Workup For Ischemia Research Articles

UnTWISTing the BALS: A study of predictive accuracy of clinical scoring tools for testicular torsion identification in adults.

Testicular torsion is an uncommon but time-critical condition in EDs. If the diagnosis is missed or delayed, there are significant medicolegal and patient fertility implications. Scoring tools are advocated for use in children but have limited validation in adults. The aim of the present study was to explore the predictive accuracy of the testicular torsion scoring tools, Testicular Workup for Ischemia and Suspected Torsion (TWIST) and Boettcher Alert Score (BALS), in adult patients with a final ED diagnosis of torsion. All patients with an ED working diagnosis of testicular torsion were identified retrospectively. Data collected from digital medical records included demographics, processes of care and clinical information. The outcome of interest was the predictive performance of the scores for a confirmed diagnosis of testicular torsion as adjudicated by an urologist or a surgeon. Fifty-four patients had complete clinical data, of whom 13 had confirmed torsion. The TWIST score had a high area under the receiver operating characteristics curve (AUROC) of 0.89 (95% confidence interval [CI] = 0.78-0.999) with a score of 6-7 corresponding to a positive predictive value (PPV) of 80% (95% CI = 38-96%). The BAL score had an AUROC of 0.79 (95% CI = 0.69-0.92). PPV for a score ≥2 was 38% (95% CI = 22-56%). A high TWIST score correlates to a high likelihood of torsion and can inform surgical decision-making in the absence of US.

Predictive factors for manual detorsion success in testicular torsion.

In cases of testicular torsion (TT), prompt diagnosis and treatment are highly associated with organ salvage, and manual detorsion (MD) is a recommended maneuver as a first intervention. In our study, we aimed to investigate the effect of predictive factors of TT in predicting the success of MD. A retrospective, 2-center study was conducted on patients diagnosed with TT between January 2015 and 2024. Demographic, clinical, ultrasound, and laboratory characteristics at presentation were analyzed. MD was routinely performed as the first intervention in all patients. Predictive parameters were compared in the MD success and failure groups. Univariate and multiple logistic regression analysis was used to identify risk factors for MD failure. A total of 94 patients were included in the study. The median age of the patients was 20 (IQR: 12-69) years, and the median symptom duration was 6 (IQR: 4-12) hours. MD confirmed by Doppler ultrasonography was successful in 52 (55.3%) patients and unsuccessful in 42 (44.7%). Age, symptom duration, Testicular Workup for Ischemia and Suspected Torsion (TWIST) score, TWIST risk groups, WBC, neutrophil, monocyte counts, and Monocyte/Eosinophil ratio (MER) were statistically different between the two groups. In multiple logistic regression analysis, the risk factors for failure of MD were found to be being over 18years of age, the duration of symptoms being longer than 9h, and MER > 28. Current urology guidelines suggest that age, symptom duration, and MER are reliable predictors of the success of MD, which is recommended in all cases of TT.

Implementation of a health system intervention to reduce time from presentation to surgical intervention for pediatric testicular torsion

