Persistent foramen ovale closure in divers with a history of decompression sickness

Objective

To study the effect of percutaneous patent foramen ovale (PFO) closure in divers with a history of decompression sickness (DCS).

Study design

(1) Retrospective study of patient records and (2) telephonic follow-up. Patients with unexplained decompression sickness, who were referred to a cardiologist with a focus on diving medicine between 2000 and 2017, were included in the study

Results

A total of 62 divers with DCS were included. In all cases transoesophageal echocardiography (TEE) was performed, showing 29 PFOs and 6 atrial septum defects (ASDs) in total n?=?35 (56%). The highest prevalence was found in divers with cutaneous and vestibular DCS. At follow-up (mean follow-up duration 6.8 years), 21 PFOs/ASDs were closed using a percutaneous procedure. One diver was lost to follow-up. One diver quit diving. The remaining divers were able to resume unrestricted diving; there was no recurrence of major DCS. Of the divers with an open PFO or ASD, 14 were included of whom 7 are currently diving. All (except one diver with a small PFO) divers are using a conservative diving profile to reduce nitrogen load and the appearance of venous nitrogen bubbles. There was no recurrence of major DCS in this group.

Conclusion

Percutaneous PFO closure may be an effective and safe treatment for divers who have suffered a major DCS to return to unrestricted diving. Alternatively, conservative treatment seems safe when divers refrain from unrestricted diving and use a conservative technique in order to reduce nitrogen load.

     

Delayed Recompression for Decompression Sickness: Retrospective Analysis

Introduction

Most cases of decompression sickness (DCS) occur soon after surfacing, with 98% within 24 hours. Recompression using hyperbaric chamber should be administrated as soon as feasible in order to decrease bubble size and avoid further tissue injury. Unfortunately, there may be a significant time delay from surfacing to recompression. The time beyond which hyperbaric treatment is non effective is unclear. The aims of the study were first to evaluate the effect of delayed hyperbaric treatment, initiated more than 48h after surfacing for DCS and second, to evaluate the different treatment protocols.

Methods

From January 2000 to February 2014, 76 divers had delayed hyperbaric treatment (≥48h) for DCS in the Sagol center for Hyperbaric medicine and Research, Assaf-Harofeh Medical Center, Israel. Data were collected from their medical records and compared to data of 128 patients treated earlier than 48h after surfacing at the same hyperbaric institute.

Results

There was no significant difference, as to any of the baseline characteristics, between the delayed and early treatment groups. With respect to treatment results, at the delayed treatment divers, complete recovery was achieved in 76% of the divers, partial recovery in 17.1% and no improvement in 6.6%. Similar results were achieved when treatment started early, where 78% of the divers had complete recovery, 15.6% partial recovery and 6.2% no recovery. Delayed hyperbaric treatment using US Navy Table 6 protocol trended toward a better clinical outcome yet not statistically significant (OR=2.786, CI95%[0.896-8.66], p=0.07) compared to standard hyperbaric oxygen therapy of 90 minutes at 2 ATA, irrespective of the symptoms severity at presentation.

Conclusions

Late recompression for DCS, 48 hours or more after surfacing, has clinical value and when applied can achieve complete recovery in 76% of the divers. It seems that the preferred hyperbaric treatment protocol should be based on US Navy Table 6.     

Norwegian deep diving trials

In 1983 NUTEC, together with two diving companies, completed two dives with 12 divers (6 in each dive) to pressures equivalent to 350 m s.w., one dive lasted for 17 d, and the other, 24 d. The purpose of the dives was to demonstrate that the diving companies were prepared for diving to 300 m depth in the North Sea. No major medical or physiological problems arose during the dives, although all divers had minor symptoms of high pressure nervous syndrome during compressions. During decompression three decompression sickness incidents occurred, which involved pain only, and all were successfully treated. All divers went through comprehensive medical physiological examinations before and after the dives. No significant changes from values measured before diving have been found in the six divers who have so far been examined after diving, except that five of them were considerably more sensitive to CO2 after the dive than before. Several problems arose in connection with the divers' breathing equipment, thermal protection and communication, which need to be improved.     

