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Background and objective: Endosonography with intrathoracic nodal sampling is proposed as the single test with the highest granuloma detection rate in suspected sarcoidosis stage I/II. However, most studies have been performed in limited geographical regions. Studies suggest that oesophageal endosonographic nodal sampling has higher diagnostic yield than endobronchial endosonographic nodal sampling, but a head‐to‐head comparison of both routes has never been performed. Methods: Global (14 hospitals, nine countries, four continents) randomized clinical trial was conducted in consecutive patients with suspected sarcoidosis stage I/II presenting between May 2015 and August 2017. Using an endobronchial ultrasound (EBUS) scope, patients were randomized to EBUS or endoscopic ultrasound (EUS)‐B‐guided nodal sampling, and to 22‐ or 25‐G ProCore needle aspiration (2 × 2 factorial design). Granuloma detection rate was the primary study endpoint. Final diagnosis was based on cytology/pathology outcomes and clinical/radiological follow‐up at 6 months. Results: A total of 358 patients were randomized: 185 patients to EBUS‐transbronchial needle aspiration (EBUS‐TBNA) and 173 to EUS‐B‐fine‐needle aspiration (FNA). Final diagnosis was sarcoidosis in 306 patients (86%). Granuloma detection rate was 70% (130/185; 95% CI, 63–76) for EBUS‐TBNA and 68% (118/173; 95% CI, 61–75) for EUS‐B‐FNA (p = 0.67). Sensitivity for diagnosing sarcoidosis was 78% (129/165; 95% CI, 71–84) for EBUS‐TBNA and 82% (115/141; 95% CI, 74–87) for EUS‐B‐FNA (p = 0.46). There was no significant difference between the two needle types in granuloma detection rate or sensitivity. Conclusion: Granuloma detection rate of mediastinal/hilar nodes by endosonography in patients with suspected sarcoidosis stage I/II is high and similar for EBUS and EUS‐B. These findings imply that both diagnostic tests can be safely and universally used in suspected sarcoidosis patients. This global RCT in patients with suspected sarcoidosis stage I/II with an indication for endosonographic nodal sampling showed a similarly high granuloma detection rate and sensitivity for diagnosing sarcoidosis with endobronchial ultrasound versus endoscopic ultrasound‐B. The findings imply that both diagnostic tests (endobronchial/oesophageal) can be used safely and universally in suspected sarcoidosis patients. [ABSTRACT FROM AUTHOR]

Background: Bronchoscopic transbronchial cryobiopsy is increasingly used for the histological assessment of diffuse parenchymal lung disease. Diagnostic performance may be improved by more accurate targeting of biopsy to radiologic abnormalities, and complication rates may be reduced by avoiding biopsy of pleura or larger vessels. Objectives: To report the preliminary experience of using CT-fluoroscopic guidance for accurate targeting of bronchoscopic transbronchial cryobiopsy. Methods: Bronchoscopic cryobiopsy was performed in a hybrid CT theatre. 3D CT images were acquired following positioning of the cryoprobe in a distal airway segment. Where cryoprobe position was observed to be too close to the chest wall/diaphragm pleura, or not within the region of interest within the lung parenchyma, re-positioning of probe was undertaken and repeat 3D images were acquired to confirm positioning prior to cryobiopsy. Results: CT-fluoroscopic transbronchial cryobiopsy was successfully performed in 4 patients: 3 patients with interstitial lung infiltrates, and one with an enlarging left upper lobe mass. Images were reviewed following each acquisition to accurately assess the probe position within the lung parenchyma, and relative to other thoracic structures. Intra-procedural imaging was of sufficient quality to allow the accurate positioning of the cryoprobe tip with respect to both the parenchymal region of interest and pleural surfaces. No complications were experienced, and all procedures yielded diagnostic specimens. Conclusions: Our preliminary experience confirms the feasibility of performing transbronchial cryobiopsy under CT-fluoroscopic guidance. Accurate targeting of transbronchial cryobiopsy may be achieved using CT-fluoroscopic guidance. Positioning of the probe tip, both with respect to parenchymal region of interest and to pleural surfaces, can be established with high accuracy. [ABSTRACT FROM AUTHOR]

Changes in the railroad industry in North America, and around the world, have forced shippers to reconsider how they move rail shipments, particularly in and around large industrial facilities. Current costing and operational strategies of many rail carriers are encouraging shippers to operate private, inhouse rail operations. Limitations of this industrial practice include the lack of operational management skills and the availability of required railroad locomotive equipment. This exploratory research attempts to answer several basic questions, including 1) to what extent do private rail operations exist 2) what are the basic reasons that private rail operations exist, and 3) what are the locomotive powering options for private rail operations. Findings indicate that there are a large number of private rail operations in existence in the United States and Canada, often using contract operators, and that there are significant issues in managing these operations and in obtaining locomotives for the practice. [ABSTRACT FROM AUTHOR]

The article discusses the development of an interactive teaching methodology to improve the basic transportation course. Active learning teaches students both how to access information and to examine issues critically in ways that more common methodologies do not. In active learning, students are asked to actively dig for knowledge while teachers normally coach from the sidelines. In general, students are given questions or assignments to be researched out of class. This research is to be presented in the class at a later time, with questioning and critique from both the instructor and, eventually, other students. Interactive teaching provides a situation in which the learner and the teacher can be more flexible in the process. The term "flexible" education has begun to be used where individuals or a class can change processes to research immediate questions or subjects. It has been determined that information systems and flexible teaching structures allow this type of learning to take place. Another component of the educational process, which is gaining widespread support, is collaborative learning through group participation.

Background: Endobronchial ultrasound (EBUS) transbronchial needle aspiration (TBNA) is an important diagnostic procedure for the interrogation of mediastinal lymph nodes. There is limited data describing the accuracy & safety of this technique for the diagnosis of tuberculous mediastinal lymphadenitis., Methods: A multi-centre retrospective study of all EBUS-guided TBNA procedures that referred samples for mycobacteriology was performed. Results were correlated with post-procedural diagnoses after a period of surveillance and cross-checked against relevant statewide tuberculosis (TB) registries, and sensitivity and specificity was calculated. In addition, nucleic acid amplification techniques (NAAT) were assessed, and sensitivity and specificity calculated using positive mycobacterial culture as the reference gold standard., Results: One hundred and fifty-nine patients underwent EBUS-TBNA and had tissue referred for mycobacterial culture, of which 158 were included in the final analysis. Thirty-nine were ultimately diagnosed with TB (25%). Sensitivity of EBUS-TBNA for microbiologically confirmed tuberculous mediastinal lymphadenitis was 62% (24/39 cases). Specificity was 100%. Negative predictive value (NPV) and diagnostic accuracy for microbiologic diagnosis was 89% [95% confidence intervals (CI), 82-93%] and 91% (95% CI, 84-94%) respectively. For a composite clinicopathologic diagnosis of TB NPV and accuracy were 98% (95% CI, 93-99%) and 98% (95% CI, 95-99%) respectively. Sensitivity for NAAT was 38% (95% CI, 18-65%)., Conclusions: EBUS-TBNA is a safe and well tolerated procedure in the assessment of patients with suspected isolated mediastinal lymphadenitis and demonstrates good sensitivity for a microbiologic diagnosis of isolated mediastinal lymphadenitis. When culture and histological results are combined with high clinical suspicion, EBUS-TBNA demonstrates excellent diagnostic accuracy and NPV for the diagnosis of mediastinal TB lymphadenitis. We suggest EBUS-TBNA should be considered the procedure of choice for patients in whom TB is suspected.