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The small group travel experience

We’re excited to announce that a selection of new 2019 tour dates and prices is now available. Click through to explore the tours and book your next adventure!

Offering a look at some of Africa’s most poignant history, spectacular game, and stunning coastline, our new Splendors of Southern Africa tour has something for everyone with visits to four countries: South Africa, Zambia, Zimbabwe, and Mozambique.Read our new blog post to find out more.

Two distinct and fascinating trips await travelers to Portugal and Spain. Discover the northern destinations of Oporto, Santiago de Compostela, Bilbao, and Barcelona; or venture south to explore Evora, Moorish Spain, and Madrid on two popular vacations.

Just a short 5-hour flight from the Northeastern US, Iceland stuns visitors with its scenic beauty, diverse landscape, and hospitable locals.

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We like the model – small groups, excellent tour directors, solid hotels, good mix of group/independent activities.

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Small Group Tours to Africa the Middle East

From the sub-Sahara to the Mediterranean, our well-crafted small group tours and safaris offer a wealth of spectacles and sights: jaw-dropping wildlife, momentous historic and religious wonders, exotic cities and natural wonders.

Tour membership limited to 12-24 guests 14 days from $7,284 total price from Boston, New York, Wash, DC ($6,295 air, land safari inclusive plus $989 airline taxes and fees)

A glimpse of a world primeval awaits on this singular safari to Botswana’s Chobe National Park, where elephants preside over a bounty of wildlife; Zimbabwe’s dazzling and powerful Victoria Falls; and Zambia’s exceptional Lower Zambezi National Park, a remote jewel of an unspoiled preserve.

Tour membership limited to 12-18 guests 17 days from $7,996 total price from Boston, New York, Wash, DC ($7,195 air, land safari inclusive plus $801 airline taxes and fees)

“On safari” … it’s one of the most alluring phrases in all of travel. And Kenya and Tanzania count among the most alluring places to be “on safari.” As our small group travels from grasslands to highlands, to reserves and national parks, we enjoy intimate game drives, see stupendous landscapes, stay in excellent accommodations, and meet gracious local people.

All the best in pulmonary critical care
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, Pleural Disease
Apr 21 2012

Mechanisms of Pneumothorax in the Critically Ill

Air can accumulate in the pleural space in three ways:

Diagnosis of Pneumothorax in the ICU

Pneumothorax can be difficult to recognize in a critically ill patient. Physical exam and clinical signs and symptoms are unreliable and nonspecific, but may raise clinical suspicion for pneumothorax:

Because clinical signs are unreliable, radiography is required to diagnose pneumothorax.

Chest Ultrasound to Diagnose Pneumothorax

Mounting evidence suggests that thoracic ultrasonography by an experienced operator can be as accurate as chest X-ray at diagnosing pneumothorax. However, a brief training period is required.

Mounting evidence

The "lung point" (absence of sliding lung next to sliding lung) has a 100% specificity for pneumothorax, but its sensitivity is lower. The lung point sign is dependent on at least part of the lung contacting the chest wall -- therefore, it's better to diagnose small pneumothoraces and becomes less sensitive as a pneumothorax increases in size.

The presence of B-lines along with sliding lung has a 100% negative predictive value for pneumothorax at the point examined -- multiple areas must be examined to rule out pneumothorax with confidence.

Video tutorial on the bedside ultrasound for pneumothorax (thanks to the Sneakers for Women On Sale Black Leather 2017 55 65 95 Philippe Model Leather 5.5 6.5 9.5 Philippe Model Black 0Xi0WVpmi

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Chest CT and Chest X-ray to Diagnose Pneumothorax

Chest CT is the gold standard for diagnosing pneumothorax, as well as determining size. Size is of less importance than clinical severity (hypoxia, distress, pain, hemodynamics) and pneumothorax size should not dictate management on its own.

Authors argue that chest X-rays have become effectively obsolete and should not be relied upon to diagnose pneumothorax in the critically ill patient. Pitfalls include potential loculated pneumothoraces occurring in heterogeneous ARDS or patients with pleural adhesions, as well as difficulties interpreting supine films. Although they essentially argue ultrasound should replace chest-X-rays, it's clear that most intensivists do not have this expertise.

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