Top-Down Effect of Direct Current Stimulation on the Nociceptive Response of Rats

Transcranial direct current stimulation (tDCS) is an emerging, noninvasive technique of neurostimulation for treating pain. However, the mechanisms and pathways involved in its analgesic effects are poorly understood. Therefore, we investigated the effects of direct current stimulation (DCS) on thermal and mechanical nociceptive thresholds and on the activation of the midbrain periaqueductal gray (PAG) and the dorsal horn of the spinal cord (DHSC) in rats; these central nervous system areas are associated with pain processing. Male Wistar rats underwent cathodal DCS of the motor cortex and, while still under stimulation, were evaluated using tail-flick and paw pressure nociceptive tests. Sham stimulation and naive rats were used as controls. We used a randomized design; the assays were not blinded to the experimenter. Immunoreactivity of the early growth response gene 1 (Egr-1), which is a marker of neuronal activation, was evaluated in the PAG and DHSC, and enkephalin immunoreactivity was evaluated in the DHSC. DCS did not change the thermal nociceptive threshold; however, it increased the mechanical nociceptive threshold of both hind paws compared with that of controls, characterizing a topographical effect. DCS decreased the Egr-1 labeling in the PAG and DHSC as well as the immunoreactivity of spinal enkephalin. Altogether, the data suggest that DCS disinhibits the midbrain descending analgesic pathway, consequently inhibiting spinal nociceptive neurons and causing an increase in the nociceptive threshold. This study reinforces the idea that the motor cortex participates in the neurocircuitry that is involved in analgesia and further clarifies the mechanisms of action of tDCS in pain treatment.     

The acute effects of different training loads of whole body vibration on flexibility and explosive strength of lower limbs in divers

The purpose of this study was to examine the acute effects of different vibration loads (frequency and amplitude) of whole-body vibration (WBV) on flexibility and explosive strength of lower limbs in springboard divers. Eighteen male and female divers, aged 19 ± 2 years, volunteered to perform 3 different WBV protocols in the present study. To assess the vibration effect, flexibility and explosive strength of lower limbs were measured before (Pre), immediately after (Post 1) and 15 min after the end of vibration exposure (Post 15). Three protocols with different frequencies and amplitudes were used in the present study: a) low vibration frequency and amplitude (30 Hz/2 mm); b) high vibration frequency and amplitude (50 Hz/4 mm); c) a control protocol (no vibration). WBV protocols were performed on a Power Plate platform, whereas the no vibration divers performed the same protocol but with the vibration platform turned off. A two-way ANOVA 3 x 3 (protocol × time) with repeated measures on both factors was used. The level of significance was set at p < 0.05. Univariate analyses with simple contrasts across time were selected as post hoc tests. Intraclass coefficients (ICC) were used to assess the reliability across time. The results indicated that flexibility and explosive strength of lower limbs were significantly higher in both WBV protocols compared to the no vibration group (NVG). The greatest improvement in flexibility and explosive strength, which occurred immediately after vibration treatment, was maintained 15 min later in both WBV protocols, whereas NVG revealed a significant decrease 15 min later, in all examined strength parameters. In conclusion, a bout of WBV significantly increased flexibility and explosive strength in competitive divers compared with the NVG. Therefore, it is recommended to incorporate WBV as a method to increase flexibility and vertical jump height in sports where these parameters play an important role in the success outcome of these sports.     

Isolation of a tryptic fragment from Clostridium perfringens theta-toxin that contains sites for membrane binding and self-aggregation

