The question of what phonetic quality defines rhotics as a natural class has been debated. Clinical reports indicate that in many languages, rhotics are developmentally late to emerge and subject to errors that are resistant to remediation, suggesting that rhotics may be distinguished by “complexity in articulation.” In American English, the complexity of articulation may derive from its doubly articulated nature; simultaneous palatal and pharyngeal tongue constrictions are consistent features across variants. For other languages with a rhotic liquid, however, it is unclear if this pharyngeal constriction gesture is also an articulatory feature. Using ultrasound, this study compares rhotics from different language families to describe the presence or absence of pharyngeal constriction. Results indicate that pharyngeal constriction is observed across languages in rhotic allophones that have been described as difficult for children to acquire.
INTRODUCTION: Malakoplakia is a rare inflammatory disorder that occurs in the clinical setting of persistent infections, immunosuppression and tumors. The most common sites of involvement are the urinary, gastrointestinal and respiratory tracts, skin, brain and lymph nodes where they can mimic malignancies. CASE DESCRIPTION/METHODS: A 60-year-old woman with myasthenia gravis and stage IV metastatic thymoma (status-post resection and chemo-radiation) presented with persistent weight loss, bloating, nausea, tenesmus and hematochezia. Her recent history included treatment-resistant Giardia lambia infection for one year as well as recently diagnosed Norovirus and Enteroaggregative Escherichia coli, diagnosed by stool pathogen PCR testing. On colonoscopy, the rectum contained a 7 cm region of polypoid, non-circumferential, non-obstructing nodules (Figure 1) which were highly suspicious for tumor. Microscopically, biopsies revealed rectal lamina propria infiltration by epithelioid cells with small central nuclei, eosinophilic cytoplasm (Figure 2) and lamellated cytoplasmic calcifications (Figure 3). The cells expressed cytoplasmic CD68 (Figure 2) and Von Kossa stain highlighted the calcifications, consistent with Michaelis-Gutmann bodies (Figure 3). Immunostain for pancytokeratin and Ziehl-Neelsen and Gomori's methenamine silver stains were negative. The final diagnosis was malakoplakia. A re-biopsy of the lesion showed positivity for Cytomegalovirus (CMV) immunostain and high levels of CMV viremia (1010IU/mL), for which she was treated with Gancyclovir. DISCUSSION: Malakoplakia is a rare gastrointestinal disorder without specific symptoms, endoscopic features or gross findings and tends to masquerade as a tumor. As illustrated herein, it is often an unexpected diagnosis that depends on pathological recognition of characteristic microscopic features. The correct diagnosis is critical to avoid inappropriate radical treatment. Various micro-organisms have been implicated in its development including bacteria, most commonly E. coli, viruses, fungi and even protozoa such as Taeniaspecies and it is characterized by defective bactericidal activity of the macrophages. Pathologists should be aware that malakoplakia can coexist with malignancy and tuberculosis, therefore, thorough sampling of mass lesions and appropriate adjunctive stains are advisable. Risk factors in our case included an immunocompromised state, multiple concurrent infections, and advanced malignancy, although no malignancy was identified in the biopsies.
BACKGROUND: The appropriate management of a fine needle aspiration (FNA) supply cart and equipment set up is essential to ensure the smooth and optimal operation of a busy FNA clinic. We applied Lean strategies such as value stream mapping (VSM), the 5S method (Sort, Set in order, Shine, Standardize, Sustain), and Kanban to remove waste and improve patient flow in an FNA clinic. METHODS: The workflow analysis suggested that existent problems such as suboptimal inventory management and unavailability of standard operating procedures (SOPs) caused a 10% to 85% increase in total procedure time. To improve inventory management, we created a 2-bin Kanban system. We used the "Scan to Web" app and a Google Drive form to create a cost-effective electronic inventory management system. We distributed the essential SOPs in the format of video clips using our YouTube channel and leveraged barcode technology to access the links. RESULTS: Upon completion of our process improvement project, we succeeded to eliminate the stock-out events and maintain a process cycle efficiency of 87%. The 5S audit checklist result increased from 6% to 100% implementation, which is consistent with focused improvement. The developed inventory system enabled us to track the supply usage, forecast demands, and improve the accuracy of orders. CONCLUSIONS: Lean methods such as VSM, 5S, and Kanban combined with open source technologies can be implemented to ensure material availability, track inventory, and provide immediate access to SOPs on demand. The developed system also led to increased efficiency and improved flow, as well as responsiveness to changes in
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