{"id":2185,"date":"2020-07-14T14:58:59","date_gmt":"2020-07-14T18:58:59","guid":{"rendered":"http:\/\/wordpress.world.dan.org\/?post_type=dan_health_resources&#038;p=2185"},"modified":"2020-09-17T11:59:44","modified_gmt":"2020-09-17T15:59:44","slug":"pulmonary-and-venous-disorders","status":"publish","type":"dan_health_resources","link":"https:\/\/world.dan.org\/fr\/health-medicine\/health-resource\/dive-medical-reference-books\/the-heart-diving\/pulmonary-and-venous-disorders\/","title":{"rendered":"Chapitre 6 : Troubles pulmonaires et veineux"},"content":{"rendered":"<p class=\"has-medium-font-size\"><em><strong>\u201cThe risk of a DVT occurring on a flight lasting more than four hours is between 1 in 4,650 flights and 1 in 6,000 flights.\u201d<\/strong><\/em><\/p>\n\n\n\n<p>Your lungs have many functions in your body beyond just oxygenating your blood. One of their other important roles is filtering the venous blood that returns from the body. The venous system is characterized by slower blood flow than the arterial system, which contributes to the occasional formation of a blood clot (known as a \u201cperipheral venous thrombosis\u201d), which could be transported into the lungs and could even cause a pulmonary embolism (or blockage in the vessels of the lungs).<\/p>\n\n\n\n<p>Dans ce chapitre, vous apprendrez ce qui suit :<\/p>\n\n\n\n<ul class=\"wp-block-list\"><li><a href=\"#dvt\">Thrombose veineuse profonde<\/a><\/li><li><a href=\"#pulmonary-embolism\">Embolie pulmonaire<\/a><\/li><li><a href=\"#immersion-pulmonary-edema\">\u0152d\u00e8me pulmonaire d'immersion<\/a><\/li><\/ul>\n\n\n\n<div style=\"height:100px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n\n\n\n<hr class=\"wp-block-separator\"\/>\n\n\n\n<h2 class=\"wp-block-heading\" id=\"dvt\">Thrombose veineuse profonde<\/h2>\n\n\n\n<div class=\"wp-block-image\"><figure class=\"alignright size-large\"><img loading=\"lazy\" decoding=\"async\" width=\"256\" height=\"171\" src=\"https:\/\/world.dan.org\/wp-content\/uploads\/2020\/07\/deep-vein-thrombosis-53224042-DAN-256x171-1.jpg\" alt=\"\" class=\"wp-image-9436\" srcset=\"https:\/\/world.dan.org\/wp-content\/uploads\/2020\/07\/deep-vein-thrombosis-53224042-DAN-256x171-1.jpg 256w, https:\/\/world.dan.org\/wp-content\/uploads\/2020\/07\/deep-vein-thrombosis-53224042-DAN-256x171-1-18x12.jpg 18w\" sizes=\"auto, (max-width: 256px) 100vw, 256px\" \/><\/figure><\/div>\n\n\n\n<p>Deep vein thrombosis (DVT) is a condition in which a blood clot (a \u201cthrombus\u201d) forms in one or more of the body\u2019s deep veins, usually in the legs. If a clot breaks free and travels through the circulatory system, it can lead to life-threatening conditions. For example, if a clot lodges in the lungs, it is known as a pulmonary embolism (PE) and affects the lungs\u2019 ability to oxygenate the blood (see \u201cPulmonary Embolism\u201d). Collectively, DVT and PE are sometimes referred to as venous thromboembolisms (VTEs).<\/p>\n\n\n\n<p>A clot that originates as a DVT can also cause a stroke in individuals with a patent foramen ovale (PFO, a hole in the wall between the atria \u2014 see \u201cPatent Foramen Ovale\u201d for details about this condition); in such a case, the clot travels through the veins to the right atrium of the heart, passes through the PFO to the left atrium and then travels through the arteries to the brain.