human
***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: IMPORTANCE Tissue verification of noncaseating granulomas is recommended for the diagnosis of sarcoidosis . Bronchoscopy with transbronchial lung biopsies , the current diagnostic st and ard , 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 R and omized 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 r and omized 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 result ed in greater diagnostic yield . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00872612 A patient 's tolerance of fiberoptic bronchoscopy depends on the effectiveness of local anesthesia . This study compares the three different methods of local anesthesia in common use After sedation , patients ( n = 53 ) received either 4 ml of 2.5 percent cocaine by intratracheal injection ( TI ) ( n = 18 ) , by bronchoscopic injection ( BI ) ( n = 19 ) , or had 4 ml of 4 percent lidocaine delivered by nebulizer 20 min before the procedure ( NEB ) ( n = 16 ) . Patients and bronchoscopists scored the procedure using visual analog ( VAS ) and severity scales . Objective measurements of cough counts and episodes of stridor were recorded by phonopneumography . Patients ' VAS scores showed a clear preference for the transtracheal method compared with either bronchoscopically injected cocaine ( p less than 0.001 ) or nebulized lidocaine ( p less than 0.001 ) . Patients also reported that the TI method produced less cough during intubation of the larynx and inspection of the airways ( BI and NEB , p less than 0.01 ) . The TI method was also preferred by the bronchoscopists ( BI and NEB , p less than 0.001 ) ; they reported less cough and easier tracheal intubation . The mean cough count was significantly lower for the TI group , 49 ( 43 ) compared with 95 ( 52 ) for BI ( p less than 0.01 ) , and 81 ( 43 ) for the NEB group ( p less than 0.05 ) . Patients ' and bronchoscopists ' VAS showed significant correlation with cough ( r = 0.63 - 69 , p less than 0.01 ) . Stridor occurred in only two patients after TI , compared with 15 in the other two groups . Extra local anesthesia was required by 16 patients after BI , by all the NEB group , but by only one patient after TI . Subjective and objective measurement shows that 4 ml of 2.5 percent cocaine injected into the trachea produced excellent local anesthesia for fiberoptic bronchoscopy , there were no extra complications , and it was the method preferred by both patients and bronchoscopists OBJECTIVE The route of bronchoscope insertion varies between centres , without a firm rationale based on well- design ed studies . We therefore compared nasal and oral insertion of a flexible bronchoscope and evaluated efficacy and patient satisfaction . DESIGN Prospect i ve r and omised study of patients who underwent flexible bronchoscopy from May to September 2003 and who were r and omly assigned to nasal and oral insertion approaches .  RESULTS Clinical characteristics , factors related to the procedure and patient satisfaction were analysed . In total , 307 patients were r and omly assigned to the nasal ( n = 158 ) or oral insertion groups ( n = 149 ) . No difference in baseline characteristics was identified between the groups . Insertion by the oral route was associated with a smaller amount of lidocaine use during the procedure ( P = 0.04 ) and less frequent insertion site bleeding ( P = 0.005 ) . Patients assigned to oral insertion reported less discomfort during anaesthesia ( P = 0.01 ) and scope insertion ( P < 0.001 ) , as well as less dyspnoea ( P = 0.04 ) and coughing ( P = 0.03 ) . CONCLUSION Oral insertion of a flexible bronchoscope was associated with less discomfort for patients than nasal insertion , although the route of insertion had no significant effect on outcome BACKGROUND Conscious sedation for patients undergoing flexible bronchoscopy ( FB ) is suggested to alleviate discomfort and improve satisfaction despite controversy regarding its benefits . In Taiwan , the general FB practice involves local anesthesia only . This study aim ed to assess the benefits and risks of conscious sedation in diagnostic FB . METHODS This prospect i ve case control study enrolled 44 non-se date d and 44 se date d patients who underwent diagnostic FB .  