BACKGROUND: Piperine is a spice principle, and its protective role against oxidative damage and lipid peroxidation has been reported. In this study, we aimed to investigate the effects of piperine in the prevention of ischemia-reperfusion injury to the small intestine.
METHODS: Rats were allocated to three groups of 8 rats each. Rats in the sham group underwent laparotomy and observation only. Animals in the control and study groups underwent 45 minutes ischemia followed by 60 minutes reperfusion. In the study group, 10 mg/kg piperine was administered intraperitoneally just before the reperfusion procedure. Blood samples were obtained for measurement of lactate levels, and resection of the terminal ileum was performed to evaluate the histopathologic specimens and tissue malondialdehyde, superoxide dismutase, and glutathione activities. All results were expressed as mean±SD. Comparisons between groups were made by using the one way analysis of variance (ANOVA).
RESULTS: Lactate and malondialdehyde levels were significantly higher in the control group than the study and sham groups (p<0.001). In the study group, superoxide dismutase, and glutathione activities were significantly higher than in the control group (p<0.001). The sham group had the highest activities. Histopathologic examination showed disruption of villous pattern and lamina propria in the control group.
CONCLUSION: Intraperitoneal administration of 10 mg/kg piperine just before the reperfusion may reduce ischemia-reperfusion injury to the small intestine.

BACKGROUND: It was aimed in this study to clarify the wounding potential of free-falling bullets fired at 90° or close to right angles.
MEHTOHDS: In this study, 9x19 mm and 7.65x17 mm bullets, which are commonly used among civilians, were used. The muzzle velocities of these ammunitions were measured. According to the muzzle velocity data, the free-falling motion and strike velocity of the 9x19 mm and 7.65x17 mm bullets were simulated using the EBV4® External Ballistics Software at angles of 65°-90° with firings at 5° intervals. The simulation results were compared with critical velocity of tissues. In addition, the judicial records and press reports on this type of wound were examined and evaluated in light of the literature.
RESULTS: The strike velocity and kinetic energy of free-falling bullets, which were fired into the air at 5° intervals between 65°-90°, were measured. The average strike velocity and kinetic energy of 9x19 mm bullets were 92.25 m/sec and 34.05 J and of 7.65x17 mm bullets were 79.66 m/sec and 14.91 J, respectively. As a result of the archives examination, 65 such wounds were detected between 2000 and 2012, and 27 of them resulted in death.
DISCUSSION: According to these results, the strike velocity of free-falling 9x19 mm and 7.65x17 mm bullets, which were fired into the air, exceeds the threshold and critical velocity limits of skin and flat bones, and the kinetic energy of the bullets is able to cause significant wounding. Even though the symptoms and features of these types of wounds may not be similar to those of ordinary gunshot wounds in the first medical examination, the first responders should be aware of the possibility of gunshot wounds, and they should take into account the criminal investigation phase during the treatment process; the necessary precautions should be taken in order to preserve the evidence.

BACKGROUND: We aimed to compare pain relief and safety of two doses of morphine in adult emergency department (ED) patients with acute limb trauma pain.
METHODS: A total of 200 adult ED patients over 20 years of age requiring opioid analgesia were randomly allocated to two groups. Following a first dose of intravenous morphine sulfate at 0.10 mg/kg, a randomized double-blind placebo-controlled trial of intravenous morphine sulfate at 0.05 mg/kg versus the same amount of placebo was performed. Measurement of visual analogue scale pain intensity and assessment of adverse effects were performed at baseline (before morphine at 0.10 mg/kg), 30 minutes from baseline (just before study drug administration), and at 60 minutes from baseline (30 minutes after study drug).
RESULTS: No significant difference was found between groups at 30 minutes from baseline. There was significant reduction in final pain after 1 hour in the 0.15 mg/kg compared to 0.10 mg/kg group (p<0.05). In addition, there was a significant improvement in the mean score of pain in the same group (p<0.05). The percent of pain reduction in the intervention and control group relative to the basic measures was 52.70% and 35.82%, respectively. Adverse effects were present in both groups; however, there was no statistically significant difference between groups.
CONCLUSION: Using two doses of morphine instead of one is a safe and effective method for pain reduction in isolated limb trauma. We recommend performing a second injection of 0.05 mg/kg morphine 30 minutes after the initial standard dose of 0.10 mg/kg to decrease pain in these patients.

