613 cases of splenic rupture without risk factors or previously diagnosed disease: a systematic review

Background Rupture of the spleen in the absence of trauma or previously diagnosed disease is largely ignored in the emergency literature and is often not documented as such in journals from other fields. We have conducted a systematic review of the literature to highlight the surprisingly frequent occurrence of this phenomenon and to document the diversity of diseases that can present in this fashion. Methods Systematic review of English and French language publications catalogued in Pubmed, Embase and CINAHL between 1950 and 2011. Results We found 613 cases of splenic rupture meeting the criteria above, 327 of which occurred as the presenting complaint of an underlying disease and 112 of which occurred following a medical procedure. Rupture appeared to occur spontaneously in histologically normal (but not necessarily normal size) spleens in 35 cases and after minor trauma in 23 cases. Medications were implicated in 47 cases, a splenic or adjacent anatomical abnormality in 31 cases and pregnancy or its complications in 38 cases. The most common associated diseases were infectious (n = 143), haematologic (n = 84) and non-haematologic neoplasms (n = 48). Amyloidosis (n = 24), internal trauma such as cough or vomiting (n = 17) and rheumatologic diseases (n = 10) are less frequently reported. Colonoscopy (n = 87) was the procedure reported most frequently as a cause of rupture. The anatomic abnormalities associated with rupture include splenic cysts (n = 6), infarction (n = 6) and hamartomata (n = 5). Medications associated with rupture include anticoagulants (n = 21), thrombolytics (n = 13) and recombinant G-CSF (n = 10). Other causes or associations reported very infrequently include other endoscopy, pulmonary, cardiac or abdominal surgery, hysterectomy, peliosis, empyema, remote pancreato-renal transplant, thrombosed splenic vein, hemangiomata, pancreatic pseudocysts, splenic artery aneurysm, cholesterol embolism, splenic granuloma, congenital diaphragmatic hernia, rib exostosis, pancreatitis, Gaucher's disease, Wilson's disease, pheochromocytoma, afibrinogenemia and ruptured ectopic pregnancy. Conclusions Emergency physicians should be attuned to the fact that rupture of the spleen can occur in the absence of major trauma or previously diagnosed splenic disease. The occurrence of such a rupture is likely to be the manifesting complaint of an underlying disease. Furthermore, colonoscopy should be more widely documented as a cause of splenic rupture

Vocal Cord Paralysis and Dysphagia after Aortic Arch Reconstruction and Norwood Procedure

OBJECTIVES: Determine the incidence of vocal cord paralysis and dysphagia after aortic arch reconstruction including Norwood procedure. SETTING: Tertiary Children’s Hospital STUDY DESIGN: Retrospective cohort. METHODS: Database/chart review of neonates requiring Norwood or arch surgery between January 2005 through December 2012. Demographics, postoperative vocal cord function, dysphagia, need for gastrostomy tube and/or tracheotomy, and long-term follow-up were reviewed. RESULTS: One hundred fifty-one consecutive subjects(96 Norwood, 55 aortic arch) were reviewed. Median age at repair was 9 days(IQR 7–13) for Norwood, 24 days(IQR 12–49) for arch reconstruction(p<0.001). Documentation of VC motion abnormality was found in 60/104(57.6%) subjects, and unavailable in 47:16 without documentation and 31 who expired prior to extubation. There were no significant differences in proportions of documented VC motion(p=0.337), dysphagia(p=0.987), and VC paralysis(p=0.706) between the arch and Norwood groups. Dysphagia was found in 73.5% of Norwood and 69.2% of arch subjects who had documented VC paralysis. Even without UVCP, dysphagia was present (56% Norwood,61% arch). Overall, 120/151(79.5%) required feeding evaluation and modified feeding regimen. Gastrostomy was required in 31% of Norwood and 23.6% of arch reconstruction overall. To date, mortality in this series is 55/151(36.4%) patients. Of those with VC paralysis, only 23(22%) had any otolaryngology follow-up after discharge from surgery. Over 75% with VC paralysis with follow-up after hospital discharge had persistent VC paralysis 11.5 months after diagnosis. CONCLUSION: There is high incidence of UVCP and dysphagia after Norwood and arch reconstruction. Dysphagia was highly prevalent in both groups even without UVCP. Preoperative discussion on vocal cord function and dysphagia should be considered

Towards a Tabletop Gaming Motivations Inventory (TGMI)

Tabletop gaming is currently experiencing a golden age. The size of the tabletop gaming industry and the number of people engaged with the hobby are at a peak, and are still increasing. However, what motivates people to engage with tabletop games is not well studied. This study aims to understand the motivations for tabletop game play; it does so by introducing a questionnaire, called the tabletop gaming motivation inventory (TGMI), to measure these motivations. The inventory is based on literature, in particular literature which deals with similar inventories used to investigate video gaming motivations. We carried out a survey with tabletop game players (N = 867). Our inventory is validated using factor analyses, which lead to a final questionnaire consisting of 11 factors based on 39 items. Moreover, we investigated how these motivations vary with respect to prior experience of players, their frequency of play and geographical locations

Interpreting the anomalous:finding meaning in out-of-body and near-death experiences

Much contemporary research on anomalous experiences has been focused on issues of confirming the authenticity of the phenomena, or to determine the underlying processes by which these phenomena may manifest themselves. This research has largely been nomothetic in nature relying mainly on laboratory experiments and/or questionnaire surveys. Traditionally, however, there has existed a third strand of exploration in this field of study–phenomenological research—which in recent times has been somewhat overlooked in this field of work. In an attempt to redress this shortcoming, the authors propose the use of Interpretative Phenomenological Analysis (IPA) to research anomalous experience. IPA possesses strong theoretical and philosophical underpinnings and a focus on describing and interpreting the process, intricacy and novelty of personal experience. The authors argue that IPA appears ideally suited as a method of qualitative investigation to address important fundamental research questions posed by the study of anomalous experiences