Testicular salvage rates for torsion are time-dependent1. Door to detorsion time has been identified as an independent testicular survival factor2. We describe an initiative to reduce door to incision (DTI) time for pediatric testicular torsion. An institutional multidisciplinary quality improvement initiative with a primary outcome of reducing DTI time for pediatric testicular torsion was developed with multidisciplinary stakeholders. Several process and balancing measures were used as secondary outcomes to help interpret and verify the observed change in DTI time. Interventions were implemented in cycles. Initial interventions standardized assessment of suspected torsion by Emergency Medicine utilizing a validated scoring system. A threshold Testicular Workup for Ischemia and Suspected Torsion (TWIST) score led to parallel notification of essential services for rapid assessment and case prioritization3. Subsequently, bedside ultrasound in the Emergency Department was implemented. Progress was tracked in a live dashboard and analyzed with X-mR process control charts and Nelson rules. These tools are used in quality improvement and process control to demonstrate the significance of changes as they are being implemented, prior to when traditional hypothesis testing would be able to do so. We aimed to increase the proportion of cases with DTI times under 4h from 64% to >90% within one year. We observed 22 torsion cases prior to and 62 following initial implementation. The percentage of cases with DTI times under 4h improved from 64% to 95%. At week 29, a shift identified a significant change on the X chart, with reduction in mean DTI time from 221 to 147min. At the same time, a shift on the mR chart identified reduction in patient-to-patient variation. Mean time from arrival to Urology evaluation decreased from 140 to 56min, mean time from arrival to scrotal ultrasound decreased from 70 to 36min, and mean time from scrotal ultrasound to surgical incision decreased from 128 to 80min. These improvements highlight the two key successes of our project: application of the TWIST score and bedside ultrasound for rapid assessment of suspected testicular torsions, and parallel processing of the evaluation and management. Implementation of a protocol for pediatric testicular torsion increased the proportion of cases with DTI time <4h to 95%, decreased mean DTI time, and decreased variation. Our protocol provides a model to improve timeliness of care in treating pediatric testicular torsion.

The diagnosis and treatment of testicular torsion in children with non-scrotal initial symptoms.

To explore the clinical characteristics of testicular torsion in children with non-scrotal initial symptoms who were misdiagnosed. A retrospective analysis of 73 cases children with testicular torsion and non-scrotal symptoms who were admitted to our department from October 2013 to December 2021 was performed. Patients were divided into misdiagnosis (27 cases) and clear diagnosis at first visit (46 cases) groups. Clinical data, including age at surgery, clinical presentation, physical examination, number of visits (≥2 times), affected side, time from initial symptoms to surgery, and surgical outcomes, were collected. The TWIST (Testicular Workup for Ischemia and Suspected Torsion) score was calculated and analyzed. Statistically significant differences between the misdiagnosis and clear diagnosis groups were seen in the time from initial symptoms to surgery, the number of visits, the degree of testicular torsion, and the rate of orchiectomy (P < 0.05). There were no statistically significant differences (P > 0.05) in age, affected side, TWIST score, guardian, direction of testicular torsion, intra-vaginal or extra-vaginal torsion, and Arda classification. Postoperative follow-up was 6-40 months. Of the 36 patients who required an orchiopexy, 1 had testicular atrophy at six months and 2 were lost to follow-up. The contralateral testis of the 37 children who underwent orchiectomies developed normally without torsion. The clinical manifestations of testicular torsion in children are diverse and can easily lead to misdiagnosis. Guardians should be aware of this pathology and seek timely medical attention. When the initial diagnosis and treatment of testicular torsion is difficult, the TWIST score during the physical examination may be useful, especially for patients with intermediate-to-high risk scores. Color Doppler ultrasound can assist in making the diagnosis, but when testicular torsion is highly suspected, routine ultrasound is not necessary as it may lead to delayed surgical treatment.

CORROBORATING TESTICULAR WORK UP FOR ISCHEMIAAND SUSPECTED TORSION [TWIST] SCORE IN THE EVALUATION OF TESTICULAR TORSION IN PATIENTS PRESENTING WITH ACUTE SCROTUM: A STUDY FROM A TERTIARY CARE CENTRE IN CENTRAL INDIA

Objective: To study the testicular workup for ischemia and suspected torsion (TWIST) score for evaluation of patients presenting with acute scrotum. Method:An observational study was done amongst the patients presenting with acute scrotum of the emergency department of a tertiary care hospital. The scoring system , as described by Barbosa, et al, consisted of testicular swelling(2), hard testicle(2), absent cremastric reex(1), nausea/vomiting(1), high riding testis(1). Along the entire duration of the study the same standard of resources were used in terms of radiological investigations and the surgery performed. Results: In the testicular torsion group, the mean TWIST score was 5.4 ranging from 4 to 7 while in the non torsion group it was 2.81 ranging from 2 to 6. In the testicular torsion group the no. of patients belonging to low, intermediate and high risk was 0, 2 and 8, respectively, while the number of patients without testicular torsion was 5, 5 and 1 in low, intermediate and high risk groups respectively. Conclusion: The testicular workup for ischemia and suspected torsion (TWIST) score can be used a tool for evaluation of patients presenting with acute scrotum. The score has a high positive predictive value for testicular torsion

Unjumbling the TWIST score for testicular torsion: systematic review and meta-analysis.

