BACKGROUND: The present objective was to evaluate effects of acetaminophen and mannitol on renal function and histopathology in crush injuries.
METHODS: Thirty-six rats weighing 370–400 g each were used. No surgery was performed on the first (control) group. The gastrocnemius muscle regions of each rat in the remaining 5 groups were compressed for 2 or 24 hours. In the 4th group, 100 mg/ kg acetaminophen was intraperitoneally administered. In the 5th group, 1 g/kg mannitol was administered. In the 6th group, 100 mg/kg acetaminophen and 1 g/kg mannitol were administered.
RESULTS: No statistically significant differences were observed among the treatment groups in terms of sodium, potassium, alanine aminotransferase (ALT), and average creatinine clearance values. Hydropic degeneration, tubular necrosis, presence of immunoperoxidase and myoglobin, tubulus epithelial cell degeneration, and presence of PAS-dyed material in tubular lumen was more prominently decreased in the acetaminophen group than the mannitol group. Improvement was observed in the group that was administered both drugs, compared to the mannitol-only group, though findings were still worse than those of the group administered acetaminophen only.
CONCLUSION: In crush injuries, acetaminophen improves histopathological renal damage better than mannitol. When used in conjunction with mannitol, the toxic effect of acetaminophen on the liver is decreased.

BACKGROUND: The present objective was to identify effects of early melatonin application on healing of anastomotic wound and inflammation in an experimental sepsis model.
METHODS: A total of 60 Wistar albino rats were divided into 2 groups. Cecal ligation puncture (CLP) and colonic resection anastomosis were performed on both the control group and the melatonin treatment group. Both groups were divided into 3 subgroups consisting of 10 rats each. One subgroup from each group underwent re-laparotomy at the 16th hour, the next on the 3rd day, and the final subgroup on the 7th day. Presently evaluated were effects of melatonin treatment of early sepsis on interleukin-6 (IL-6), interleukin-10 (IL-10), interferon gamma (INF-γ), and C-reactive protein (CRP) levels, as well as burst pressures (BPs), collagen and hydroxyproline (OHP) content of the anastomotic segments, histopathologic healing, immunohistochemical expressions, CD34, and transforming growth factor beta (TGF-β).
RESULTS: IL-6 and INF-γ levels of the treatment group showed a significant decrease at the 16th hour and an increase on the 3rd and 7th postoperative days. IL-10 levels were significantly higher at the 16th hour and significantly lower on the 3rd and 7th postoperative days in the control group (p<0.001 for each). The treatment group also showed significantly higher capillary permeability, fibroblast proliferation, and collagen deposits (p<0.001 for each). CD34 expression was significantly increased in the treatment group on the 7th postoperative day (p=0.005).
CONCLUSION: Application of melatonin in early sepsis significantly improved colonic anastomotic healing in a rat model.

BACKGROUND: The present objective was to investigate endogen erythropoietin (EPO) level and relationship to oxidative stress within the first 24 hours of blunt chest trauma-induced pulmo-nary contusion (PCn) in a rat model.
METHODS: Thirty-five rats were divided into 3 groups. In the baseline control group (BC, n=7), rats were uninjured and untreated. In the positive control group (PC, n=21) rats were injured but untreated. In the EPO-24 group (n=7), rats were injured and a single dose of intra-peritoneal EPO (5000 IU/kg) was administered immediately after lung injury. The PC group was divided into 3 subgroups: PC-6 (n=7), PC-12 (n=7), and PC-24 (n=7). The BC group was subjected to thoracotomy, and the right lung was harvested. The PC subgroups were eu-thanized at 6, 12, and 24 hours after injury, respectively. The EPO-24 group was euthanized at the 24th hour after injury. Lung samples were obtained, levels of malondialdehyde (MDA) and EPO were analyzed, and activities of superoxide dismutase (SOD) and catalase (CAT) were then measured in homogenized lung tissue samples. Histologic damage to lung tissue in the BC group, the EPO-24 group, and PC subgroup euthanized at the 24th hour after injury were scored by a single pathologist blinded to group assignation.
RESULTS: Mean MDA levels, as well as SOD and CAT activities, of the BC and EPO-24 groups were significantly lower than those of the PC group (p<0.005). Mean EPO concentra-tion of the PC group was significantly higher than that of the BC group (p<0.005). Lung tis-sue damage scores measured at 24 hours after injury were significantly lower in the EPO-24 group than in the PC group (p<0.005).
CONCLUSION: In the present PCn rat model, EPO concentrations, as well as SOD and CAT levels, were high in lung tissue, when measured at 24 hours after PCn. When administered early after chest trauma, EPO significantly attenuated oxidative damage and tissue damage in the early phase, as assessed by biochemical markers and histologic scoring.

