The Boston Marathon Response Why Did It Work So Well?

Walls RM, Zinner MJ. — Wed, 19 Jun 2013 00:00:00 GMT

On Monday, April 15, 2013, Boston emergency medical services and other agencies transported scores of casualties to local hospitals within 90 minutes of the 2 explosions at 2:50 PM near the Boylston Street finish line of the 117th Boston Marathon. Brigham and Women's Hospital received 39 casualties overall, 31 on Monday, and 23 of these in the first hour. Many of these patients had severe injuries, including penetrating head and neck injuries and exsanguinating orthopedic blast injuries. Other trauma centers in the area received similar patients in similar numbers. Overall, only 3 people were killed by these explosive devices, and all 3 died before reaching the hospital. Not one patient who arrived at a hospital subsequently died. How did this happen?

Endosonography vs Conventional Bronchoscopy for the Diagnosis of Sarcoidosis The GRANULOMA Randomized Clinical Trial Endosonography vs Bronchoscopy for Diagnosis of Sarcoidosis

von Bartheld MB, Dekkers OM, Szlubowski A, et al. — Wed, 19 Jun 2013 00:00:00 GMT

Importance

Tissue verification of noncaseating granulomas is recommended for the diagnosis of sarcoidosis. Bronchoscopy with transbronchial lung biopsies, the current diagnostic standard, has moderate sensitivity in assessing granulomas. Endosonography with intrathoracic nodal aspiration appears to be a promising diagnostic technique.

Objective

To evaluate the diagnostic yield of bronchoscopy vs endosonography in the diagnosis of stage I/II sarcoidosis.

Design, Setting, and Patients

Randomized clinical multicenter trial (14 centers in 6 countries) between March 2009 and November 2011 of 304 consecutive patients with suspected pulmonary sarcoidosis (stage I/II) in whom tissue confirmation of noncaseating granulomas was indicated.

Interventions

Either bronchoscopy with transbronchial and endobronchial lung biopsies or endosonography (esophageal or endobronchial ultrasonography) with aspiration of intrathoracic lymph nodes. All patients also underwent bronchoalveolar lavage.

Main Outcomes and Measures

The primary outcome was the diagnostic yield for detecting noncaseating granulomas in patients with a final diagnosis of sarcoidosis. The diagnosis was based on final clinical judgment by the treating physician, according to all available information (including findings from initial bronchoscopy or endosonography). Secondary outcomes were the complication rate in both groups and sensitivity and specificity of bronchoalveolar lavage in the diagnosis of sarcoidosis.

Results

A total of 149 patients were randomized to bronchoscopy and 155 to endosonography. Significantly more granulomas were detected at endosonography vs bronchoscopy (114 vs 72 patients; 74% vs 48%; P < .001). Diagnostic yield to detect granulomas for endosonography was 80% (95% CI, 73%-86%); for bronchoscopy, 53% (95% CI, 45%-61%) (P < .001). Two serious adverse events occurred in the bronchoscopy group and 1 in the endosonography group; all patients recovered completely. Sensitivity of the bronchoalveolar lavage for sarcoidosis based on CD4/CD8 ratio was 54% (95% CI, 46%-62%) for flow cytometry and 24% (95% CI, 16%-34%) for cytospin analysis.

Conclusion and Relevance

Among patients with suspected stage I/II pulmonary sarcoidosis undergoing tissue confirmation, the use of endosonographic nodal aspiration compared with bronchoscopic biopsy resulted in greater diagnostic yield.

Trial Registration

clinicaltrials.gov Identifier: NCT00872612

JAMA: Surgery Topic Collection

The Boston Marathon Response Why Did It Work So Well?

Endosonography vs Conventional Bronchoscopy for the Diagnosis of Sarcoidosis The GRANULOMA Randomized Clinical Trial Endosonography vs Bronchoscopy for Diagnosis of Sarcoidosis