A systematic review and meta-analysis of the studies evaluating the utility of the Testicular Work-up for Ischemia and Suspected Torsion (TWIST) score in establishing or excluding the diagnosis of testicular torsion (TT) is herewith presented in an attempt to quantify the available evidence. The study protocol was outlined in advance. The review has been conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA). The PubMed, PUBMED Central, PMC databases & Scopus followed by Google (Scholar & search engine) were systematically interrogated with the keywords TWIST score, testis and testicular torsion. Fourteen sets of data (n = 1940) from 13 studies were included; data from 7 studies (giving a detailed score-wise break-up) (n = 1285) were dis-integrated and re-integrated to tweak the cut-offs for low and high risk. For every 4 patients presenting to the Emergency Department (ED) with acute scrotum, one patient will eventually be diagnosed with TT. The mean TWIST score was higher in patients with testicular torsion (5.13 ± 1.53 vs 1.50 ± 1.40 for those without TT). TWIST score can be used to predict testicular torsion at cut-off of 5 with a sensitivity, specificity, PPV, NPV, and accuracy of 0.71 (0.66, 0.75; 95%CI), 0.97 (0.97, 0.98; 95%CI), 90.2%, 91.0%, and 90.9% respectively. While the slider for cut-off was shifted from 4 to 7, there was a rise in specificity and PPV of the test with a corresponding decline in sensitivity, NPV, and accuracy. The sensitivity witnessed a sharp decline from 0.86 (0.81-0.90; 95%CI) @ cut-off 4 to 0.18 (0.14-0.23; 95%CI) @ cut-off 7. The area under the SROC curve for cut-off 5 was more than that for cut-offs 4, 6 & 7. TWIST cut-off of 2 may be used to predict the absence of testicular torsion with a sensitivity, specificity, PPV, NPV, and accuracy of 0.76 (0.74, 0.78; 95%CI), 0.95 (0.93, 0.97; 95%CI), 97.9%, 56.5%, and 80.7%, respectively. While the cut-off is lowered from 3 to 0, there is a corresponding rise in the specificity and PPV, while the sensitivity, NPV, and accuracy are compromised. The sensitivity witnesses a sharp decline from 91 to 35%. The area under the SROC curve for cut-off 2 was more than that for cut-off @ 0, 1 or 3. The sum of sensitivity and specificity of TWIST scoring system to ascertain the diagnosis of TT is more than 1.5 for cut-off values 4 & 5 only. The sum of sensitivity and specificity of TWIST scoring system to confirm the absence of TT is more than 1.5 for cut-off values 3 & 2 only. TWIST is a relatively simple, flexible, and objective tool which may be swiftly administered even by the para-medical personnel in the ED. The overlapping clinical presentation of diseases originating from the same organ may prevent TWIST from absolutely establishing or refuting the diagnosis of TT in all the patients with acute scrotum. The proposed cut-offs are a trade-off between sensitivity and specificity. Yet, the TWIST scoring system is immensely helpful in the clinical decision-making process and saves time-lag associated with investigations in a significant majority of patients.

Stress Echocardiography in the Diagnosis of Coronary Microvascular Ischemia: The Forgotten Old Faithful Tool?