BACKGROUND: Routine surgical exploration after penetrating upper extremity trauma (PUET) to exclude arterial injury leads to a large number of negative explorations and iatrogenic injuries. Selective non-operative management (SNOM) is gaining in favor for patients with PUET. The present study was undertaken to assess the validity of SNOM in PUET and to present a practical management algorithm.
METHODS: All consecutive patients presenting to a tertiary referral center following PUET were included in this prospective observational cohort study. Patients were managed along Advanced Trauma Life Support (ATLS©) guidelines, and based on clinical manifestations, either underwent emergency surgery or were treated conservatively with or without additional diagnostic investigations. Computed tomography angiography (CTA) was indicated by a preset protocol based on the physical examination.
RESULTS: During the four-month study period, 161 patients with PUET were admitted. Sixteen (9.9%) patients underwent emergency surgery, revealing 14 vascular injuries. Another 8 (5.0%) patients underwent vascular exploration following CTA. The remaining patients (n=137) were managed non-operatively for vascular matters. Eighteen (11.2%) patients required semi-elective surgical intervention for fractures or nerve injuries. During the follow- up, no missed vascular injuries were detected.
CONCLUSION: Neither routine exploration nor routine CTA is indicated after PUET. Stable patients should undergo additional investigation based on clinical findings only. SNOM is a feasible and safe strategy after PUET.

BACKGROUND: Free flap surgery in the pediatric population has gained widespread acceptance regarding its technical utility and reliability. Initial concerns as to the feasibility and reliability of the procedure in children were resolved over time.
METHODS: Thirty children (15 boys, 15 girls) were treated in Sisli Etfal Training and Research Hospital, Plastic and Reconstructive Surgery Clinic. Their mean age was 10.8 years. Defects were located on the lower extremity (n=22), head and neck (n=5) and upper extremity (n=3). The etiologies of the defects included vehicle accident, sequelae of burn, traumatic contractures, crush injury, epulis in the maxilla, and gunshot wound.
RESULTS: The free flaps performed in our series were latissimus dorsi muscle flap, combined latissimus dorsi and serratus muscle flaps, serratus anterior muscle flap, cross latissimus dorsi muscle flap, scapular osteomyocutaneous flap, parascapular fasciocutaneous flap, fibular osteocutaneous flap, anterolateral thigh flap, medial circumflex femoral artery perforator flap, and crista iliaca osteocutaneous flap.
CONCLUSION: The advantages of free flaps in children, which include better adaptation of the flap growth and better learning capacity of the children, provide the surgeon with more satisfactory functional and aesthetic results.

BACKGROUND: Scorpion sting resulting in envenomation is a life-threatening emergency and causes serious health problems in tropical and subtropical regions. The aim of this study was to present the epidemiologic and clinical features of 123 cases presenting with symptoms of scorpion poisoning, a cause of preventable mortality and morbidity.
METHODS: This study retrospectively analyzed the epidemiologic and demographic features of a total of 123 patients who presented to Diyarbakýr State Hospital Emergency Service with scorpion sting between January 2008 and December 2009.
RESULTS: Among 123 patients who presented to Diyarbakýr State Hospital Emergency Service with scorpion sting between January 2008 and January 2009, 62.6% (n=77) were female and 37.4% (n=46) were male. The mean age of the patients was 33.5±17.3 years (2-80), and 27 (22%) patients were younger than 18 years. The place of residence was rural region in 98 (79.7%) patients and the city center in 25 (20.3%). The majority of victims were stung by scorpions while they were at active work (42.3%) or asleep (19.5%) in bed. Eleven (8.95%) patients were stung by a scorpion while putting on their own clothes.
CONCLUSION: This simple descriptive study will hopefully help healthcare providers take measures to prevent scorpion stings, which should take into consideration local epidemiological features.