All received the st and ard upper airway preparation , while se date d patients received clinical ly judged increments of midazolam and alfentanil for conscious sedation .  Patient discomforts and the operator 's opinions during FB were assessed using the verbal analogue score ( VAS , 0 - 10 scale ) . Willingness to return was assessed as five scales to monitor patient satisfaction . Safety profiles throughout the procedures were also assessed . RESULTS Compared to non-se date d patients , se date d ones expressed less discomfort , with lower VAS scores regarding scope insertion ( 3.5 [ 0 - 10 ] vs. 0 [ 0 - 5 ] , p < 0.001 ) , cough ( 5 [ 0 - 10 ] vs. 0 [ 0 - 5 ] , p < 0.001 ) , dyspnea ( 3 [ 0 - 10 ] vs. 0 [ 0 - 8 ] , p < 0.001 ) , pain ( 3 [ 0 - 10 ] vs. 0 [ 0 - 5 ] , p < 0.001 ) , and global tolerance of the procedures ( 5 [ 1 - 10 ] vs. 0 [ 0 - 9 ] , p < 0.001 ) . More se date d patients expressed willingness to return ( 70.5 % vs. 36.4 % , p = 0.001 ) . The bronchoscopist also rated lower VAS scores on cough and dyspnea in se date d patients . Se date d patients had less hypertension but more hypoxemic episodes during the procedure , which were all transient and not life-threatening . CONCLUSIONS Conscious sedation with clinical ly judged midazolam and alfentanil reduces discomforts , improves satisfaction , and carries slight , but manageable , hypoxemia risks in patients undergoing FB Background : The clinical benefits associated with the use of the bispectral index ( BIS ) to monitor the depth of sedation during flexible fiberoptic bronchoscopy ( FFB ) are question able . Objectives : To evaluate the added value in terms of procedural safety and patients ' awareness of monitoring sedation depth using the BIS compared to conventional clinical judgment alone in patients undergoing FFB under propofol sedation . Methods : The cohort included 81 patients undergoing diagnostic or therapeutic bronchoscopy under propofol sedation that were prospect ively r and omized to guide the depth of sedation by BIS monitoring ( BIS group ; n = 40 ) or conventional monitoring ( control group ; n = 41 ) . Results : The mean duration s of the procedure were 18 and 19 min in the BIS and control groups , respectively . No significant difference was noted in the dosage of propofol used between the BIS and control groups ( 168.7 vs. 167.3 mg , respectively ) . Average sedation-related oxygen saturation drop and transcutaneous CO2 rise were not significantly different between groups . There was also no significant difference in the percentage of patients that required either hemodynamic support ( 5 vs. 7.5 % , respectively ) , oxygen supplementation by 100 % O2 mask ( 67.5 vs. 82.5 % , respectively ) or Ambu face mask manual ventilation ( 2.5 vs. 5 % , respectively ) between the groups . No significant difference was noted in terms of patients ' awareness during the procedure , which was assessed following recovery by a structured Brice interview . Conclusion : Using BIS to guide the depth of sedation during propofol sedation in patients undergoing FFB of relatively short duration offers no clinical ly significant advantages over conventional monitoring Optimisation of topical anaesthesia for flexible fibreoptic bronchoscopy ( FOB ) is becoming increasingly important as a wider range of more complex , and thereby more prolonged , interventional endoscopic procedures are becoming available . Lignocaine is the most commonly used topical anaesthetic agent for bronchoscopy , but there is variability in current practice as to its optimum mode of administration . In this prospect i ve , r and omised , placebo-controlled , blinded study , we examine whether there was enhanced effectiveness of additional nebulised lignocaine as compared to our current regime utilising two visual analogue scales as markers of efficacy . Treatment groups were matched in terms of age ( p = 0.39 ) , gender , concomitant sedation ( p = 0.51 midazolam ; p = 0.12  fentanyl )  and dose of background administered lignocaine  ( 290 mg ) . We found no significant additional differences between any of the treatment groups in terms of general ease of procedure ( p = 0.09 ) or in cough severity ( p = 0.12 ) . We conclude that this study does not support the hypothesis that additional nebulised lignocaine confers any additional benefit to the ease of procedure or cough severity in patients undergoing fibreoptic bronchoscopy . We suggest that preparation regimes for bronchoscopic examinations need optimization STUDY OBJECTIVES The present study was performed to determine whether the risk of bleeding after transbronchial lung biopsy is increased in patients taking aspirin .  