<\/p>\n\n\n\n<p>La TVP n'est pas li\u00e9e \u00e0 la plong\u00e9e, mais les plongeurs voyagent souvent et les voyages constituent un facteur de risque important pour la TVP. Dans environ la moiti\u00e9 des cas de TVP, l'individu ne pr\u00e9sente aucun sympt\u00f4me notable avant l'apparition de la maladie. Le plus souvent, la maladie se d\u00e9clare au niveau du mollet. Les sympt\u00f4mes peuvent \u00eatre les suivants<\/p>\n\n\n\n<ul class=\"wp-block-list\"><li>Gonflement de la jambe, de la cheville ou du pied affect\u00e9<\/li><li>Douleur dans le mollet qui s'\u00e9tend \u00e0 la cheville ou au pied<\/li><li>Chaleur dans la zone affect\u00e9e<\/li><li>A change in the color of the skin \u2014 to pale, red or blue<\/li><\/ul>\n\n\n\n<p>La plupart des TEV li\u00e9es \u00e0 un voyage en avion surviennent dans les deux semaines suivant le vol et disparaissent dans les huit semaines. Si elle n'est pas trait\u00e9e, une TVP qui d\u00e9bute dans le mollet s'\u00e9tend \u00e0 la cuisse et au bassin dans environ 25 % des cas. Une TVP de la cuisse et du bassin non trait\u00e9e a un risque d'environ 50 % de conduire \u00e0 une EP, qui est la complication la plus grave de la TVP. De nombreux cas de TVP sont asymptomatiques et se r\u00e9sorbent spontan\u00e9ment. Toutefois, la TVP r\u00e9appara\u00eet souvent chez une personne qui a d\u00e9j\u00e0 souffert d'un \u00e9pisode de la maladie.<\/p>\n\n\n\n<div class=\"wp-block-image\"><figure class=\"aligncenter size-large\"><img loading=\"lazy\" decoding=\"async\" width=\"800\" height=\"500\" src=\"https:\/\/world.dan.org\/wp-content\/uploads\/2020\/07\/deep-vein-thrombosis-89651743-DAN-800x500-1.jpg\" alt=\"\" class=\"wp-image-11557\" srcset=\"https:\/\/world.dan.org\/wp-content\/uploads\/2020\/07\/deep-vein-thrombosis-89651743-DAN-800x500-1.jpg 800w, https:\/\/world.dan.org\/wp-content\/uploads\/2020\/07\/deep-vein-thrombosis-89651743-DAN-800x500-1-360x225.jpg 360w, https:\/\/world.dan.org\/wp-content\/uploads\/2020\/07\/deep-vein-thrombosis-89651743-DAN-800x500-1-768x480.jpg 768w, https:\/\/world.dan.org\/wp-content\/uploads\/2020\/07\/deep-vein-thrombosis-89651743-DAN-800x500-1-18x12.jpg 18w\" sizes=\"auto, (max-width: 800px) 100vw, 800px\" \/><\/figure><\/div>\n\n\n\n<p>Most DVTs occur in individuals with pre-existing risk factors for DVT who remain motionless for a long time \u2014 such as when traveling a long distance by plane, car or train; when doing deskwork over a period of many hours; or when bedridden. This is because immobility slows down the blood flow in the veins (a condition known as \u201cvenous stasis\u201d); in addition, pressure on the calf from an inadequate seat can injure the vein walls. If you sit still for 90 minutes, the blood flow in your calf drops by half, and that doubles your chance of developing a blood clot. For every additional hour you spend sitting, your risk of a blood clot increases by 10 percent.<\/p>\n\n\n\n<p>The incidence of DVT in the general population is one-tenth of one percent, but it is higher in those who have risk factors and those who travel often. Long-distance air travel may double or even quadruple the risk of suffering a VTE. Although DVT is often called the \u201ceconomy class disease,\u201d business-class travelers are susceptible, too. The risk of a DVT occurring on a flight lasting more than four hours is between 1 in 4,650 flights and 1 in 6,000 flights; this is lower than the risk in the general population, but that\u2019s because people who take long trips are likely to be healthier than average. The incidence of DVT among travelers with a low to intermediate pre-existing risk for VTE who take a journey longer than eight hours was found to be 0.3 percent for symptomatic cases and 0.5 percent when including asymptomatic cases as well.<\/p>\n\n\n\n<p><strong>Les facteurs de risque de la TVP sont les suivants<\/strong><\/p>\n\n\n\n<ul class=\"wp-block-list\"><li>L'\u00e2ge avanc\u00e9 (le risque augmente apr\u00e8s 40 ans)<\/li><li>Ob\u00e9sit\u00e9 (d\u00e9finie par un indice de masse corporelle sup\u00e9rieur \u00e0 30)<\/li><li>Utilisation d'\u0153strog\u00e8nes (contraceptifs hormonaux ou traitement hormonal de substitution)<\/li><li>Grossesse (y compris la p\u00e9riode postnatale)<\/li><li>Thrombophilie (tendance anormalement \u00e9lev\u00e9e du sang \u00e0 coaguler)<\/li><li>Ant\u00e9c\u00e9dents de MTEV ou ant\u00e9c\u00e9dents familiaux de MTEV<\/li><li>Cancer actif<\/li><li>Maladie grave<\/li><li>Intervention chirurgicale, hospitalisation ou traumatisme r\u00e9cent<\/li><li>Mobilit\u00e9 limit\u00e9e<\/li><li>Central venous catheterization (the presence of a catheter in one\u2019s chest, for use in administering medication or nutrients and\/or drawing blood samples)<\/li><\/ul>\n\n\n\n<p>Entre 75 % et 99 % des personnes qui d\u00e9veloppent une TEV li\u00e9e \u00e0 un voyage pr\u00e9sentaient plus d'un de ces facteurs de risque.