BACKGROUND: Of overall traffic accidents in 2011 in Turkey, 7.58% (n=21,107) were motorcycle accidents. Motorcycle accidents and their impact on healthcare costs are investigated in our study.
METHODS: Motorcycle accidents that occurred with/without a collision between 1 July 2010 and 30 June 2011 were studied prospectively through the inspection of patients visiting the Emergency Service. The healthcare costs relevant to each person injured in a motorcycle accident were investigated via forms. Data were analyzed using frequencies, Kolmogorov-Smirnov, Mann-Whitney U, and chi-square tests on the SPSS v16.0 program.
RESULTS: Ninety-one people involved in accidents, with a mean age of 28.47 years, were studied. The average healthcare expenditure for the 91 patients studied between reception and discharge was US$253.02 (median, US$55.90; range, US$11.52 - 7137.19). According to our study, there was no definitive correlation between the healthcare costs and the time of the accident, motorcycle type, nature of the road surface, protective equipment, weather, or daylight.
CONCLUSION: According to the current study, the risk of an accident increases with young adults. Concordantly, healthcare costs increase. Thus, it is important that the legal rules with respect to the age and education necessary for receiving a license to operate a motorcycle should be redefined, and if necessary, regulated.

BACKGROUND: In the present study, it was aimed to assess the demographics, clinical features, and treatment costs of cases referred to our hospital after the Syrian civil war.
METHODS: Of 1355 Syrian civil war victims referred to our hospital during the 14-month period between June 2011 and July 2012, 482 cases presenting to the emergency department were included in the study. The electronic data of these patients were retrospectively analyzed.
RESULTS: Of 482 cases, 428 were male (88.8%) and 54 (11.2%) were female, with a mean age of 30.4±14.9 years (1-79 years). The mean age was 30.8±17.2 years (1-79 years) in males and 27.3±16.9 years (1.5-66 years) in females. There was a significant difference in terms of sex (p=0.007). It was found that the majority of the cases (41.1%) were aged 21-30 years. The highest number of admissions was recorded in June 2011 (159 patients, 33%), whereas the lowest number of admissions was in September 2011 (5 patients, 1%). All cases were transported to our hospital from nearby district hospitals and camps by emergency medical services. The most frequent presenting complaint was gunshot injury (338 cases, 70.1%). The most common diagnosis was extremity injury (153 cases, 31.7%). The number of forensic cases was found as 364 (75.5%). Of all the cases, 136 cases (28.2%) were managed in the emergency service, and the remaining cases were admitted to other services. They were most frequently admitted to the orthopedics ward (146 cases, 30.3%). The mean length of the hospital stay was 9.9 days (1-141).Overall, 456 cases (94.6%) were discharged, 22 cases died, and 4 cases were transferred to other facilities. The mean cost per case was estimated as 3723Turkish lira (TL) (15-69556). A positive correlation was found between cost and length of hospital stay.
CONCLUSION: Among all Syrian cases, the majorities of young males and gunshot injuries was striking. Most of the cases were discharged after appropriate management. Preventive measures can avoid these negative outcomes and so avoidable costs will not occur, and this can preclude the damage to the budgets of the countries.

BACKGROUND: We aimed to present the primary experience of one surgeon with a new surgical technique performed on the first 13 cases and to evaluate outcomes following an extraoral endoscopic approach to subcondylar fractures.
METHODS: Fifteen subcondylar fractures in 13 patients, who were treated at Ondokuz Mayis University Hospital between January 2010 and June 2011, were included in this study. Patients were operated on using either endoscopic or open approach.
RESULTS: Rigid plate fixation was completed endoscopically using extraoral approach in nine fractures, while six fractures were plated by conversion to a full-open approach. In all six fractures that could not be fixed endoscopically, the proximal fragments were medially displaced, whereas seven of nine fractures that were successfully fixed endoscopically were laterally displaced.
CONCLUSION: An extraoral endoscopic approach for subcondylar fractures is feasible and can be carried out with decreased morbidity. This approach is recommended for those with limited experience in endoscopy to treat low laterally displaced subcondylar fractures as their initial cases.