BACKGROUND: Trauma is a major cause of disability and death among children worldwide, particularly in developed countries. The present aim was to compare efficacies of the Pediatric Trauma score (PTS), the Glasgow Coma Scale score (GCS), and the Injury Severity Score (ISS) in the prediction of mortality in children injured by trauma.
METHODS: A total of 588 children admitted to the emergency ward of the Poursina Medical and Educational Center from 2010–2011 with trauma were included. The PTS, GCS, and ISS were calculated for all patients. Predictive efficacy of these scores was compared using receiver operating characteristic (ROC) curve with 95% confidence interval.
RESULTS: Of the patient population, 62.1% were male and 37.9% female, with a mean age of 7.31±3.8 years. Road accident (42.2%) was the most common cause of injury. Overall, 2.4% of participants died. Regarding the prediction of mortality, the best cut-off point for the GCS was ≤8, with 98.4% sensitivity and 92.3% specificity. The same point for the PTS was ≤0.5, with 100% sensitivity and 31% specificity. For the ISS it was ≥16.5, with 92.5% sensitivity and 62% specificity. All variables based on mortality prediction were statistically significant (p<0.0001).
CONCLUSION: When compared to the PTS and ISS, the GCS may be a better predictor of mortality in cases of childhood trauma.

BACKGROUND: The present objective was to evaluate clinical stages, complications, treatment modalities, and termination of treatment in patients who presented to the emergency department with snakebite.
METHODS: A total of 132 snakebite cases were retrospectively examined using emergency department records.
RESULTS: The majority of patients, 42.9% (n=57), had grade 0 snakebite. The local complication most frequently observed was pain (42.4%, n=56); the most common systemic complication was prolonged international normalized ratio (INR) level (5.3%, n=7). Local complications were observed in patients at all stages, while systemic complications were observed only in patients at advanced stages. Antivenom was administered in 46.4% (n=61) of patients, 52.2% (n=69) of patients were hospitalized, and 47.7% (n=63) of patients were discharged after 6–12 hours of monitoring. No negative outcome was observed during 6-month or year-long follow-up.
CONCLUSION: Complications should be evaluated based on type of toxin, and appropriate treatment should be initiated efficiently, according to clinical stage. This approach reduces or prevents the development of complications.

BACKGROUND: Obstruction and inflammation of the appendix lumen is the leading physiopathological process during acute appendicitis (AA). Although the relationship between inflammation and endothelial nitric oxide synthases (eNOS) has been well described, no recent data describing the relationship between inflammation during AA and polymorphism of the eNOS gene has been reported. Given the limited data available, we believed that defining the relationship between AA and eNOS would be a beneficial contribution.
METHODS: A total of 201 patients admitted to the emergency department with AA and 201 healthy volunteers selected from among the relatives of patients were included. Polymorphism of the eNOS was assessed.
RESULTS: Intron 4a/4a was positive in 119 participants, genotype G894T GT was positive in 71 patients with AA, and 786-1 was positive in 71 patients with AA. These results suggest that no statistically significant correlation exists between genotypes of AA patients and control subjects regarding 4a/b, G894-GT, and 786-1 eNOS polymorphisms.
CONCLUSION: Though the present results suggest that no statistically significant correlation exists between AA and eNOS gene polymorphism, to claim otherwise is also impractical. We believe that the present results will lay the groundwork for future, larger studies.