Trypsin cleaves Clostridium perfringens theta-toxin (perfringolysin O or PFO) at a single site between residues 303 and 304 (Ohno-Iwashita, Y., Iwamoto, M., Mitsui, K., Kawasaki, H., and Ando, S. (1986) Biochemistry 25, 6048-6053; Tweten, R. K. (1988b) Infect. Immun. 56, 3228-3234) and yields an amino-terminal fragment of 30,208 Da (T1) and a carboxyl-terminal fragment of 22,268 Da (T2). Both peptides were purified by reverse phase chromatography of trypsin-nicked PFO. Neither peptide retained hemolytic activity. Peptide T1 had no apparent effect on the hemolytic activity of PFO, whereas T2 was found to inhibit the hemolytic activity of PFO and was analyzed further. The order of binding of T2 and PFO to membranes did not alter the inhibitory effect of T2 on PFO-induced hemolysis, indicating that competitive binding by T2 for PFO membrane binding sites was not the basis for the observed inhibition. Further analysis showed that T2 could inhibit membrane-dependent fluorescence energy transfer (FET) between PFO molecules labeled with fluorescein (fluorescent donor) or tetramethylrhodamine (fluorescent acceptor). This provided evidence that T2 could complex with PFO. T2 was also found to be incapable of self-aggregation (as opposed to PFO), since preincubation of T2 with either erythrocytes or erythrocyte ghost membranes did not affect the T2-dependent inhibition of hemolysis or FET. These data indicate that T2 inhibits PFO-dependent hemolysis by forming a complex with PFO, which inhibits aggregation and that the membrane binding site and a single aggregation site remain intact on T2.     

Past and recent physical activity and bone mineral density in college-aged women

Low bone mineral density (BMD) has been determined as an independent factor of osteoporosis. The purpose of this study was to assess physical activity's effect on BMD in college-aged women. Bone density measurements were obtained. A survey was administered to assess past and recent physical activity levels. Logistic regression revealed high school sports participation and lean tissue were significant predictors of femoral BMD, whereas present physical activity and lean tissue were significant predictors of spinal BMD. Women in the present study who did not participate in high school sports were 7 times more likely to have low BMD than were those who participated. This study revealed a protective effect of past and present physical activity on BMD in college-aged women. Children and young adults should be encouraged to participate in physical activity because it helps reduce their risk factors for osteoporosis later in life.     

Specifics of Gas Bubble Formation and Growth in Tissues during Decompression after Saturation Dives

It is shown that the decompression schedules after saturation diving to the depth of 30 m designed to hold the nitrogen supersaturation for the most “slow” tissues at the acceptable levels is significantly shorter than the decompression schedules with zero supersaturation of these tissues with nitrogen and all dissolved gases. Equality of the risk for decompression sickness (DCS) onset during this decompression schedule to the risk of DCS onset under non-stop ascent to the surface after saturation diving to the depth of 6.1 m indicates that the effect of the high ambient pressure decreases the density of gas bubble seeds in tissues and the growth rate of their total volume. The DCS symptoms in the experienced divers under dangerous decompression profiles not appear due to the lower density of gas bubble seeds in their tissues relatively to the average level inherent to the many of humans.     

Complications and mid-term outcome after percutaneous patent foramen ovale closure in patients with cryptogenic stroke

Background: Percutaneous patent foramen ovale (PFO) closure seems to reduce the risk of recurrent thromboembolism. We report the safety and efficacy of percutaneous PFO closure in our centre. Methods: All patients, >16 years of age, who underwent a percutaneous PFO closure in our centre were included. Reoccurrence of stroke, transient ischaemic attack (TIA) and peripheral thromboembolism were assessed. Periprocedural and midterm complications are reported. Results: Eighty-three consecutive patients (mean age 49±13 years) were included. Indications for PFO closure were cryptogenic stroke (59.0%), TIA (33.7%), peripheral embolism (2.4%) and other (4.8%). For PFO closure, a Cardioseal/Starflex device was used in 63 patients and an Amplatzer PFO occluder device in 20 patients. Stroke recurred in 1.2%, TIA in 3.6%, peripheral embolism in 0% during a mean follow-up of 1.9±1.2 years. Major periprocedural complications occurred in 1.2%. The mid-term complication rate was 2.4% and only consisted of minor complications. During follow-up, a residual right-to-left shunt was present in 5.7% of the patients. No significant difference in outcome, complications or residual shunting could be documented between the two device types. Conclusion: In our centre, the percutaneous closure of a PFO seems to be a safe and effective procedure to prevent recurrence of paradoxical thrombo-embolic events. (Neth Heart J 2008;16:332-6.)     