BACKGROUND: Spinal cord injuries result in critical pecuniary and/or non-pecuniary losses due to the developing neurological problems. The objective of this study was to evaluate spinal injuries in terms of clinical severity and prognosis. Spinal injuries lead to serious clinical results due to the high rates of morbidity and mortality; however, there is a lack of reliable information on spinal injuries in our country.
METHODS: Following the approval of the Faculty Ethics Committee, this retrospective study was conducted on 91 patients aged ≥18 (59 male, 32 female) with spinal trauma who were admitted to the Emergency Department of Ondokuz Mayis University over three years. The patients were assessed in terms of demographics, clinical severity, developing complications, and mortality.
RESULTS: Forty-three patients had complete injuries, while 48 had incomplete injuries. Forty-six patients suffered spinal injuries due to fall from height, 35 patients due to traffic accidents, and 10 patients due to other reasons. Several complications were observed in 52 patients, while no complication occurred in 39 patients. We determined that 19 of 92 patients involved in this study died, while 72 were discharged from the hospital.
CONCLUSION: Spinal cord injuries generally result in unfavorable clinical results. Therefore, an appropriate approach (early diagnosis and true treatment) in emergency services has great significance.

BACKGROUND: The aim of this study was to evaluate the clinical and epidemiological features of 132 patients with orbital wall fracture who were treated at Þiþli Etfal Teaching and Research Hospital, Istanbul, between 2005-2012.
METHODS: The medical records of the patients with a diagnosis of orbital fracture were reviewed and analyzed. The patients were evaluated by age, gender, etiology, symptoms, examination findings, fracture location, associated injuries, treatment, and complications.
RESULTS: The mean follow-up time was 9 (6-16) months. The male-to-female ratio was 5.3-1. The average age was 32 (6-82) years. The leading causes of orbital fractures were traffic accidents (36%) followed by assaults (32%). The most frequently affected orbital wall was the medial wall (33%). The main symptom was throbbing pain in the traumatized area (100%), and the main examination finding was periorbital edema and ecchymosis (100%). The most frequent associated injury was cerebral trauma (14%). Sixty-seven patients (50.1%) were managed with medical treatment, and 65 patients (49.9%) underwent surgical treatment. The most common complication in the late period was dermatomal sensory loss (11%).
CONCLUSION: This study makes clear that the frequency of orbital injuries may be decreased by preventing traffic accidents, by taking precautions in the event they occur, and by promulgating social and educational work against violence.

BACKGROUND: We evaluated the functional status and postoperative complications of bipolar hemiarthroplasty patients with femoral neck fractures, which we operated using anterior and posterior approaches.
MEHTOHDS: Between November 2007 and February 2011, 224 patients were evaluated according to their surgical exposure type in two groups. The first group, which was approached anteriorly to the joint capsule, included 92 patients, and the second group, approached posteriorly, included 132 patients. The mean follow-up period for group 1 was 16.4 months and for group 2 was 18.9 months.
RESULTS: Harris hip score of group 1 was 81.7 and of group 2 was 79.2. In group 1, 19 patients had very good, 52 patients good, 15 patients moderate, and 6 patients insufficient results. In group 2, 29 patients had very good, 74 patients good, 21 patients moderate, and 8 patients insufficient results. Although we had higher hip dislocation and infection rates in group 2, there were no statistical differences between the two groups.
DISCUSSION: Surgical exposure type does not affect functional outcome in bipolar hip arthroplasty patients. Although statistically insignificant, we had higher hip dislocation and infection rates using the posterior approach in the selected femoral neck fracture patients. An anterior approach to the joint capsule appears to be more reliable.