BACKGROUND: Acute mesenteric ischemia (AMI) remains fatal in 50–70% of cases. AMI is recognized as a vascular emergency, requiring rapid and efficient clinical evaluation and treatment. In the present retrospective study, the possible utility of the neutrophillymphocyte ratio (NLR) in the early diagnosis of AMI was explored. The potential use of this ratio to distinguish AMI from non-vascular bowel necrosis (NVBN) was investigated.
METHODS: A total of 58 AMI, 62 NVBN, and 62 control patients were enrolled between May 1, 2010 and April 30, 2015. Patients who underwent laparotomies and/or bowel resections to treat AMI were included, as were NVBN patients who underwent segmental bowel resection to treat incarcerated and strangulated hernias. Controls were patients who presented to the emergency room with non-specific abdominal pain.
RESULTS: Mortality rate was 51.7% in the AMI and 4.8% in the NVBN groups. White blood cell (WBC) count, C-reactive protein (CRP) level, and red cell distribution width (RDW) were highest in the AMI group. NLR was higher in the AMI and NVBN groups than in the control group (p<0.001), though no difference in NLR was found between the AMI and NVBN groups. In addition, WBC count, CRP level, and NLR were higher in the NVBN group than in the controls (p<0.001).
CONCLUSION: We suggest that preoperative NLR aids in the diagnosis of AMI, and can be used to distinguish this condition from NVBN. NLR should be calculated, in addition to clinical examination.

BACKGROUND: The present objective was to compare medial mini-open and percutaneous treatment of pediatric supracondylar fractures according to fluoroscopy time, duration of surgery, and iatrogenic ulnar nerve injury.
METHODS: A total of 104 Gartland type III supracondylar humerus fractures were prospectively evaluated between 2011 and 2013. Patients were divided into 2 groups according to type of fixation. In Group A (41 patients), medial pin was inserted with mini-open incision with 2 lateral pins inserted percutaneously. In Group B (63 patients), all pins were inserted percutaneously. Mean follow-up time was 14.1±1.2 months in Group A, and 14.6±2.1 months in Group B. All patients were postoperatively evaluated for nerve injury with both motor and sensory function assessment. Length of surgery, total fluoroscopy time, fluoroscopy time for medial pin insertion, Baumann’s angle, humeral capitellum angle, final carrying angle, and range of motion were recorded.
RESULTS: Sensorial evaluation showed that Group A had 3 poor, and 1 fair results, and Group B had 2 poor, and 1 fair results. No statistically significant differences were observed, including no differences in either surgery or total fluoroscopy times between groups. However, fluoroscopy time during medial pin placement was significantly lower in the mini-open group.
CONCLUSION: In conclusion, similar results of both techniques were observed, and both carry risk of iatrogenic ulnar nerve injury. Medial pin placement is easier and less demanding when used with mini-open technique.