<\/p>\n\n\n\n<p>Height is also a factor in one\u2019s risk of developing a travel-related DVT. People who are either very short \u2014 less than 5 feet, 3 inches (1.6 meters) \u2014 or very tall \u2014 more than 6 feet, 3 inches (1.9 meters) \u2014 appear to be at increased risk as a result of their inability to adjust their seats sufficiently to accommodate their height. In addition to effects of immobility, shorter passengers may suffer greater than usual seat-edge pressure on the backs of their knees, and taller passengers may be cramped due to insufficient leg room. All of these factors can contribute to injury of deep veins, venous stasis and activation of the blood\u2019s clotting mechanisms.<\/p>\n\n\n\n<p>Those who are at increased risk of DVT should wear compression socks whenever they fly or drive long distances and should consult their primary-care provider regarding the possible benefit of taking a clot-preventative such as aspirin. Although the risk of DVT for healthy people is small, everybody should be aware of the factors that can precipitate the condition \u2014 and avoid long periods of immobility. The best way to prevent DVT is to get up and walk around from time to time. It also helps to flex your feet and calf muscles regularly if you must remain seated for any length of time. Finally, it is also helpful in preventing DVT to stay well hydrated.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\">Effet sur la plong\u00e9e<\/h3>\n\n\n\n<p>Toute personne chez qui on a diagnostiqu\u00e9 une TVP aigu\u00eb ou qui prend des anticoagulants doit s'abstenir de plonger. Il est possible de reprendre la plong\u00e9e en toute s\u00e9curit\u00e9 apr\u00e8s une TVP, mais l'\u00e9valuation de l'aptitude \u00e0 la plong\u00e9e doit \u00eatre faite au cas par cas.<\/p>\n\n\n\n<div style=\"height:25px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n\n\n\n<hr class=\"wp-block-separator\"\/>\n\n\n\n<h2 class=\"wp-block-heading\" id=\"pulmonary-embolism\">Embolie pulmonaire<\/h2>\n\n\n\n<p>A pulmonary embolism (PE) is an obstruction (or \u201cembolus\u201d) that lodges in the vasculature of the pulmonary system, or lungs. The embolus may be air, fat or a blood clot (or \u201cthrombus\u201d). If a PE is caused by a thrombus, the clot typically originated in the deep vein system of the legs \u2014 a condition known as deep vein thrombosis (DVT); see \u201cDeep Vein Thrombosis\u201d for a discussion of DVT. The resulting obstruction in the flow of blood to the lungs typically causes a drop in cardiac output and a significant drop in blood pressure.<\/p>\n\n\n\n<div class=\"wp-block-image\"><figure class=\"alignright size-large\"><img loading=\"lazy\" decoding=\"async\" width=\"256\" height=\"215\" src=\"https:\/\/world.dan.org\/wp-content\/uploads\/2020\/07\/pulmonary-embolism-94626226-DAN-256x215-1.jpg\" alt=\"\" class=\"wp-image-11559\" srcset=\"https:\/\/world.dan.org\/wp-content\/uploads\/2020\/07\/pulmonary-embolism-94626226-DAN-256x215-1.jpg 256w, https:\/\/world.dan.org\/wp-content\/uploads\/2020\/07\/pulmonary-embolism-94626226-DAN-256x215-1-14x12.jpg 14w\" sizes=\"auto, (max-width: 256px) 100vw, 256px\" \/><\/figure><\/div>\n\n\n\n<p>L'apparition de l'EP peut \u00eatre aigu\u00eb ou chronique. L'EP aigu\u00eb provoque souvent des sympt\u00f4mes \u00e9vidents pour l'individu, tandis que l'EP chronique ne r\u00e9v\u00e8le souvent sa pr\u00e9sence que par des r\u00e9sultats tr\u00e8s subtils qui sont pass\u00e9s inaper\u00e7us pour l'individu affect\u00e9. Une EP non trait\u00e9e a un taux de mortalit\u00e9 \u00e9lev\u00e9. Le pronostic est particuli\u00e8rement sombre pour les personnes qui pr\u00e9sentent en m\u00eame temps une TVP, un thrombus du ventricule droit ou un dysfonctionnement du ventricule droit. On estime que 1,5 % des d\u00e9c\u00e8s sont diagnostiqu\u00e9s comme \u00e9tant dus \u00e0 une EP.