A rare case of De Garengeot hernia: CT findings.

We report a case of "De Garengeot's hernia" (DGH), a rare condition that occurs when the inflamed appendix is localized inside a femoral hernia. The appendix may be involved in inflammatory or necrotic processes and the treatment is emergency surgery. It is usually discovered by chance during surgery. It occurs in 0.5%-5% of all femoral hernias. In 0.08%-0.13% of cases, the appendix can present inflammatory or necrotic processes due to the narrowness of the neck of the femoral canal; in these cases, an emergency surgery is required through a no standard surgical procedure. In the other cases, it is usually found accidentally during surgical repair of the hernia or more rarely diagnosed preoperatively by CT. Therefore, the purpose of our study is to report a case of DGH describing CT main findings in order to improve the preoperative diagnosis.

Walk Your Talk: Real-World Adherence to Guidelines on the Use of MRI in Multiple Sclerosis.

(1) Although guidelines about the use of MRI sequences for Multiple Sclerosis (MS) diagnosis and follow-up are available, variability in acquisition protocols is not uncommon in everyday clinical practice. The aim of this study was to evaluate the real-world application of MS imaging guidelines in different settings to clarify the level of adherence to these guidelines. (2) Via an on-line anonymous survey, neuroradiologists (NR) were asked about MRI protocols and parameters routinely acquired when MS patients are evaluated in their center, both at diagnosis and follow-up. Furthermore, data about report content and personal opinions about emerging neuroimaging markers were also retrieved. (3) A total of 46 participants were included, mostly working in a hospital or university hospital (80.4%) and with more than 10 years of experience (47.9%). We found a relatively good adherence to the suggested MRI protocols regarding the use of T2-weighted sequences, although almost 10% of the participants routinely acquired 2D sequences with a slice thickness superior to 3 mm. On the other hand, a wider degree of heterogeneity was found regarding gadolinium administration, almost routinely performed at follow-up examination (87.0% of cases) in contrast with the current guidelines, as well as a low use of a standardized reporting system (17.4% of cases). (4) Although the MS community is getting closer to a standardization of MRI protocols, there is still a relatively wide heterogeneity among NR, with particular reference to contrast administration, which must be overcome to guarantee an adequate quality of patients' care in MS.

Tracheal ring fracture secondary to percutaneous tracheostomy: is tracheal flaccidity a risk factor?

OBJECTIVE: To evaluate the risk factors of tracheal ring fracture and whether previous tracheal ring flaccidity predisposes to it in consecutive, mechanically ventilated, intensive care unit patients undergoing different percutaneous dilatational tracheostomy procedures (Ciaglia Blue Rhino, PercuTwist, and Ciaglia BlueDolphin). DESIGN: Single-center retrospective study performed between November 2006 and July 2013. SETTING: Single-center university hospital. PARTICIPANTS: Two hundred nineteen consecutive intensive care unit patients. INTERVENTIONS: Video bronchoscopic percutaneous dilatational tracheostomies using different techniques, including Ciaglia Blue Rhino, PercuTwist, and Ciaglia BlueDolphin, were performed consecutively. During the procedure, the tracheal wall response to the routine external palpation was evaluated endoscopically to find the interanular space. An abnormal change in the tracheal ring shape (fingerprint) with anterior airway wall collapse was diagnosed as tracheal flaccidity. MEASUREMENTS AND MAIN RESULTS: Tracheal ring fracture occurred in 21 patients (9.6%). The proportion of tracheal ruptures was 16 (76.2%) after PercuTwist, 3 (14.3%) after Ciaglia Blue Dolphin, and 2 (9.5%) after the Blue Rhino technique. Significant risk factors for tracheal rupture were PercuTwist procedure (p = 0.02), tracheal flaccidity (p = 0.0001), and a period of intubation before a percutaneous dilatational tracheostomy procedure>14 days (p = 0.01). CONCLUSIONS: In addition to the PercuTwist technique and intubation>14 days before tracheostomy, tracheal flaccidity was a significant risk factor for tracheal ring fracture. In the presence of this finding, a less traumatic tracheostomy procedure should be applied.