Ischemia is an imbalance between myocardial oxygen supply and demand and includes both macrovascular and microvascular causes. When patients present with typical angina or equivalents, many tests can assess for ischemia. If positive and symptomatic despite medical therapy, patients are referred for coronary angiography. If no macrovascular ischemia is detected, workup for ischemia with no obstructive coronary artery disease (INOCA) and coronary microvascular dysfunction (CMD) should be performed if clinically indicated.

Impact of the ISCHEMIA randomized clinical trial on the management of patients with chronic coronary syndrome

Abstract Background In the ISCHEMIA trial, patients with chronic coronary syndromes (CCS) and moderate or severe ischemia had no significant difference in combined ischemic events with an initial invasive compared with a conservative strategy [1]. Coronary computed tomography angiography (CCTA) was part of the pre-randomization workup of ISCHEMIA and is gaining popularity over ischemia testing or initial invasive coronary angiography (ICA) as the initial diagnostic strategy for CCS [2]. Purpose To analyse whether the results of the ISCHEMIA trial had a sizeable impact on the diagnostic algorithm for CCS by analysing trends in referral to ICA and/or revascularization. Methods ICAs performed in CCS patients between November 2019 and February 2022 at a high-volume centre were analysed. Two groups were defined based on procedure date: i) pre-ISCHEMIA, including ICAs performed before March 2020 (date of trial publication); ii) post-ISCHEMIA, including ICAs performed ≥3 months (i.e., blanking period) after trial publication. The primary outcome was the incidence of referral to ICA by CCTA. Secondary objectives included referral to ICA or revascularization by ischemia testing, referral to revascularization by CCTA, and referral by CCTA to ICA that did not require further intervention. Results A total of 2,365 patients qualified for the analysis, of which 487 (20.6%) and 1878 (79.4%) in the pre-ISCHEMIA and post-ISCHEMIA groups, respectively. There were no notable differences in baseline characteristics between groups. The primary outcome occurred more frequently in the post-ISCHEMIA group (73.5% vs 32.5%, p&amp;lt;0.01). Referral to ICA by ischemia testing was lower in the post-ISCHEMIA group (31.6%, vs 52.5% p&amp;lt;0.01), while referral for revascularization by CCTA was more frequent (8.3% vs 12.0% p&amp;lt;0.01). There were no significant differences in referral to revascularization by ischemia testing (3.4% vs 3.0%, p=0.73) and referral by CCTA to ICA that did not require further intervention (60.3% vs 60.8%, p=0.90). Conclusions At two years from publication, the ISCHEMIA trial seems to have impacted significantly on the decision-making algorithm for patients with CCS. The frequency of referral to ICA and revascularization by CCTA considerably increased, paralleled by decreased referral to ICA by ischemia testing. Funding Acknowledgement Type of funding sources: None.

Validation of TWIST score in the diagnosis of testicular torsion in children: A Prospective study

Early diagnosis is key in testicular torsion. This study is to validate the diagnostic value of the “Testicular Workup for Ischemia and Suspected Torsion (TWIST)” score for evaluating acute scrotum in children. Patients from 1 month old to 16 years old presented to Children’s hospital No.1 with acute scrotum between June 1 st, 2020, and May 31 st, 2021 were prospectively studied. General surgeons performed an examination and recorded signs and symptoms in the collection form. After that, all patients had Scrotal Doppler Ultrasound (DUS). We calculated the sensitivity, specificity, positive predictive, and negative predictive values of the TWIST score. The ROC curve was used to find out the optimal cut-off in diagnosing Testicular torsion (TT) in Children. Among 68 children with acute scrotum, 16 cases had TT (23.5%). The median age was 12.5 years in the TT group and 9 years in the non-TT group. None of 32 patients with the TWIST score ≤ 2 had TT and among 20 patients with a score of 3 – 4, only one had TT. More importantly, in the high-risk group with a score ≥ 5, 15 had TT (93.8%). ROC curve revealed an AUC of 0.987 (p&lt;0,001) representing a high diagnostic value. The sensitivity and specificity for TT at 5-point cut-off were 93.7% and 98.1%, respectively. The TWIST scoring system has high sensitivity and specificity values. Therefore, it should be used as a useful tool for the diagnosis of testicular torsion. The score ≥ 5 is an indicator of testicular torsion, hence emergency surgical intervention is required.