BACKGROUND: In patients with penetrating abdominal traumas (PATs), selective non-operative management (SNOM) has been widely accepted. This study was designed to investigate the practice trends among Turkish surgeons regarding SNOM.
MEHTOHDS: The study was conducted as an online survey. Participants’ demographic characteristics and their management trends and opinions regarding patients with PATs and SNOM were studied. Data were recorded using MS Excel® and analyzed.
RESULTS: A total of 180 surgeons participated in the survey. SNOM approach rate in patients with stab injuries (SI) was 64%, whereas in patients with gunshot injuries (GSI), this rate was 52%. However, more than 90% of the surgeons declared that additional diagnostic studies were required before selecting SNOM approach in both SI and GSI. In addition, most of the surgeons who did not use SNOM in practice reported that they did not want to risk the patients’ lives or their careers.
DISCUSSION: Although our surgeons have constructive opinions and tendencies regarding contemporary approaches in the management of PATs, it is seen that nearly half of them prefer not to perform SNOM in practice for various reasons. We believe that approval of trauma and emergency surgery disciplines as subspecialties and funding- centralized trauma centers might correct this deficiency.

Dabigatran is a newer oral anticoagulant, indicated for chronic atrial fibrillation anticoagulation. Experience with an emergent laparotomy in a patient on dabigatran is presented. Difficulties of this medication and strategies to deal with the coagulopathy from this direct thrombin inhibitor are described.

A 66-year-old male was brought to our hospital following a car accident. He had subarachnoid hemorrhage, multiple rib fractures, and left hemopneumothorax. He was referred to the Cardiology Department for elevated troponin levels (42 ng/ml, reference 0-1 ng/ml). The electrocardiogram was free of ischemia, whereas the transthoracic echocardiography revealed dilated right heart chambers, enlarged tricuspid annulus and coaptation failure of the tricuspid valvular leaflets. There was rupture on the subvalvular apparatus of the anterior leaflet of the tricuspid valve with accompanying prolapse, causing severe tricuspid valvular regurgitation. The patient did not present right ventricular failure signs and symptoms; he was referred to surgery after the resolution of associated thoracic and cranial injuries.

Vasospasm that develops in association with ergotamine use is a rarely seen but well-understood complication. A case is presented here of multiple fractures in which arteriospasm affecting all the arteries of the lower limb on the same side occurred 10 days post-trauma. In this case, the arteriospasm resulting from ergotamine addiction and high doses of ergotamine, which may be confused with post-traumatic angiospasm, was treated with a marcaine infusion by epidural catheter and heparin, iliomedin and nitronal infusion intravenously. This clinical condition should be borne in mind for all trauma cases determined to have arterial vasospasm, and the use of ergotamine must be queried when taking the anamnesis from the patient.

Isolated hepatic duct confluence injury due to trauma is unusual. Two cases of isolated bile duct injury are presented, which were diagnosed and managed successfully at our institution.

A rare case of pediatric brachial plexus laceration is presented. A five-year-old boy who sustained a sharp laceration on his right axillary region was immediately operated. The axillary artery, radial, ulnar and musculocutaneous nerve branches of the brachial plexus, and the lateral root of the median nerve were totally lacerated. The medial root of the median nerve was partially transected. All of the lacerated brachial plexus elements and axillary artery were immediately repaired. Significant functional recovery was determined even six months after the repair. Motor and sensory functions of the affected extremity were almost totally restored at the postoperative 21st month, except for the ulnar nerve motor functions. There was no cold intolerance or trophic change at the injured extremity. Primary repair of a brachial plexus laceration injury in the pediatric population can be expected to produce successful functional recovery results, even in a relatively short period after the repair.

The presence of appendix vermiformis in an inguinal hernia sac is called Amyand’s hernia. The disease is named after Claudius Amyand, who performed the first documented and successful appendectomy during a hernioplasty in 1975. Finding an appendix within an inguinal hernia is reported at a rate of 0.51%-1% in the adult population, whereas there is no reported frequency of Amyand’s hernia in children due to its rare occurrence. Here, we report two cases of Amyand’s hernia. The first is a newborn, diagnosed with strangulated Amyand’s hernia by preoperative ultrasound examination of the groin. In this case, the appendix had compromised blood supply, so we performed appendectomy during the hernioplasty. The second patient was diagnosed with Amyand’s hernia during elective hernioplasty. In this case, the appendix had no evidence of circulatory or inflammatory disorders, so we performed simple hernioplasty and left the appendix in the abdominal cavity. In Amyand’s hernia, there are no standards in approaching the appendix. Appendectomy is not a necessity unless there are circulatory or inflammatory injuries.