A home-made animal model in comparison with a standard manikin for teaching percutaneous dilatational tracheostomy.

OBJECTIVES: As airway management specialists, thoracic surgeons should be familiar with percutaneous dilatational tracheostomy. To optimize the learning curve, we propose a home-made pig model obtained from a slaughterhouse for training residents in the technical aspects of performing percutaneous dilatational tracheostomy. The satisfaction of the residents' training experience using this model was compared with that using a standard manikin model. METHODS: Fifty residents participated in the present study. At the end of the session, each participant completed a questionnaire assessing the pig model and the manikin by assigning a score (ranging from 1 to 4) to five specific characteristics including (i) reality of skin turgor; (ii) landmark recognition; (iii) feasibility of the procedure; (iv) reality of the model and (v) preference of each model. The differences between models were statistically analysed. RESULTS: Forty-five participants completed the study. The pig model, compared with the manikin model, presented a higher value regarding the reality of skin turgor (1.7 ± 0.5 vs 0.4 ± 0.8; respectively, P < 0.0001); landmark recognition (3.8 ± 0.5 vs 2.0 ± 0.5; respectively; P < 0.0001) and reality of the model (3.0 ± 0.8 vs 1.3 ± 1.0; respectively; P < 0.0001). No difference was found regarding the feasibility of the procedure (3.7 ± 0.6 vs 3.5 ± 0.5; respectively, P = 0.1). The pig model was preferred to the manikin (3.2 ± 0.7 vs 1.6 ± 1.0; respectively, P < 0.0001). CONCLUSIONS: Our pig model allowed residents to develop the skills required for successful percutaneous dilatational tracheostomy. In particular, they developed confidence with certain manoeuvres such as needle and guide-wire placement, dilatation of the trachea and insertion of a cannula, before attempting the procedure on a live patient.

Elective tracheostomy in intensive care unit: Looking between techniques, a three cases report.

There is no optimal tracheostomy (TS) technique, proved to be the best. For this reason, operators' skills, clinical anatomical and physio-pathological features of the patient should be considered as discriminating factors in the choice of percutaneous dilation tracheostomy (PDT) technique. This article includes reports of three cases of PDT: In the first case distance between jugular notch and the first tracheal ring was too long, the second case involving a patient with mild ectasia of the ascending aorta and aortic regurgitation with De Musset's sign with great risk of perioperative bleeding and a third case, of tracheomalacia with inflammatory stenosis at the 4(th) tracheal ring. All together, this case series describes how decisions were made by an experienced staff, in which the patient characteristics were assessed and techniques best suited for each case were implemented.

Percutaneous endoscopic gastrostomy for critically ill patients in a general intensive care unit.

BACKGROUND AND AIM: percutaneous endoscopic gastrostomy (PEG) is an effective way of providing enteral feeding to patients with functionally normal gastrointestinal tract who cannot meet their nutritional needs because of inadequate oral intake. This retrospective study evaluated the clinical outcome of critically ill patients with high assistance level undergoing PEG in a general ICU over a 12 year period. PATIENTS AND METHODS: we studied a cohort of 82 patients who underwent PEG over a 12-year period between 1 January 1999 and 31 December 2010. Patients were followed-up for 1 year after PEG placement. RESULTS: There were no complications related either to the procedure or to the management of PEG, even in house nursing.In one patient, PEG with a collapsible bumper was successfully removed because the patient fully recovered from his neurological problem. Catheter substitution was necessary in three patients during the first year, because of stoma inflammation due to enteric reflux between the stoma and the catheter. One year after PEG, 66 patients were still alive while 16 patients died from the underlying disease during hospitalization. None of the patients with PEG had aspiration pneumonia. CONCLUSIONS: PEG, in expert hands, is a safe and effective procedure for enteral nutrition. Moreover, catheters should be chosen in relation to the duration of enteral feeding and as to whether the patient is likely to recover from his underlying disease.