Commentary to: Validation of testicular workup for ischemia and suspected torsion score in patients with acute scrotum

Barbosa et al. described the TWIST score in 2013 and reported 100% NPV and PPV for low-risk and high-risk groups respectively. They suggested that color Doppler ultrasound (CDUS) may not be needed in 80% of patients with acute scrotum. At least 5 studies (Table 3) have since attempted to validate the TWIST score and none had a perfect NPV or PPV. The NPV for low-risk group has ranged from 77% to 99% and PPV for high-risk group has ranged from 56% to 93% with results worse in prepubertal patients.

Pheochromocytoma manifesting as cortical blindness secondary to PRES with associated TMA: a case report and literature review

BackgroundPheochromocytomas are neoplasms originating from neuroectodermal chromaffin cells leading to excess catecholamine production. They are notorious for causing a triad of headaches, palpitations, and sweats. Though the Menard triad is one to be vigilant of, symptomatic presentation can vary immensely, hence the tumor earning the label “the great masquerader.”Case presentationWe report a case of pheochromocytoma initially presenting with cortical blindness secondary to posterior reversible encephalopathy syndrome and thrombotic microangiopathy from malignant hypertension. Our patient was seen in our facility less than a week prior to this manifestation and discharged after an unremarkable coronary ischemia work-up. In the outpatient setting, she had been prescribed multiple anti-hypertensives with remarkably elevated blood pressure throughout her hospitalization history.ConclusionPheochromocytoma presenting with malignant hypertension and hypertensive encephalopathy should be expected if left untreated; nonetheless, the precipitation of cortical blindness is rare in the literature. This case contributes an additional vignette to the growing literature revolving adrenal tumors and their symptomatic presentation along with complex management. It also serves to promote increased diagnostic suspicion among clinicians upon evaluating patients with refractory hypertension.

Validation of testicular workup for ischemia and suspected torsion score in patients with acute scrotum

The Testicular Workup for Ischemia and Suspected Torsion (TWIST) score was created to help physicians in the clinical evaluation of acute scrotum in which testicular torsion (TT) is suspected. There have been only a few reports on validation of the TWIST score since the original study was published. To validate the TWIST score as a scoring system. We reviewed the records of 106 patients with acute scrotum in our prospectively maintained database. The patients were divided into two groups by the final diagnosis: testicular torsion (group TT) or non-testicular torsion (group NTT). We retrospectively calculated the TWIST score of the patients. Patients were divided into low (0-2), intermediate (3-4), or high (5-7) risk groups according to the total score. Fifteen patients (14%) had TT. The median age at presentation was 13.3 years (range 1.6-16.2) in group TT and 10.4 years (range 0.25-18.9) in group NTT, respectively. The sensitivity of clinical and Color Doppler ultrasonography (CDUS) findings to diagnose TT was 100%, whereas the specificity was 93.4%. Positive predictive value (PPV) and negative predictive value (NPV) were 71.4% and 100%, respectively. According to the calculated TWIST score, 65, 23, and 18 patients belonged to low, intermediate, and high risk groups, respectively. TT was found in 1(1.3%), 3(13%), and 11 (61%) patients of low, intermediate, and high risk groups, respectively. The NPV of the TWIST score for the low risk group was 98.5%, whereas the PPV of the TWIST score for the high risk group was 61.1%. Among the four patients with TT in low risk and intermediate risk groups, three patients presented to our institutions within 6h after the onset. The torsion was 180° in two of the three patients. The TWIST score can be useful for clinical diagnosis of testicular torsion, but is inferior to clinical findings along with CDUS. We should consider the possibility that a TWIST score could be underestimated when patients present with acute scrotum immediately after onset or the affected testis is mildly twisted.