DESIGN Prospect i ve cohort study . PATIENTS AND INTERVENTIONS After excluding patients with other coagulation problems , 1,217 patients who had undergone transbronchial lung biopsy during a prospect i ve 1.5-year study period were included in this study . The use of aspirin was not discontinued before the procedure . Two hundred eighty-five patients ( 23 % ) had consumed aspirin within 24 h of the procedure , and most of them ( 82 % ) used aspirin on a daily basis . Transbronchial biopsies were performed , and the bleeding incidence was compared between the groups . RESULTS A total of 57 patients ( 4.7 % ) experienced procedure-related bleeding . Minor bleeding occurred in 5 of 285 patients ( 1.8 % ) taking aspirin and in 27 of 932 control patients ( 2.9 % ; not significant ) . Moderate bleeding was seen in 3 of 285 patients ( 1.1 % ) in the aspirin group and in 13 of 932 patients ( 1.4 % ) in the control group ( not significant ) . Major bleeding occurred in only 9 patients , 2 of 285 ( 0.9 % ) in the aspirin group and 7 of 932 ( 0.8 % ) in the control group ( not significant ) . All bleeding was controlled by endoscopic means , and there were no fatalities and no need for blood transfusions . CONCLUSIONS We conclude that the risk of severe bleeding after transbronchial lung biopsy is small ( ie , < 1 % ) and that the use of aspirin is not associated with any increased risk of bleeding BACKGROUND The optimal concentration of lignocaine to be used during flexible bronchoscopy ( FB ) remains unknown . This r and omized controlled trial compared the efficacy and safety of 1 % and 2 % lign 
    Output:
    
agent
***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: IMPORTANCE Tissue verification of noncaseating granulomas is recommended for the diagnosis of sarcoidosis . Bronchoscopy with transbronchial lung biopsies , the current diagnostic st and ard , 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 R and omized 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 r and omized 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 result ed in greater diagnostic yield . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00872612 A patient 's tolerance of fiberoptic bronchoscopy depends on the effectiveness of local anesthesia . This study compares the three different methods of local anesthesia in common use After sedation , patients ( n = 53 ) received either 4 ml of 2.5 percent cocaine by intratracheal injection ( TI ) ( n = 18 ) , by bronchoscopic injection ( BI ) ( n = 19 ) , or had 4 ml of 4 percent lidocaine delivered by nebulizer 20 min before the procedure ( NEB ) ( n = 16 ) . Patients and bronchoscopists scored the procedure using visual analog ( VAS ) and severity scales . Objective measurements of cough counts and episodes of stridor were recorded by phonopneumography . Patients ' VAS scores showed a clear preference for the transtracheal method compared with either bronchoscopically injected cocaine ( p less than 0.001 ) or nebulized lidocaine ( p less than 0.001 ) . Patients also reported that the TI method produced less cough during intubation of the larynx and inspection of the airways ( BI and NEB , p less than 0.01 ) . The TI method was also preferred by the bronchoscopists ( BI and NEB , p less than 0.001 ) ; they reported less cough and easier tracheal intubation . The mean cough count was significantly lower for the TI group , 49 ( 43 ) compared with 95 ( 52 ) for BI ( p less than 0.01 ) , and 81 ( 43 ) for the NEB group ( p less than 0.05 ) . Patients ' and bronchoscopists ' VAS showed significant correlation with cough ( r = 0.63 - 69 , p less than 0.01 ) . Stridor occurred in only two patients after TI , compared with 15 in the other two groups . Extra local