<\/p>\n\n\n\n<p>Risk factors for DVT \u2014 and thus for PE \u2014 include recent surgery; a stroke; a diagnosis of autoimmune disease, malignancy or heart disease; obesity; smoking; hypertension; and a previous DVT.<\/p>\n\n\n\n<p>Symptoms of PE include chest pain (also known as \u201cdyspnea\u201d), pain or swelling of the calf (signaling a DVT), hypotension (abnormally low blood pressure), an altered level of consciousness and syncope (fainting). Distension of the neck veins in the absence of other conditions \u2014 such as pneumothorax (a buildup of air in the membrane surrounding the lungs, sometimes referred to as a collapsed lung) or heart failure \u2014 may also be observed in individuals suffering a PE.<\/p>\n\n\n\n<p>PE should be one of the first conditions considered when attempting to make a diagnosis in someone exhibiting acute onset of any of the symptoms listed above and any of the associated risk factors. Appropriate diagnostic tests may include measurement of the individual\u2019s levels of a hormone called brain natriuretic peptide (BNP) and of a protein known as cardiac troponin, as well as a CT angiogram of the lungs.<\/p>\n\n\n\n<p>Treatment should focus initially on managing the significant cardiopulmonary impairments that are usually involved in a PE. Such care may include breathing support from an artificial ventilator and fluid management. The use of anticoagulant medication is also important, both to treat the embolus and to stop the development of another thrombus. Thrombolysis (known as \u201cclot-busting\u201d), embolectomy (surgical removal of the embolus) or the placement in the vena cava (one of the large vessels in the chest) of a filter designed to prevent any future clots from reaching the lungs may also be considered \u2014 especially in anyone who goes into shock, because mortality in such cases approaches 50 percent. Similar measures may be called for in cases of PE caused by a venous gas bubble. Hyperbaric oxygen therapy may be indicated as well, if the individual\u2019s condition does not improve or deteriorates even after the application of supportive measures.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\">Effet sur la plong\u00e9e<\/h3>\n\n\n\n<p>Despite many medical advances, five-year all-cause mortality in individuals who have suffered a PE due to underlying risk factors remains more than 30 percent. And pulmonary hypertension \u2014 elevated pressure in the arteries that carry blood from the heart to the lungs, a condition that limits one\u2019s exercise capacity \u2014 often persists in individuals who have had a PE, even after successful treatment. Thus any determination of fitness for diving by those who have had a PE must include an evaluation of their lung function, underlying conditions, anticoagulation status, exercise capacity and cardiac status.<\/p>\n\n\n\n<div style=\"height:25px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n\n\n\n<hr class=\"wp-block-separator\"\/>\n\n\n\n<h2 class=\"wp-block-heading\" id=\"immersion-pulmonary-edema\">\u0152d\u00e8me pulmonaire d'immersion<\/h2>\n\n\n\n<p>Immersion pulmonary edema (IPE) is a form of pulmonary edema \u2014 an accumulation of fluid in the tissues of the lungs \u2014 that specifically affects divers and swimmers. Immersion at depth is a key factor in the development of IPE. That\u2019s because immersion in an upright position causes a significant shift of fluid from the peripheral to the central circulatory system, resulting in higher pressure in the capillaries of the pulmonary system. Elements of the diving milieu that contribute to IPE\u2019s occurrence include the fact that divers breathe gases that are denser than air at sea level, which means more negative pressure within chest is needed to inhale; the likelihood of gas bubbles becoming trapped in the vasculature of the lungs; the cold underwater environment; and the potential in underwater settings for exertion or panic, which can exacerbate elevated capillary pressure.