Quality Improvement Project to Improve the Timeliness of Care for Children With Testicular Torsion in the Emergency Department.

Testicular torsion (TT) is a urologic emergency that requires timely diagnosis and surgery. We noted variation in the door-to-detorsion times for patients with TT at our institution and our orchiectomy rate was 25.8%. We aimed to decrease the mean door-to-detorsion time from 124.6 to 114.6 minutes or less over 12 months. A multidisciplinary team of pediatric emergency medicine, radiology, urology physicians, and nurses, was formed. Our key drivers were use of Testicular Workup for Ischemia and Suspected Torsion (TWIST) score, prompt urology consultation, and efficient transfer from emergency department (ED) to operating room. Our process measures were TWIST score documentation rate and early urology consultation rate, outcome measures were door-to-detorsion time and orchiectomy rate, and balancing measure was ultrasound utilization rate. Early urology consultation occurred when the ED provider documented telephone communication with urology, immediately after placing a testicular doppler ultrasound (TDUS) order and before TDUS result. Over 2 years, 45 cases of TT were diagnosed. TWIST score documentation was implemented and was sustained at 78%. This improved early urology consultations from 40% to 60%. The mean door-to-detorsion time improved from 124.6 to 114.2 minutes. There was no reduction in the orchiectomy rate or TDUS utilization rate. A quality improvement project to improve the timeliness of care for children with TT resulted in expedited ED care but did not impact the orchiectomy rate.

Validation of TWIST (Testicular Workup for Ischemia and Suspected Torsion) Score System for Differential Diagnosis in Acute Scrotum in Tertiary Teaching Hospital

The acute scrotum is a common urological emergency and has a broad differential diagnosis. There is no clear consensus on a particular algorithm to follow in the diagnosis of testicular torsion. Testicular Workup for Ischemia and Suspected Torsion (TWIST) Score, a risk scoring system based on signs and symptoms, can be invaluable in managing patients with the acute scrotum, specifically testicular torsion. This study aimed to evaluate the effectiveness of the TWIST scoring system for differential diagnosis of acute scrotal patients. The study was conducted using secondary data, medical records from 111 male patients diagnosed with acute scrotum in Saiful Anwar General Hospital Malang between January 2015 and December 2018. Data about the onset of pain, first contact, history, physical examination findings, any adjunct test performed, and intra-operative findings were collected. The effectiveness of the TWIST score in diagnosing testicular torsion was determined by calculating the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). Of the 111 patients, 43 patients (38.7%) had testicular torsion. The mean age was 17.49 (6.69) years. A total of 39 patients were classified as high risk as per the TWIST Score with cut point 5 had 83.7% sensitivity, 95.6% specificity, 92.3% positive predictive value (PPV), and 90.3% negative predictive value (NPV). The area under the curve was 0.93. The use of the TWIST Score in clinical practice can accurately determine high-risk patients who can proceed straight to the operating theatre without the need for an ultrasound.

Diagnosing with a TWIST: Systematic Review and Meta-Analysis of a Testicular Torsion Risk Score.