anesthesia was required by 16 patients after BI , by all the NEB group , but by only one patient after TI . Subjective and objective measurement shows that 4 ml of 2.5 percent cocaine injected into the trachea produced excellent local anesthesia for fiberoptic bronchoscopy , there were no extra complications , and it was the method preferred by both patients and bronchoscopists OBJECTIVE The route of bronchoscope insertion varies between centres , without a firm rationale based on well- design ed studies . We therefore compared nasal and oral insertion of a flexible bronchoscope and evaluated efficacy and patient satisfaction . DESIGN Prospect i ve r and omised study of patients who underwent flexible bronchoscopy from May to September 2003 and who were r and omly assigned to nasal and oral insertion approaches .  RESULTS Clinical characteristics , factors related to the procedure and patient satisfaction were analysed . In total , 307 patients were r and omly assigned to the nasal ( n = 158 ) or oral insertion groups ( n = 149 ) . No difference in baseline characteristics was identified between the groups . Insertion by the oral route was associated with a smaller amount of lidocaine use during the procedure ( P = 0.04 ) and less frequent insertion site bleeding ( P = 0.005 ) . Patients assigned to oral insertion reported less discomfort during anaesthesia ( P = 0.01 ) and scope insertion ( P < 0.001 ) , as well as less dyspnoea ( P = 0.04 ) and coughing ( P = 0.03 ) . CONCLUSION Oral insertion of a flexible bronchoscope was associated with less discomfort for patients than nasal insertion , although the route of insertion had no significant effect on outcome BACKGROUND Conscious sedation for patients undergoing flexible bronchoscopy ( FB ) is suggested to alleviate discomfort and improve satisfaction despite controversy regarding its benefits . In Taiwan , the general FB practice involves local anesthesia only . This study aim ed to assess the benefits and risks of conscious sedation in diagnostic FB . METHODS This prospect i ve case control study enrolled 44 non-se date d and 44 se date d patients who underwent diagnostic FB .  All received the st and ard upper airway preparation , while se date d patients received clinical ly judged increments of midazolam and alfentanil for conscious sedation .  Patient discomforts and the operator 's opinions during FB were assessed using the verbal analogue score ( VAS , 0 - 10 scale ) . Willingness to return was assessed as five scales to monitor patient satisfaction . Safety profiles throughout the procedures were also assessed . RESULTS Compared to non-se date d patients , se date d ones expressed less discomfort , with lower VAS scores regarding scope insertion ( 3.5 [ 0 - 10 ] vs. 0 [ 0 - 5 ] , p < 0.001 ) , cough ( 5 [ 0 - 10 ] vs. 0 [ 0 - 5 ] , p < 0.001 ) , dyspnea ( 3 [ 0 - 10 ] vs. 0 [ 0 - 8 ] , p < 0.001 ) , pain ( 3 [ 0 - 10 ] vs. 0 [ 0 - 5 ] , p < 0.001 ) , and global tolerance of the procedures ( 5 [ 1 - 10 ] vs. 0 [ 0 - 9 ] , p < 0.001 ) . More se date d patients expressed willingness to return ( 70.5 % vs. 36.4 % , p = 0.001 ) . The bronchoscopist also rated lower VAS scores on cough and dyspnea in se date d patients . Se date d patients had less hypertension but more hypoxemic episodes during the procedure , which were all transient and not life-threatening . CONCLUSIONS Conscious sedation with clinical ly judged midazolam and alfentanil reduces discomforts , improves satisfaction , and carries slight , but manageable , hypoxemia risks in patients undergoing FB Background : The clinical benefits associated with the use of the bispectral index ( BIS ) to monitor the depth of sedation during flexible fiberoptic bronchoscopy ( FFB ) are question able . Objectives : To evaluate the added value in terms of procedural safety and patients ' awareness of monitoring sedation depth using the BIS compared to conventional clinical judgment alone in patients undergoing FFB under propofol sedation . Methods : The cohort included 81 patients undergoing diagnostic or therapeutic bronchoscopy under propofol sedation that were prospect ively r and omized to guide the depth of sedation by BIS monitoring ( BIS group ; n = 40 ) or