Increased cortical thickness in sports experts: a comparison of diving players with the controls

Sports experts represent a population of people who have acquired expertise in sports training and competition. Recently, the number of studies on sports experts has increased; however, neuroanatomical changes following extensive training are not fully understood. In this study, we used cortical thickness measurement to investigate the brain anatomical characteristics of professional divers with extensive training experience. A comparison of the brain anatomical characteristics of the non-athlete group with those of the athlete group revealed three regions with significantly increased cortical thickness in the athlete group. These regions included the left superior temporal sulcus, the right orbitofrontal cortex and the right parahippocampal gyrus. Moreover, a significant positive correlation between the mean cortical thickness of the right parahippocampal gyrus and the training experience was detected, which might indicate the effect of extensive training on diving players' brain structure.     

Value of bromocriptine in unexplained primary infertility: a double-blind controlled trial.

In a double-blind controlled study, 47 women with unexplained primary infertility were allocated at random to treatment with either bromocriptine 2.5 mg twice daily (24 patients) or placebo (23). Both groups showed a fall in serum prolactin concentrations but the reduction was much greater in the bromocriptine-treated group. Neither group showed a change in serum oestrogen or progesterone concentrations. Bromocriptine significantly reduced the duration of the follicular phase of the menstrual cycle but had no effect on the luteal phase. Five women conceived during treatment with placebo and seven during treatment with bromocriptine, but analysis of the cumulative conception rates showed no significant difference between the groups. The women who conceived were significantly younger and had a significantly shorter history of infertility than the women who did not conceive, but subtracting the number of years of infertility from age eliminated this difference. The results show that bromocriptine in the dose and duration of administration used in the trial is of no value in unexplained primary infertility.     

Functional plasticity of spinal circuits in long-term sports activity adaptation

Physical activity-dependent mechanisms of functional changes in spinal cord circuitry were studied in athletes involved in sports for a long time. New data were obtained for functional plasticity the cervical and lumbosacral motor spinal systems develop as a result of various long-term sports activities. Compared with nonathletes, ski racers and basketball players were found to have an extended representation area of upper- and lower-limb muscle α-motoneurons with a high reflex excitability. The area was extended by involving upper segments in all cases. Several indices of functional plasticity of the cervical and lumbar regions of the spinal cord in ski racers, who are engaged in moderate cyclic activity, were higher than in basketball players, whose movements are more various.     

Arresting pore formation of a cholesterol-dependent cytolysin by disulfide trapping synchronizes the insertion of the transmembrane beta-sheet from a prepore intermediate

Perfringolysin O (PFO), a member of the cholesterol-dependent cytolysin family of pore-forming toxins, forms large oligomeric complexes comprising up to 50 monomers. In the present study, a disulfide bridge was introduced between cysteine-substituted serine 190 of transmembrane hairpin 1 (TMH1) and cysteine-substituted glycine 57 of domain 2 of PFO. The resulting disulfide-trapped mutant (PFO(C190-C57)) was devoid of hemolytic activity and could not insert either of its transmembrane beta-hairpins (TMHs) into the membrane unless the disulfide was reduced. Both the size of the oligomer formed on the membrane and its rate of formation were unaffected by the oxidation state of the Cys(190)-Cys(57) disulfide bond; thus, the disulfide-trapped PFO was assembled into a prepore complex on the membrane. The conversion of this prepore to the pore complex was achieved by reducing the C190-C57 disulfide bond. PFO(C190-C57) that was allowed to form the prepore prior to the reduction of the disulfide exhibited a dramatic increase in the rate of PFO-dependent hemolysis and the membrane insertion of its TMHs when compared with toxin that had the disulfide reduced prior mixing the toxin with membranes. Therefore, the rate-limiting step in pore formation is prepore assembly, not TMH insertion. These data demonstrate that the prepore is a legitimate intermediate during the insertion of the large transmembrane beta-sheet of the PFO oligomer. Finally, the PFO TMHs do not appear to insert independently, but instead their insertion is coupled.     

A single eubacterial origin of eukaryotic pyruvate: ferredoxin oxidoreductase genes: implications for the evolution of anaerobic eukaryotes.