BACKGROUND: Though traumatic posterior fossa epidural hematoma (PFEDH) is rare, the associated rates of morbidity and mortality are higher than those of supratentorial epidural hematoma (SEDH). Signs and symptoms may be silent and slow, but rapid deterioration may set in, resulting in death. With the more frequent use of computed tomography (CT), early diagnosis can be achieved in patients with cranial fractures who have suffered traumatic injury to the posterior fossa. However, some hematomas appear insignificant or are absent on initial tomography scans, and can only be detected by serial CT scans. These are called delayed epidural hematomas (EDHs). The association of EDHs in the supratentorial-infratentorial compartments with linear fracture and delayed EDH (DEDH) was presently investigated.
METHODS: A total of 212 patients with SEDH and 22 with PFEDH diagnosed and treated in Göztepe Training and Research Hospital Neurosurgery Clinic between 1995 and 2005 were included. Of the PFEDH patients, 21 underwent surgery, and 1 was followed with conservative treatment. In this group, 4 patients underwent surgery for delayed posterior fossa epidural hematoma (DPFEDH).
RESULTS: Mean age of patients with PFEDH was 12 years, and that of the patients with SEDH was 18 years. Classification made according to localization on cranial CT, in order of increasing frequency, revealed of EDHs that were parietal (27%), temporal (16%), and located in the posterior fossa regions (approximately 8%). Fracture line was detected on direct radiographs in 48% of SEDHs and 68% of PFEDHs. Incidence of DPFEDH in the infratentorial compartment was statistically significantly higher than incidence in the supratentorial compartment (p=0.007). Review of the entire EDH series revealed that the likelihood of DEDH development in the infratentorial compartment was 10.27 times higher in patients with linear fractures than in patients with supratentorial fractures (p<0.05).
CONCLUSION: DPFEDH, combined with clinical deterioration, can be fatal. Accurate diagnosis and selection of surgery modality can be lifesaving. The high risk of EDH development in patients with a fracture line in the posterior fossa on direct radiographs should be kept in mind. These patients should be kept under close observation, and serial CT scans should be conducted when necessary.

BACKGROUND: The present objective was to assess implementation of the Ottawa ankle rules (OAR) as a method of fracture prediction in the emergency department (ED) of a Turkish state hospital.
METHODS: Patients who presented to the ED of our hospital with acute ankle injury were evaluated. All were examined by a general practitioner, after which a series of ankle and foot x-rays (anteroposterior and lateral) were performed. Radiography was examined by a radiologist and an orthopedic surgeon, both of whom were blinded to OAR results. Radiographic results were compared to results of OAR implementation. Sensitivity and specificity of the OAR in the diagnosis of fracture was calculated.
RESULTS: A total of 251 (61.97%) patients were diagnosed as positive (+) for fracture after OAR implementation, 154 (38.02%) as negative (–). Clinically significant fracture was detected in 62 (15.3%) patients. A total of 61 (98.4%) patients with significant fracture were OAR (+); 1 (1.6%) was OAR (–). However, 190 (55.4%) patients without fracture were OAR (+); 153 (44.6%) were OAR (–) (p<0.001). Sensitivity, specificity, and positive and negative predictive values of OAR implementation in the prediction of fracture were 98.39%, 44.61%, 24.30%, and 99.35%, respectively. Area under the curve (AUC) was 0.71. According to these results, it was determined that use of radiography could be reduced by 38.02% if the OAR were implemented.
CONCLUSION: The OAR are a highly sensitive means of screening of patients with acute ankle and mid-foot injuries. Application of the OAR by well-trained general practitioners can lead to significant reduction in the number of x-rays performed, thereby reducing cost of treatment and radiation exposure, in addition to saving time for patients and staff.

BACKGROUND: General surgery is one of the branches in which the distinction between complication and malpractice is difficult to distinguish. In this study, presentation of the main forensic medical parameters considered for the evaluation of medical malpractice in cases of general surgery deaths in which medical malpractice has been alleged and discussing related concepts through the literature are aimed.
METHODS: Allegations of medical malpractice against general surgery physicians sent to the First Forensic Expertise Board of the Council of Forensic Medicine between January 1, 2012 and December 31, 2013 for which the relation of casuality between medical malpractice and death had been determined were retrospectively evaluated.
RESULTS: Medical malpractice was ruled in 21.9% (n=23) of 105 cases. The most common primary disease diagnoses were trauma-injury (n=32, 30.5%), cholecystitis (n=25, 23.8%) and appendicitis (n=8, 7.6%). When treatment types were compared according to malpractice decision, rate of malpractice in medicine-only treatment was found to be significantly higher compared to surgery + medical treatment (p=0.003, p<0.01). No statistically significant difference was found regarding the rate of malpractice between cases of emergency and elective surgery (p>0.05). When incidence of medical malpractice was compared between cases with clinical diagnosis and diagnosis determined by autopsy, a statistically significant difference was found (p=0.031, p<0.05). Malpractice was ruled at a significantly lower rate in cases in which diagnosis was confirmed with autopsy (p=0.028, p<0.05).
DISCUSSION: It can be concluded that physicians are as successful in emergency conditions as in elective conditions and correct administration of medical treatment is of vital importance. Moreover, the Council of Forensic Medicine considers the clinical follow-up data as well as the autopsy data in medical malpractice evaluation.