<\/p>\n\n\n\n<div class=\"wp-block-image\"><figure class=\"aligncenter size-large\"><img loading=\"lazy\" decoding=\"async\" width=\"800\" height=\"500\" src=\"https:\/\/world.dan.org\/wp-content\/uploads\/2020\/07\/immersion-pulmonary-edema-1609237258-DAN-800x500-1.jpg\" alt=\"\" class=\"wp-image-11578\" srcset=\"https:\/\/world.dan.org\/wp-content\/uploads\/2020\/07\/immersion-pulmonary-edema-1609237258-DAN-800x500-1.jpg 800w, https:\/\/world.dan.org\/wp-content\/uploads\/2020\/07\/immersion-pulmonary-edema-1609237258-DAN-800x500-1-360x225.jpg 360w, https:\/\/world.dan.org\/wp-content\/uploads\/2020\/07\/immersion-pulmonary-edema-1609237258-DAN-800x500-1-768x480.jpg 768w, https:\/\/world.dan.org\/wp-content\/uploads\/2020\/07\/immersion-pulmonary-edema-1609237258-DAN-800x500-1-18x12.jpg 18w\" sizes=\"auto, (max-width: 800px) 100vw, 800px\" \/><\/figure><\/div>\n\n\n\n<p>Maintaining a proper fluid balance in your lung tissue and its vasculature requires a dynamic combination of various opposing forces. Unopposed changes in any of these forces can result in a buildup of excess fluid \u2014 or edema \u2014 in your pulmonary tissue. The main variables involved in regulating this fluid balance are the following:<\/p>\n\n\n\n<ul class=\"wp-block-list\"><li>Pression oncotique (forme de pression exerc\u00e9e par les prot\u00e9ines) dans les capillaires pulmonaires, les plus petits vaisseaux du syst\u00e8me circulatoire.<\/li><li>Oncotic pressure in the pulmonary system\u2019s interstitial fluid (fluid in the cavities of your lung tissue)<\/li><li>Perm\u00e9abilit\u00e9 des capillaires pulmonaires<\/li><li>Pression hydrostatique (pression d'un fluide au repos) dans les capillaires pulmonaires<\/li><li>Pression hydraulique (pression d'un fluide comprim\u00e9 ou pomp\u00e9) dans le liquide interstitiel<\/li><li>Pression dans les alv\u00e9oles, les minuscules sacs d'air des poumons.<\/li><\/ul>\n\n\n\n<p>These factors, which collectively are known as \u201cStarling forces,\u201d can all be quantified and placed in an equation that can then be used to calculate the net differential of<br>les forces.<\/p>\n\n\n\n<p>Pulmonary edema is caused by changes in these forces \u2014 such as a drop in the levels of key proteins in the blood; leakage from the pulmonary capillaries due to sepsis (a life-threatening complication of infections); an increase in hydrostatic pressure in the pulmonary capillaries due to heart failure; and negative pressure in the alveoli due to resistance from breathing through a faulty regulator. Additional issues that can contribute to the development of pulmonary edema include side effects of some cardiovascular drugs; ARDS (acute respiratory distress syndrome, a life-threatening condition that prevents oxygen from getting to the lungs); reperfusion (a procedure that restores circulation after a heart attack or stroke); cardiomyopathy (a weakening of the heart muscle); high-altitude pulmonary edema; a pulmonary embolus (a blood clot lodged in a vessel in the lungs); re-expansion (the reinflation of a collapsed lung); pulmonary hypertension (elevated pressure in the arteries that carry blood from the heart to the lungs); lung cancer; hemorrhage (uncontrolled bleeding); and various disorders of the nervous system. Other factors can include overhydration by well-intentioned divers who have heard the conventional wisdom that dehydration is a risk factor for decompression sickness, as well as poor physical conditioning, which can result in increased negative pressure in the alveoli during deep inspiration.