{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,7]],"date-time":"2026-10-07T23:16:58Z","timestamp":1791415018526,"version":"4.3.3"},"reference-count":66,"publisher":"MDPI AG","issue":"10","license":[{"start":{"date-parts":[[2023,5,12]],"date-time":"2023-05-12T00:00:00Z","timestamp":1683849600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Healthcare"],"abstract":"<jats:p>Objective: The aim of this study was to assess the association between the presence of a right-to-left shunt (RLS) and neurological decompression sickness (NDCS) and asymptomatic brain lesions among otherwise healthy divers. Background: Next to drowning, NDCS is the most severe phenotype of diving-related disease and may cause permanent damage to the brain and spinal cord. Several observational reports have described the presence of an RLS as a significant risk factor for neurological complications in divers, ranging from asymptomatic brain lesions to NDCS. Methods: We systematically reviewed the MEDLINE, Embase, and CENTRAL databases from inception until November 2021. A random-effects model was used to compute odds ratios. Results: Nine observational studies consisting of 1830 divers (neurological DCS: 954; healthy divers: 876) were included. RLS was significantly more prevalent in divers with NDCS compared to those without (62.6% vs. 27.3%; odds ratio (OR): 3.83; 95% CI: 2.79\u20135.27). Regarding RLS size, high-grade RLS was more prevalent in the NDCS group than the no NDCS group (57.8% versus 18.4%; OR: 4.98; 95% CI: 2.86\u20138.67). Further subgroup analysis revealed a stronger association with the inner ear (OR: 12.13; 95% CI: 8.10\u201318.17) compared to cerebral (OR: 4.96; 95% CI: 2.43\u201310.12) and spinal cord (OR: 2.47; 95% CI: 2.74\u20137.42) DCS. RLS was more prevalent in divers with asymptomatic ischemic brain lesions than those without any lesions (46.0% vs. 38.0%); however, this was not statistically significant (OR: 1.53; 95% CI: 0.80\u20132.91). Conclusions: RLS, particularly high-grade RLS, is associated with greater risk of NDCS. No statistically significant association between RLS and asymptomatic brain lesions was found.<\/jats:p>","DOI":"10.3390\/healthcare11101407","type":"journal-article","created":{"date-parts":[[2023,5,12]],"date-time":"2023-05-12T09:26:13Z","timestamp":1683883573000},"page":"1407","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":3,"title":["Right-to-Left Shunt in Divers with Neurological Decompression Sickness: A Systematic Review and Meta-Analysis"],"prefix":"10.3390","volume":"11","author":[{"given":"Spyros","family":"Peppas","sequence":"first","affiliation":[{"name":"Department of Internal Medicine, MedStar Washington Hospital Center, Washington, DC 20010, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-4682-5991","authenticated-orcid":false,"given":"Leonidas","family":"Palaiodimos","sequence":"additional","affiliation":[{"name":"Department of Medicine, Jacobi Medical Center, Bronx, NY 10461, USA"},{"name":"Albert Einstein College of Medicine, Bronx, NY 10461, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6230-7214","authenticated-orcid":false,"given":"Sanjana","family":"Nagraj","sequence":"additional","affiliation":[{"name":"Department of Medicine, Jacobi Medical Center, Bronx, NY 10461, USA"},{"name":"Albert Einstein College of Medicine, Bronx, NY 10461, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Damianos G.","family":"Kokkinidis","sequence":"additional","affiliation":[{"name":"Section of Cardiovascular Medicine, Yale University\/Yale New Haven Hospital, New Haven, CT 06520, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2281-9001","authenticated-orcid":false,"given":"Nidhish","family":"Tiwari","sequence":"additional","affiliation":[{"name":"Department of Medicine, Jacobi Medical Center, Bronx, NY 10461, USA"},{"name":"Albert Einstein College of Medicine, Bronx, NY 10461, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3989-4489","authenticated-orcid":false,"given":"Amrin","family":"Kharawala","sequence":"additional","affiliation":[{"name":"Department of Medicine, Jacobi Medical Center, Bronx, NY 10461, USA"},{"name":"Albert Einstein College of Medicine, Bronx, NY 10461, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Mohammad K.","family":"Mojadidi","sequence":"additional","affiliation":[{"name":"Division of Cardiology, Department of Medicine, Virginia Commonwealth University, Richmond, VA 23284, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-3748-294X","authenticated-orcid":false,"given":"Sanauallah","family":"Mojaddedi","sequence":"additional","affiliation":[{"name":"Division of Cardiology, Department of Medicine, Virginia Commonwealth University, Richmond, VA 23284, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0629-9248","authenticated-orcid":false,"given":"George","family":"Ntaios","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, Faculty of Medicine, School of Health Sciences, University of Thessaly, 382 21 Larissa, Greece"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Robert T.","family":"Faillace","sequence":"additional","affiliation":[{"name":"Department of Medicine, Jacobi Medical Center, Bronx, NY 10461, USA"},{"name":"Albert Einstein College of Medicine, Bronx, NY 10461, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2462-3459","authenticated-orcid":false,"given":"Jonathan M.","family":"Tobis","sequence":"additional","affiliation":[{"name":"Division of Cardiology, Department of Medicine, University of California, Los Angeles, Los Angeles, CA 90095, USA"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2023,5,12]]},"reference":[{"key":"ref_1","unstructured":"Mojadidi, M.K., Meier, B., and Tobis, J.M. 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