BACKGROUND: Conservative management procedures are implemented in cases of low-grade pediatric blunt renal trauma, but procedures for grade 4 injuries are not clearly defined. The present objective was to discuss treatment procedures in patients who presented with or developed urinoma during follow-up.
METHODS: Treatment procedures implemented in 8 patients (female: male ratio=1: 7; average age: 6) with grade 4 renal trauma who presented to the clinic between 2003 and 2012 were retrospectively analyzed.
RESULTS: Cause of renal injury was fall in 4 cases, blunt abdominal trauma in 3 cases, and being trapped in a harvesting machine in 1 case. Right renal trauma was diagnosed in 4 cases, left renal trauma in 4. Emergent exploration due to hemodynamic instability was not necessary. Although urinary extravasation was observed upon investigation in 1 patient, urinoma did not form during follow-up. Five of the 7 patients with urinoma were treated with drainage procedures (double-J catheter ( JJ) in 3, percutaneous drainage (PD) in 1, followed by JJ catheter placement). In spite of initial PD, inferior pole nephrectomy and pyeloplasty were performed in the remaining 2 cases due to decomposition of the integrity of the urinary system. In 1 patient, pyeloplasty was performed following regression of symptoms due to ureteropelvic obstruction. Catheters were removed when extravasation was not detected in the urinary system. Average time of removal was 4 months for JJ catheters and 1.5 months for PD catheters.
DISCUSSION: Pediatric grade 4 renal trauma can be successfully treated with minimally invasive procedures. Initial implementation of these procedures increases the chance of kidney salvage, even when surgical intervention is eventually performed.

BACKGROUND: The present objective was to retrospectively evaluate factors affecting functional outcome of multipart proximal humeral fracture treated with fixation or hemiarthroplasty.
METHODS: Included were 58 patients (19 women, 39 men; average age: 51.04 years; range 22–78 years) who underwent surgery for Neer type III or IV proximal humeral fractures between 2007 and 2012. All participants attended follow-up of at least 2 years. A total of 35 patients underwent open reduction and anatomical plate fixation; 23 underwent partial shoulder replacement. Patients were evaluated according to Constant-Murley shoulder scoring at final follow-up examination. Evaluated impacts on functional outcome included age, gender, American Society of Anesthesiologists (ASA) Physical Status classification, trauma energy, type of fracture, and time to surgery.
RESULTS: Mean follow-up duration was 47.25±13.29 (25–76) months. Mean Constant-Murley score was 58.65±18.62 (65.77±18.67 for the fixation group, 47.82±12.52 for the hemiarthroplasty group; p=0.001). When impact of independent variables on functional scores was assessed, ASA score and type of fracture were found to significantly affect functional outcome in the fixation group, and trauma energy was found to significantly affect functional outcome in the hemiarthroplasty group. Complications were detected in 20 patients (34.5%) upon final examination, 14 of whom (70%) had rotator cuff deficiency.
DISCUSSION: Though improved functional results may be obtained using plate fixation in the surgical treatment of multipart proximal humeral fractures, the high rates of rotator cuff failure associated with both surgical methods should be considered.