The iron sulfur protein pyruvate: ferredoxin oxidoreductase (PFO) is central to energy metabolism in amitochondriate eukaryotes, including those with hydrogenosomes. Thus, revealing the evolutionary history of PFO is critical to understanding the origin(s) of eukaryote anaerobic energy metabolism. We determined a complete PFO sequence for Spironucleus barkhanus, a large fragment of a PFO sequence from Clostridium pasteurianum, and a fragment of a new PFO from Giardia lamblia. Phylogenetic analyses of eubacterial and eukaryotic PFO genes suggest a complex history for PFO, including possible gene duplications and horizontal transfers among eubacteria. Our analyses favor a common origin for eukaryotic cytosolic and hydrogenosomal PFOs from a single eubacterial source, rather than from separate horizontal transfers as previously suggested. However, with the present sampling of genes and species, we were unable to infer a specific eubacterial sister group for eukaryotic PFO. Thus, we find no direct support for the published hypothesis that the donor of eukaryote PFO was the common alpha-proteobacterial ancestor of mitochondria and hydrogenosomes. We also report that several fungi and protists encode proteins with PFO domains that are likely monophyletic with PFOs from anaerobic protists. In Saccharomyces cerevisiae, PFO domains combine with fragments of other redox proteins to form fusion proteins which participate in methionine biosynthesis. Our results are consistent with the view that PFO, an enzyme previously considered to be specific to energy metabolism in amitochondriate protists, was present in the common ancestor of contemporary eukaryotes and was retained, wholly or in part, during the evolution of oxygen-dependent and mitochondrion-bearing lineages.     

The mechanism of pore assembly for a cholesterol-dependent cytolysin: formation of a large prepore complex precedes the insertion of the transmembrane beta-hairpins

Perfringolysin O (PFO) is a member of the cholesterol-dependent cytolysin (CDC) family of membrane-penetrating toxins. The CDCs form large homooligomers (estimated to be comprised of up to 50 CDC monomers) that are responsible for generating a large pore in cholesterol-containing membranes of eukaryotic cells. The assembly of the PFO cytolytic complex was examined to determine whether it forms an oligomeric prepore complex on the membrane prior to the insertion of its membrane-spanning beta-sheet. A PFO oligomeric complex was formed on liposomes at both 4 degrees C and 37 degrees C and shown by SDS-agarose gel electrophoresis to be comprised of a large, comparatively homogeneous complex instead of a distribution of oligomer sizes. At low temperature, the processes of oligomerization and membrane insertion could be resolved, and PFO was found to form an oligomer without significant membrane insertion of its beta-hairpins. Furthermore, PFO was found to increase the ion conductivity through a planar bilayer by large and discrete stepwise changes in conductance that are consistent with the insertion of a preassembled pore complex into the bilayer. The combined results of these analyses strongly support the hypothesis that PFO forms a large oligomeric prepore complex on the membrane surface prior to the insertion of its transmembrane beta-sheet.     

Daily energy expenditure in active and inactive persons with spinal cord injury.

Daily energy expenditure (DEE) was evaluated seventeen male subjects with spinal cord injury (SSCI), who had active (N = 9) and inactive (N = 8) lifestyles, and in seven normal males. DEE was estimated from the mean 24-hr heart rate and heart rate-energy expenditure relationship determined in an arm cranking exercise. The DEE of SSCI on active days did not differ from those of normal subjects. On inactive days, SSCI had significantly lower DEE than on active days and than normal subjects. In contrast, the mean 24-hr heart rates of SSCI on active days and inactive SSCI were significantly greater than those of normal subjects, suggesting that SSCI, particularly inactive SSCI, exhibited a slight degree of tachycardia when compared to normal subjects. On inactive days, the DEE was fairly independent of the level of spinal cord injury. However, on active days, there was a clear tendency for SSCI with a low lesion level to have a higher DEE. Even if a SSCI with a high lesion level engaged in active sports, his DEE was relatively small. This lower DEE was largely attributable to the smaller functional muscle mass due to the limitation of physical activity.     