The Testicular Workup for Ischemia and Suspected Torsion (TWIST) score is a 7-point tool to evaluate acute scrotal pain. Parameters include testicular swelling (2 points), hard testis (2), high-riding testis (1), absent cremasteric reflex (1) and nausea/vomiting (1). This review aimed to determine the diagnostic utility of TWIST and its role in risk stratification. A systematic review and meta-analysis of diagnostic test accuracy was conducted. Five risk stratification systems were explored, including the Barbosa (0-2, 3-4, 5-7) and Sheth (0, 1-5, 6-7) scoring systems, to obtain sensitivity, specificity and area under the receiver operating curve. Thirteen studies were identified, 9 prospective studies proceeded to meta-analysis of diagnostic test accuracy and 5 pediatric studies (1,060 patients, 199 torsions) were included in the primary analysis. The most accurate risk stratification system was Barbosa (0-2, 3-4, 5-7), with an AUC of 0.924 (95% CI: 0.865, 0.956). Barbosa showed favorable sensitivity in low-risk patients (0.984), facilitating rule out of torsion, and favorable specificity (0.975) in high-risk patients, facilitating urgent surgical exploration. Sensitivity and specificity in intermediate-risk patients were 0.922 and 0.682, respectively, indicating a need for further workup with ultrasound. Using this stratification, 65.2% of patients were low-risk, 19.9% were intermediate-risk and 14.9% were high-risk. Per 100 presentations of acute scrotum, there was a missed torsion rate of 1.6/100, ultrasound rate of 19.9/100 and negative exploration rate of 2.5/100. TWIST is an effective tool for suspected testicular torsion and is appropriate for widespread adoption. The Barbosa scoring system is reliable and reduces reliance on scrotal ultrasound.

Testicular torsion in children.

As a family physician caring for a large pediatric population, I evaluate numerous adolescents with testicular pain. Given the gravity of prognosis for late treatment of children with testicular torsion, what are best practices for its assessment and management? The Testicular Workup for Ischemia and Suspected Torsion (TWIST) score has been developed and validated to identify children at risk of testicular torsion. If the TWIST score is 0 and clinical suspicion is low in the office setting, a referral to urology for urgent consultation is not needed. If the TWIST score is 1 or higher or if the clinical presentation suggests torsion, manual detorsion should be attempted and the patient should be urgently sent to the nearest emergency department.

The BAL-Score Almost Perfectly Predicts Testicular Torsion in Children: A Two-Center Cohort Study.

Introduction: Testicular torsion (TT) is a common emergency that warrants immediate exploration to prevent infertility or testicular loss. To improve diagnostic reliability, various scoring systems have been published. The aim of this study was to evaluate and validate different testicular torsion scores in a large cohort of children with acute scrotum.Methods: Retrospective analysis of all male children that were admitted for acute scrotum at the Pediatric Surgery Department of the Altonaer Kinderkrankenhaus and University medical Center Hamburg-Eppendorf from 01/2013 to 03/2019. Two testicular torsion scores (Boettcher Alert Score, Testicular Workup for Ischemia and Suspected Torsion Score) were applied to all data sets. Furthermore, an artificial intelligence (AI)-based score was developed and compared to the two current scores.Results: In total, 460 boys were included in the study. Of those, 48 (10.4%) had TT. Children with TT suffered most often from short duration of pain, nausea and vomiting, high riding testicle and absent cremasteric reflex. The BALS and the AI-based score had excellent predictive values and all patients with TT would have been detected.Conclusion: The BAL and the AI score show excellent predictive capabilities and may be used to identify all cases of TT in a pediatric population. The scores are easy to apply. As the BALS was slightly better, we advocate to use this score but to validate our findings in prospective multicenter studies.

Emergency scrotal exploration in children: Is it time for a change in mindset in the UK?