BACKGROUND: The present objective was to compare 90° and 180° double-plate constructions for complex distal humerus fractures, as well as to evaluate superiority of construction type.
METHODS: Retrospectively evaluated were 17 patients treated for type C distal humerus fracture according to AO/ASIF classification between January 2009 and January 2013. All attended minimum 6-month follow-up. Elbow function was assessed with anteroposterior and lateral x-ray, and Mayo elbow performance score evaluation at outpatient clinics.
RESULTS: Patient population included 14 males (82.3%) and 3 females (17.7%). Mean patient age was 40.5 years. According to AO/ASIF distal humerus classification, 3 (17.7%) type C1, 9 (52.9%) type C2, and 5 (29.4%) type C3 fractures were included. Six were open fractures (35.3%). According to Gustilo-Anderson classification, 4 (23.5%) fractures were type 1, and 2 (11.7%) were type 2. Construction performed was 90° in 11 cases (64.7%) and 180° in 6 cases (36.3%). Chevron osteotomy was performed in all cases. Mean follow-up period was 25.6 (6–52) months. Upon final examination, mean elbow flexion was 105º (85º–130º), and mean extension loss was 10º (0º–20º). According to Mayo elbow performance scoring system, 12 (70.5%) results were excellent, and 5 (29.5%) were good. No statistically significant clinical difference was found between 90° and 180° plate construction groups (p=0.169).
DISCUSSION: Surgeons should determine the construction type appropriate to individual cases of adult distal humerus type C fractures using preoperative x-rays and intraoperative means. Choice of construction type has particular importance in cases of lateral columnar fracture complexity. If no comminution is present in the lateral column, 90º double-plating leads to satisfactory outcome, while 180º plating leads to satisfactory outcome when comminution is present in the lateral column.

Torsion of the greater omentum is a rare cause of acute abdomen. Based on etiopathogenesis, it can be classified as primary or secondary. However, regardless of the cause, segmentary or diffuse omental necrosis will follow. Preoperative diagnosis is not easy, though abdominal ultrasound and computed tomography (CT) scans may show peculiar features suggestive of omental torsion. Laparoscopic resection of the affected omentum is the treatment of choice. Presently reported was a case of primary omental torsion, in addition to a comprehensive literature review.

Bullet embolism to the heart is a rare but serious complication of penetrating trauma. Distant migration of foreign bodies via the vascular system must be taken into consideration following penetrating gunshot trauma. Delays in diagnosis may result in poor management and subsequent complications that may lead to grave prognosis. Presently described was a conservatively managed case of asymptomatic intracardiac pellet embolization. Highlighted was the importance of serial scanning for intravascular migration of pellet following penetrating gunshot injury, in addition to conservative management in asymptomatic patients.

Foreign body ingestion can be caused by many factors, including hallucination in patients with mental retardation. Most ingested foreign bodies are naturally discharged, though surgical intervention is necessary in some cases. Endoscopic intervention often leads to successful outcome, though open surgery may be required in certain instances. A 29-year-old mentally retarded woman presented to emergency services with a 2-day history of right lumbar pain that increased with movement. Physical examination revealed no specific sign beyond palpable tenderness in the right lumbar region. Radiological examination revealed a metal nail in the upper right quadrant, stretching obliquely toward the retroperitoneum. Endoscopy failed, and the nail was extracted via laparotomy. Foreign body ingestion may occur in patients of any age, but is more common in the pediatric population and in patients with mental retardation. Commonly ingested foreign bodies include daily objects, toys, and dentures, though they may differ in patients with mental retardation. The treatment of such cases requires a diversity of methods and experience. Foreign body ingestion should be kept in mind when a patient presents with pain in the right lumbar region, particularly in patients with mental retardation.

Pharyngeal foreign bodies are commonly encountered in otolaryngological practice. However, in certain instances, particularly in cases of penetrating injuries, major vascular damage leads to severe morbidity and mortality. Management of these cases includes airway protection, bleeding control, imaging of major vascular injury, and prophylactic antibiotics. The case of a 2-year-old patient with penetrating pharyngeal foreign body is described in the present report.