Second to fourth digit ratio and male ability in sport: implications for sexual selection in humans

Fetal and adult testosterone may be important in establishing and maintaining sex-dependent abilities associated with male physical competitiveness. There is evidence that the ratio of the length of the 2nd and 4th digits (2D:4D) is a negative correlate of prenatal and adult testosterone. We use ability in sports, and particularly ability in football, as a proxy for male physical competitiveness. Compared to males with high 2D:4D ratio, men with low ratio reported higher attainment in a range of sports and had higher mental rotation scores (a measure of visual–spatial ability). Professional football players had lower 2D:4D ratios than controls. Football players in 1st team squads had lower 2D:4D than reserves or youth team players. Men who had represented their country had lower ratios than those who had not, and there was a significant (one-tailed) negative association between 2D:4D and number of international appearances after the effect of country was removed. We suggest that prenatal and adult testosterone promotes the development and maintenance of traits which are useful in sports and athletics disciplines and in male:male fighting.     

Kinetic aspects of the aggregation of Clostridium perfringens theta-toxin on erythrocyte membranes. A fluorescence energy transfer study

Fluorescence resonance energy transfer was used to monitor aggregation kinetics of the "thiol-activated" cytolysin (perfringolysin O (PFO) or theta-toxin) of Clostridium perfringens on erythrocyte membranes. PFO was labeled with the isothiocyanate derivatives of either fluorescein or tetramethylrhodamine. No detectable change in the hemolytic activity of PFO was detected after modification with either fluorophore at a ratio of 1:2 fluorophore molecules/cytolysin molecule. Fluorescence energy transfer (FET) between the donor (fluorescein.PFO or PFOD) and the acceptor (tetramethylrhodamine.PFO or PFOA) was detected by both quenching of donor fluorescence (520 nm) and by enhancement of acceptor fluorescence (575 nm) upon aggregation of labeled cytolysin molecules. FET was only observed when PFOD and PFOA were incubated in the presence of membranes. FET was not observed when PFOD and PFOA were incubated in a membrane-free solution or when unlabeled toxin was substituted for PFOA. FET was also found to be temperature-dependent. The temperature-dependent rates of change in FET upon mixing labeled toxin with erythrocyte membranes proceeded without a lag phase and displayed an activation energy of 18.7 kcal/mol. At all temperatures aggregation of PFO was virtually complete before the onset of hemolysis, the latter exhibiting a distinct lag phase. The lag period before onset of hemolysis was temperature-dependent and exhibited an activation energy of 23.2 kcal/mol. These results suggest that the aggregation of membrane-associated PFO is necessary to initiate the hemolytic process, and the lag phase which occurs before onset of hemolysis reflects the kinetics of PFO monomer to polymer conversion.     

Specificity of streptolysin O in cytolysin-mediated translocation

Cytolysin-mediated translocation (CMT) is a recently described process in the Gram-positive pathogen Streptococcus pyogenes that translocates an effector protein of streptococcal origin into the cytoplasm of a host cell. At least two proteins participate in CMT, the pore-forming molecule streptolysin O (SLO) and an effector protein with the characteristics of a signal transduction protein, the Streptococcus pyogenes NAD-glycohydrolase (SPN). In order to begin to elucidate the molecular details of the translocation process, we examined whether perfringolysin O (PFO), a pore-forming protein related to SLO, could substitute for SLO in the translocation of SPN. When expressed by S. pyogenes, PFO, like SLO, had the ability to form functional pores in keratinocyte membranes. However, unlike SLO, PFO was not competent for translocation of SPN across the host cell membrane. Thus, pore formation by itself was not sufficient to promote CMT, suggesting that an additional feature of SLO was required. This conclusion was supported by the construction of a series of mutations in SLO that uncoupled pore formation and competence for CMT. These mutations defined a domain in SLO that was dispensable for pore formation, but was essential for CMT. However, introduction of this domain into PFO did not render PFO competent for CMT, implying that an additional domain of SLO is also critical for translocation. Taken together, these data indicate that SLO plays an active role in the translocation process that extends beyond that of a passive pore.