conventional monitoring ( control group ; n = 41 ) . Results : The mean duration s of the procedure were 18 and 19 min in the BIS and control groups , respectively . No significant difference was noted in the dosage of propofol used between the BIS and control groups ( 168.7 vs. 167.3 mg , respectively ) . Average sedation-related oxygen saturation drop and transcutaneous CO2 rise were not significantly different between groups . There was also no significant difference in the percentage of patients that required either hemodynamic support ( 5 vs. 7.5 % , respectively ) , oxygen supplementation by 100 % O2 mask ( 67.5 vs. 82.5 % , respectively ) or Ambu face mask manual ventilation ( 2.5 vs. 5 % , respectively ) between the groups . No significant difference was noted in terms of patients ' awareness during the procedure , which was assessed following recovery by a structured Brice interview . Conclusion : Using BIS to guide the depth of sedation during propofol sedation in patients undergoing FFB of relatively short duration offers no clinical ly significant advantages over conventional monitoring Optimisation of topical anaesthesia for flexible fibreoptic bronchoscopy ( FOB ) is becoming increasingly important as a wider range of more complex , and thereby more prolonged , interventional endoscopic procedures are becoming available . Lignocaine is the most commonly used topical anaesthetic agent for bronchoscopy , but there is variability in current practice as to its optimum mode of administration . In this prospect i ve , r and omised , placebo-controlled , blinded study , we examine whether there was enhanced effectiveness of additional nebulised lignocaine as compared to our current regime utilising two visual analogue scales as markers of efficacy . Treatment groups were matched in terms of age ( p = 0.39 ) , gender , concomitant sedation ( p = 0.51 midazolam ; p = 0.12  fentanyl )  and dose of background administered lignocaine  ( 290 mg ) . We found no significant additional differences between any of the treatment groups in terms of general ease of procedure ( p = 0.09 ) or in cough severity ( p = 0.12 ) . We conclude that this study does not support the hypothesis that additional nebulised lignocaine confers any additional benefit to the ease of procedure or cough severity in patients undergoing fibreoptic bronchoscopy . We suggest that preparation regimes for bronchoscopic examinations need optimization STUDY OBJECTIVES The present study was performed to determine whether the risk of bleeding after transbronchial lung biopsy is increased in patients taking aspirin .  DESIGN Prospect i ve cohort study . PATIENTS AND INTERVENTIONS After excluding patients with other coagulation problems , 1,217 patients who had undergone transbronchial lung biopsy during a prospect i ve 1.5-year study period were included in this study . The use of aspirin was not discontinued before the procedure . Two hundred eighty-five patients ( 23 % ) had consumed aspirin within 24 h of the procedure , and most of them ( 82 % ) used aspirin on a daily basis . Transbronchial biopsies were performed , and the bleeding incidence was compared between the groups . RESULTS A total of 57 patients ( 4.7 % ) experienced procedure-related bleeding . Minor bleeding occurred in 5 of 285 patients ( 1.8 % ) taking aspirin and in 27 of 932 control patients ( 2.9 % ; not significant ) . Moderate bleeding was seen in 3 of 285 patients ( 1.1 % ) in the aspirin group and in 13 of 932 patients ( 1.4 % ) in the control group ( not significant ) . Major bleeding occurred in only 9 patients , 2 of 285 ( 0.9 % ) in the aspirin group and 7 of 932 ( 0.8 % ) in the control group ( not significant ) . All bleeding was controlled by endoscopic means , and there were no fatalities and no need for blood transfusions . CONCLUSIONS We conclude that the risk of severe bleeding after transbronchial lung biopsy is small ( ie , < 1 % ) and that the use of aspirin is not associated with any increased risk of bleeding BACKGROUND The optimal concentration of lignocaine to be used during flexible bronchoscopy ( FB ) remains unknown . This r and omized controlled trial compared the efficacy and safety of 1 % and 2 % lign 
    Output:
    