotection by Caffeine and Astaxanthin Against CNS-OT. Undersea Hyperb Med. 2025 Fourth Quarter; 52(4):599-606. Background: Central nervous system oxygen toxicity (CNS-OT) is a critical concern for Navy divers using closed-circuit rebreathers who are subjected to prolonged exposure to hyperbaric oxygen levels. We explored the potential of specific dietary supplements, caffeine, and astaxanthin, to delay the onset of CNS-OT. Methods: Experiments were conducted using male C57BL/6 mice exposed to pure oxygen at 507 kPa, with latency to tonic-clonic seizures recorded. Mice were orally administered caffeine (1.25, 2.5, or 5 mg/ kg), astaxanthin (8 mg/kg), or a vehicle (water). Results: Caffeine and astaxanthin significantly extended the latency period to seizure onset (p<0.03). Notably, combining caffeine and astaxanthin (p<0.001 vs. control) provided better protection against CNS-OT than either substance alone. Conclusions: Our results suggest that administering caffeine and astaxanthin before hyperbaric oxygen exposure delays hyperoxia-induced seizures. Keywords: dietary supplements; hyperbaric oxygen; hyperemia; reactive oxygen species

ABSTRACT Fairhead T. Recompression and Adjunctive Therapies in DCI Management in Divers: A Review of RCTs. Undersea Hyperb Med. 2025 Fourth Quarter; 52(4):607-615. Background: Decompression illness (DCI) poses significant risks for divers, particularly in remote locations with limited resources. Few randomized controlled trials (RCTs) exist, necessitating a review to consolidate current evidence and support evidence-based treatment protocols. This review evaluates RCT evidence on the effectiveness of recompression treatment and adjunctive therapies for diving-related DCI. Methods: This review included RCTs assessing recompression treatment or adjunctive therapies in managing DCI. Exclusions were non-human studies, trials on DCI prevention, non-English publications, incomplete trials, and those involving non-diving DCI. Databases searched from inception to May 15, 2023, included Ovid MEDLINE, CENTRAL, CINAHL, and EMBASE. Citation chasing was performed on June 1, 2023, using Web of Science. Risk-of-bias assessments were guided by considering the Cochrane risk-of- bias tool for randomized trials. Results: Two RCTs were identified. One trial (n=180) indicated that tenoxicam might reduce the number of required recompressions from three (range 1-8) to two (range 1-6). The other trial (n=41) showed that a shorter initial recompression treatment table could decrease the number of recompressions (median one vs. two) in cases of mild DCI. Discussion: Limitations included unblinded participants, small participant numbers, non-protocol ..

ABSTRACT Preheim B, Moayedi S, Chew KW, Sethuraman K. Cerebral Arterial Gas Embolism During Watchman Device Implantation. Undersea Hyperb Med. 2025 Fourth Quarter; 52(4):617-620. Watchman devices are increasingly implanted in patients with atrial fibrillation who cannot be anticoagulated. We report a case of a patient undergoing Watchman device insertion complicatedby cerebral arterial gas embolism. The treatment was delayed because the diagnosis was not initially considered. The patient was eventually treated with hyperbaric oxygen but sustained permanent disabilities. Watchman device implantation has a near 1% risk of arterial gas embolism. The possibility of cerebral gas embolism should be considered in patients emerging from anesthesia with neurologic deficits. Keywords: arterial gas embolism; hyperbaric oxygen therapy; watchman

ABSTRACT Popa DA, Winn AR, Masters TC, Logue C. Cold Urticaria Preventing Clearance For Scientific Diving. Undersea Hyperb Med. 2025 Fourth Quarter; 52(4):621-625. Case Description: We present a case of a 39-year-old healthy female scientific diver who developed cold urticaria (CU) 8 months prior, when immediately postpartum. She had extensive diving experience but discontinued diving during pregnancy and sought to resume diving. Before our consultation, she had seen a dermatologist and allergist for evaluation for an underlying etiology and management. Intervention: Initial management included diphenhydramine and cetirizine with topical triamcinolone based on dermatology recommendations. Her allergist later advised discontinuing diphenhydramine and remaining on cetirizine 10mg up to four times daily, given breastfeeding concerns. Epinephrine was prescribed in case of anaphylaxis. Outcome: The workup revealed no underlying pathology, and she was not cleared for diving until her CU was resolved. Despite antihistamines, she continues to be symptomatic, including in pools heated to 900F. Although drysuit certified, we could not clear her for scientific diving and advised against recreational diving given the risk of anaphylaxis. Discussion: CU is an uncommon but under-reported and under-recognized condition with potentially fatal consequences for swimmers and divers. Although symptom management focuses on antihistamines, corticosteroids and omalizumab (Xolair®) may prove helpful. Nonetheless, the risk of ..

ABSTRACT Anderson CA, Jacoby I. Necrotizing Soft Tissue Infections. Undersea Hyperb Med. 2025 Fourth Quarter; 52(4):627-639. The initial terminology used to describe 2,642 cases of necrotizing infections as “hospital gangrene”was coined by Dr. Joseph Jones, surgeon of the Confederate Army in 1871 [1]. Later in 1883, Dr. Jean- Alfred Fournier characterized necrotizing infections to the perineum. Necrotizing fasciitis was initially described and named “hemolytic streptococcal gangrene” by Meleney in 1924 [2]. He described an illness characterized by gangrene of subcutaneous tissues, followed by rapid necrosis of the overlying skin from involvement of the blood vessels supplying the skin, which are found in the affected fascial layers. All his patients grew hemolytic streptococci on cultures, and the patients were all seriously ill. Surgical extirpation appeared to be the best therapeutic approach then and remains so. The actual term Necrotizing Fasciitis was credited to Dr. Wilson much later in 1952 [3]. Media often refers to this entity as infection with «Flesh-eating bacteria.”The annual incidence of NSTI varies considerably but is often reported at approximately four per 100,000 in developed countries [4]. Mortality rates highlight the severity of disease with a 90-day mortality of 18% reported in a multi-center study including more than 400 patients [5].

ABSTRACT Tettleback WH, Hart BB. Refractory Osteomyelitis. Undersea Hyperb Med. 2025 Fourth Quarter; 52(4):641-668. Chronic refractory osteomyelitis, according to the Centers for Medicare & Medicaid Services’ (CMS) National Coverage Determination (NCD) 20.29, is an identified condition covered for treatment with adjunctive hyperbaric oxygen (HBO2) therapy. Within the NCD (20.29) chronic refractory osteomyelitis is outlined as being unresponsive to conventional medical and surgical management [1]. From a practical perspective, patients can be appropriately diagnosed with chronic refractory osteomyelitis when they demonstrate no significant improvement or demonstrate worsening of the underlying osteomyelitis despite 30 days of combined conventional surgical and medical treatment that included systemic antimicrobial therapy. To date, no conclusive randomized clinical trials examining the effects of HBO2 therapy on refractory osteomyelitis exist. Additionally, many of the initial studies that resulted in positive outcomes were conducted in hospital settings safeguarding compliance, and thus, not unexpectedly, the outcomes have not translated exactly to the outpatient clinic setting. Nonetheless, based on a comprehensive review of the scientific literature, the addition of HBO2 therapy to routine surgical and antibiotic treatment of previously refractory osteomyelitis appears to be both safe and ultimately improves infection resolution rates. In most cases, the best clinical results are obtained when HBO2 treatment is administered ..