Acute scrotal pain is a common problem in children. Amongst the various causes, only testicular torsion (TT) needs urgent, and arguably any, surgical intervention. However TT accounts for only approximately 25% of cases. The diagnosis of TT is currently based mainly on history and clinical examination in the UK. We sought to find the incidence of finding TT during emergency scrotal exploration in four paediatric surgical centres in the UK. We also assessed the preoperative utilisation of clinical risk scores and Doppler ultrasound (DUS) to aid in the diagnosis. A retrospective review of 50 consecutive scrotal explorations done for acute scrotal pain at four tertiary pediatric surgical centres in 2019, including the preoperative utilisation of DUS, was analysed. Additionally an online survey was also sent out to consultant members of the British Association of Paediatric Urology to gauge their threshold for exploration, use of preoperative investigations and incidence of finding TT in their practice. In the four UK centres reviewed, TT was found in 24.5% (SD=8.54) of explorations. The overall utilisation of preoperative DUS was 10%. The online survey revealed a low threshold for exploration. However 72% of respondents recalled finding TT in <50% of explorations, with just over a third reporting finding TT in only 10% of explorations. There was low utilisation of preoperative DUS and clinical risk scores. The incidence of finding TT during exploration in this cohort is the same as the incidence of TT in a population of children presenting with acute scrotal pain. We hypothesise that this is due to low accuracy of clinical assessment, low utilisation of preoperative clinical and radiological aids and the practice of exploring torted testicular appendages. Improving awareness and training in these modalities will increase diagnostic accuracy, limiting emergency scrotal explorations to those children with a higher risk of testicular torsion. A care pathway for children presenting with acute scrotal pain is suggested () CONCLUSIONS: There is a low incidence of finding testicular torsion during paediatric scrotal explorations in the UK. There is low preoperative utilisation of clinical risk scores and Doppler ultrasound, which if utilised, could improve diagnostic accuracy.

Performance of the TWIST Score in Patients with Testicular Torsion that Present to the Emergency Department

Abstract Objective Testicular torsion (TT) is an emergency with an incidence of 1:1,500 in patients &lt; 18 years old. Irreversible changes in the testicular parenchyma may happen. The Testicular Workup for Ischemia and Suspected Torsion (TWIST) questionnaire evaluates signs and symptoms to determine the risk of TT and improve the time of management. The aim of the present study was to compare the intraoperative findings of patients with TT with the result of the preoperative TWIST questionnaire. Methods A cohort of 33 pediatric patients that consulted to the emergency room was evaluated. The TWIST questionnaire was applied in the first approach. Imaging studies, time to the operating room (OR) and intraoperative findings were evaluated. Theoretical and real findings were compared. Results The median age was 13 years old (interquartile range [IQR] 10–15 years old). Edema and scrotal inflammation was the most frequent finding (42.4%), followed by testicular induration (21.2%), nausea and vomiting (15.2%), and horizontal testicle and absence of cremasteric reflex (9.1%). The TWIST stratification was 3% high-risk, 18.2% intermediate-risk and 78.8% low-risk. Testicular Doppler ultrasound was performed in 93.9% of the patients: vascular congestion was found in 21.9%. A total of 30.3% of the kids were taken to surgery after 163 minutes (±116.5). Intraoperative diagnosis of TT was confirmed in the high-risk patient, in 33.3% of the intermediate-risk, and in 50% of the low-risk. The receiver operating characteristic (ROC) curve showed an accuracy of 60% (p = 0.602). Conclusions The TWIST questionnaire in the first approach allows to take the high-risk patients immediately to the OR. However, it might not be a reliable tool for diagnosis of TT in intermediate and low-risk patients.

Validation of the Testicular Workup for Ischemia and Suspected Torsion (TWIST) Score in the Diagnosis of Testicular Torsion in Children With Acute Scrotum

To validate the Testicular Workup for Ischemia and Suspected Torsion (TWIST) score for the evaluation of children presenting with acute scrotum. This prospective study calculated TWIST score in patients of acute scrotum admitted to a pediatric surgery unit. The scoring system consisted of testicular swelling (2 points), hard testicle (2), absent cremasteric reflex (1), nausea/vomiting (1) and high-riding testis (1). All the patients were examined by a pediatric surgeon. Among 96 children with acute scrotum, 68 (70.8%) patients had testicular torsion. In the testicular torsion group, the mean (SD) TWIST score was 5.7 (1.2) and in no torsion group, it was 1.46 (0.67). In the testicular torsion group, the number of patients with low, intermediate, and high risk was 0, 13, and 55, respectively and in without testicular torsion these were 21, 7, and 0, respectively. TWIST score has high predictive value for testicular torsion, and can be used for clinical diagnosis of testicular torsion.