Diving & hyperbaric medicine: Overview

Abstract
Introduction: Vascular cognitive impairment (VCI) has an increasing prevalence worldwide, accounting for at least 20%-40% of all diagnoses of dementia. The decline in cognitive function seriously impairs patients' activities of daily living and social participation and reduces their quality of life. However, there is still a lack of advanced, definitive rehabilitation programmes for VCI. Hyperbaric oxygen therapy (HBOT) and repetitive transcranial magnetic stimulation (rTMS) are recognised treatments for improving cognitive impairment. The former can restore oxygen supply in the brain by increasing oxygen partial pressure in brain tissue, while the latter can enhance neuronal excitability and promote synaptic plasticity. However, no studies have explored the effect of HBO combined with rTMS on VCI.

Methods and analysis: This study is designed as a single-centre, assessor-blind, randomised controlled clinical trial with four parallel arms. A total of 72 participants will be recruited and randomly assigned to the control group, HBOT group, rTMS group and HBOT combined with rTMS group at a ratio of 1:1:1:1. All enrolled participants will receive conventional treatment. The entire intervention period is 4 weeks, with a 3-week follow-up. Outcomes will be measured at baseline (T0), after a 4-week intervention (T1) and after an additional 3-week follow-up period (T2). The primary endpoint is the Montreal Cognitive Assessment score. The secondary endpoints are Mini-Mental State Examination score, Modified Barthel Index score, latency and amplitude of P300, cerebral cortical oxygenated haemoglobin (HbO2) and deoxygenated haemoglobin (HbR) concentrations as measured by task-state functional near-infrared spectroscopy.

Ethics and dissemination: Ethics approval was obtained from the West China Hospital Clinical Trials and Biomedical Ethics Committee of Sichuan University (ethics reference: 2022 (1972)). The findings will be published in peer-reviewed journals and disseminated through scientific conferences and seminars.

Abstract
Heart rate variability (HRV) is a useful method to study the autonomic nervous system (ANS) status. As measuring devices have developed and become smaller, many researchers have become interested in the possibilities to implement the method for diving medicine research. The aim of this study was to review human ANS responses in cold water diving (water temperature <5°C), and to comprise the current knowledge of HRV studies in diving and hyperbaric exposure into one review article. A literature search was conducted on 5 Decemberth 2022, with the search terms "HRV" or "heart rate variability" and "diving" or "diver" or "divers", with search functions of the data bases PubMed and Ovid Medline. Peer reviewed original articles, review articles and case reports were accepted to this review. Twenty-six articles met the pre-defined criteria and were included in this review. Studies from very cold water conditions were rare, but suggested that cold strengthens the ANS responses of diving - especially parasympathetic nervous system (PNS) activity due to the trigeminocardiac reflex and baroreceptor and cardiac stretch receptor activity, caused cold and pressure-induced centralisation of the blood. Overall, studies showed predominant PNS activity when putting the face in water, during immersion and when ambient pressure increased.