<\/p>\n\n\n\n<p>Les sympt\u00f4mes de l'EPI comprennent des douleurs thoraciques, une dyspn\u00e9e (g\u00eane ou difficult\u00e9 \u00e0 respirer), une respiration sifflante et des expectorations roses et mousseuses pendant l'immersion ou peu apr\u00e8s la sortie de l'eau. La plupart des personnes qui souffrent d'un \u00e9pisode d'EPI n'avaient pas d'ant\u00e9c\u00e9dents ou de signes significatifs indiquant une pr\u00e9disposition \u00e0 cette affection ; n\u00e9anmoins, le risque d'EPI augmente avec l'\u00e2ge, l'ob\u00e9sit\u00e9 et une pression art\u00e9rielle \u00e9lev\u00e9e.<\/p>\n\n\n\n<p>Once pulmonary edema occurs, hypoxia (lack of an adequate supply of oxygen) leads to constriction of the pulmonary vasculature, which worsens the cascade of ill effects. The situation can be further aggravated by the accompanying dyspnea, which, when experienced underwater, can induce panic and uncontrolled ascent to the surface \u2014 leading to overinflation of the lungs and even near-drowning.<\/p>\n\n\n\n<p>To help differentiate immersion pulmonary edema from other conditions with similar symptoms (such as near-drowning, pulmonary decompression sickness and pulmonary overinflation syndrome), it is important to keep in mind that IPE\u2019s onset can occur either at depth or upon reaching the surface. And it is not necessarily precipitated by aggressive diving, a rapid ascent or the aspiration of water.<\/p>\n\n\n\n<p>Treatment for IPE should begin with removal of the affected individual from the water (to relieve the compression of the vessels in the lower extremities, allowing centrally pooled fluids to return to the extremities) and with administration of oxygen (beginning at 100 percent and later at a reduced concentration). A diuretic such as Lasix may help to reduce excess intravascular fluid, although diuresis \u2014 the body\u2019s natural excretion of fluid \u2014 may already be under way as a result of hormonal influences. The condition usually resolves quickly in a healthy diver. Prolonged hospitalization is rarely required; if it is necessary, it\u2019s usually due to contributing factors, such as an underlying cardiac problem.<\/p>\n\n\n\n<h3 class=\"wp-block-heading\">Effet sur la plong\u00e9e<\/h3>\n\n\n\n<p>Some divers have one episode of IPE and never experience the condition again, but repeated episodes are likely. Any individuals who suffer a first episode of IPE are advised to undergo a detailed examination to rule out any medical conditions that may have caused the edema and then to have a thorough discussion with their physician regarding the risks of continuing to dive. And all divers are urged to have regular maintenance on their regulators, to refrain from overhydration and to attend to proper dive planning in order to avoid exertion and panic \u2014 as well as to keep conditions such as obesity and hypertension under control.<\/p>\n\n\n\n<div style=\"height:25px\" aria-hidden=\"true\" class=\"wp-block-spacer\"><\/div>\n\n\n\n<p class=\"has-text-align-right\"><strong>Suivant : <a href=\"https:\/\/world.dan.org\/fr\/health-medicine\/health-resource\/dive-medical-reference-books\/the-heart-diving\/cardiovascular-drug-issues\/\">Chapter 7 \u2013 Issues Involving Cardiovascular Drugs &gt;<\/a><\/strong><\/p>","protected":false},"excerpt":{"rendered":"<p>&#8220;The risk of a DVT occurring on a flight lasting more than four hours is between 1 in 4,650 flights and 1 in 6,000 flights.&#8221; Your lungs have many functions [&hellip;]<\/p>\n","protected":false},"featured_media":11548,"parent":2110,"menu_order":27,"template":"","dan_health_resource_types":[405],"class_list":["post-2185","dan_health_resources","type-dan_health_resources","status-publish","has-post-thumbnail","hentry","dan_health_resource_types-dive-medical-reference-books"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v27.0 (Yoast SEO v27.3) - 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