Transbronchial needle aspiration (TBNA) offers the unique opportunity to pathologically stage patients with lung cancer at the time of diagnostic bronchoscopy. The purpose of this study was to compare the staging sensitivities of the Wang 22-gauge and 19-gauge needles. We studied 64 patients with bronchogenic carcinoma and mediastinal adenopathy. Before bronchoscopy each patient underwent chest CT. Three to four aspirates were obtained with each needle from endotracheal sites adjacent to paratracheal lymphadenopathy. In 47 patients malignant mediastinal adenopathy was confirmed by the 19-gauge needle. A total of 29 patients had malignant 22-gauge needle aspirates. Of the 64 patients, 9 had benign, reactive mediastinal lymph nodes. There were 20 patients in whom only the 19-gauge needle demonstrated malignancy and 2 patients with malignant 22-gauge needle aspirates as the sole identifier of paratracheal malignancy. As a staging tool, the 19-gauge needle was significantly more sensitive than the 22-gauge needle, 85.5 versus 52.7% (p = 0.0001). Overall, in 49 of 55 patients (89.1%) with malignant mediastinal lymphadenopathy paratracheal tumor was confirmed by TBNA. The 19-gauge TBNA staging of the mediastinum is an effective, safe, and cost-saving alternative to surgical mediastinal exploration that can be performed during initial diagnostic bronchoscopy.
Published data show that sensitivity and specificity of magnetic resonance imaging (MRI) for detecting meniscal pathology can approach 90% when compared to arthroscopic findings. The authors audited the MRI service in our unit, to judge our performance against this standard. The authors retrospectively analysed a single surgeon series of 240 scopes for all indications (meniscal pathology, osteochondral defects, ligament reconstruction). The arthroscopic reports included an outline diagram of the meniscus upon which the surgeon recorded operative findings. 112 of these patients had received a recent MRI. The authors looked at whether the MRI report showed a tear and compared this with findings detailed in the arthroscopic report. 66 patients had a positive scan. 64 of these were found to have a tear at surgery. 37 scans were reported as “no tear”, of which four were found to have a tear at surgery. Nine scans were not easy to classify as they were descriptive, for example, “signal change, possible tear” or “tear cannot be ruled out”. These tended to correspond with equivocal arthroscopic findings of “degeneration” or “fibrillation”, and were classified on balance of their subjective description. Of the nine equivocal scans, five were more positive for tear. Six out of nine equivocal scans had degenerate menisci at arthroscopy. In our series of 112 knees, MRI was 91% sensitive, 90% specific and 90% accurate, which is comparable to published data. When a definite diagnosis of “tear” or “no tear” was made at scan, there were two false positives and four false negatives. False positives may be unnecessarily exposed to the risks of surgery. Patients with negative scans had a mean delay to surgery of 33 weeks compared to 18 weeks for patients with positive scans. False negatives may therefore wait longer for surgery. Two of the false negative scans clearly showed meniscal tears which were missed by the reporting radiographer. In our series the scan itself was more accurate than the reporting. It is important to have an experienced musculoskeletal radiologist to minimise the number of missed tears. It is also important that surgeons check the scan, as well as the report, when making a decision to operate based on MRI findings.
regions to question the presumption that glocalisation necessarily generates greater sub-national variegation or whether, insofar as meaningful divergences exist, they are better explained as contingencies, particularly of the political agency of key actors such as police chiefs, elected mayors and, in England and Wales, the recently established Police and Crime Commissioners.The chapter contrasts this presumption with two countervailing arguments. Firstly, that irrespective of any governing arrangements devolving policy-making for metropolitan policing to sub-national authorities, policing agendas are converging, as authorities copy one another's responses to commonly perceived problems, such as organised crime, terrorism, migration and social cohesion.Secondly, that nation states retain considerable influence over the trajectories of local governance within their sovereign territory and that insofar as any divergences can be identified across Europe these are better understood in terms of inter-national rather than intra-national comparisons.Addressing these countervailing arguments necessitates some engagement with the meaning of nation state power in the United Kingdom and its role in shaping policing. To this end, certain particularities of the constitutional-legal settlement in the United Kingdom need to be acknowledged, including the ongoing process of devolving political authority to the constituent nations of the Union and, within England and Wales, to sub-national actors such as the directly elected mayors and Police and Crime Commissioners. In this context, pressures for greater selfdetermination within the four constituent nations of the 'United Kingdom' render abstract concepts of the national security state problematic. Following the devolution of powers to these constituent nations, commencing in the late-1990s with the establishment of the Scottish Parliament, the Welsh Assembly and the Northern Ireland Assembly, the United Kingdom is better conceptualised as a fragmenting, if not a Federalising, state rather than a coherent unitary political actor. Grounds for thinking about the fragmentation of the UK include the composition of the Brexit vote, which was primarily concentrated in provincial England and Wales, whereas voters in Scotland and Northern Ireland voted overwhelmingly to remain within the European Union. In turn this provoked Nicola Sturgeon, the First Minister of the Scottish Parliament and leader of the Scottish National Party (SNP), to argue the case for another referendum on Scottish independence from the United Kingdom, claiming this was now back on the agenda less than two years since the last vote, which the Scottish independence movement narrowly lost.Further peculiarities in the constitution of the United Kingdom complicate simple references to nation-state power, especially in relationship to policing. Scotland has always had its own legal
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