Comparison of the outcomes of testicular torsion among children presenting during the Coronavirus Disease 2019 (COVID-19) pandemic versus the pre-pandemic period: A systematic review and meta-analysis

The Impact of COVID-19 on Acute Surgeries in England Among the Under-25s: A Retrospective Study of 61,360 Appendicitis and 15,850 Testicular Torsion Admissions

BACKGROUND

Little is known about how COVID-19 impacted acute surgical activity for children and young people (CYP) across England. Appendicitis and testicular torsion are common surgical conditions where treatment delays can lead to avoidable complications. We undertook a retrospective national cohort study.

PRIMARY AIM

To describe monthly acute surgical activity in CYP during the COVID-19 pandemic. Secondary aim: To investigate evidence of delayed diagnosis and adverse outcomes, describing variations by age and socioeconomic deprivation.

METHODS

Acute hospital admissions with appendicitis or testicular pain for those under 18 were extracted using Hospital Episode Statistics. Interrupted time series modelling, Mann-Whitney and Pearson's Chi-Squared tests compared the first 14 pandemic months with the previous five years. Results were stratified by age (0-4s, 5-9s and 10-17s) and appendicitis type (all, simple and complex).

RESULTS

Admissions for appendicitis and testicular torsion fell significantly early in the COVID-19 pandemic. The proportion of children with complex appendicitis also increased during this time. Orchidectomy rates rose in April 2020 for the 0-4s (+15.6% (95% CI 7.9-23.3)) and 10-17s (+11.5% (4.9-18.2)), but when the pre-pandemic period was compared with the pandemic period as a whole, there were no overall statistically significant differences in orchidectomy rates between the study periods. Overall, there was a statistically significant rise in the orchidopexy rate during the pandemic period for the 10-17s when compared with the pre-pandemic period (Pre-pandemic: 17.0% vs Pandemic: 20.9%, p < 0.0001).

CONCLUSION

A consistent reduction in activity, with short-lived periods of delayed presentations during COVID-19 pandemic peaks, occurred without persisting overall increased complication rates. These results provide useful national context for smaller sized studies that reported complications due to delays in surgery. Future research could examine how reduced activity impacted other healthcare settings and treatment pathways.

LEVEL OF EVIDENCE

II.

Appendicitis tends to be complicated during the COVID-19 epidemic: A multicentre retrospective study

Background

In past studies, non-medical factors in the social-healthcare-patient triad associated with the prevalence of COVID-19 have led to delays in the presentation of patients with acute appendicitis and an increase in complications. However, as research progresses, there is increasing evidence of a clinical association between COVID-19 and the development of acute appendicitis.

Methods

The effect of COVID-19 prevalence and associated factors on acute appendicitis in the control (2016-2019) and exposed (2020-2023) groups was derived from a retrospective study of 3070 patients with acute appendicitis from 2016 to 2023.

Results

After the implementation of the restrictions, the rate of acute appendicitis visits in the exposed group compared to the control group dropped sharply in the initial period (P = 0.047) and recovered gradually with the relaxation of the restrictions. Similar changes occurred in the number of acute complicated appendicitis visits. In addition, after the lifting of restrictions and the COVID-19 outbreak, the proportion of acute complicated appendicitis in the exposed group increased significantly (P < 0.001) and an increase in the number of complicated appendicitis visits was observed (P < 0.001) compared with the control group. In addition, the age distribution of acute appendicitis during this period showed an ageing trend (P = 0.001).

Conclusion

COVID-19 infections may be more likely to progress to complicated appendicitis after an episode of appendicitis, even if they have been cured for the same period of time. In addition, the proportion of elderly patients with appendicitis increased after the COVID-19 epidemic.

Challenges and Solutions during the COVID-19 Pandemic: Hospitalization and Performance in Elective Pediatric Surgeries

Background and Objectives: This retrospective study aimed to investigate the impact of the COVID-19 pandemic on the most frequently performed elective pediatric surgical procedures and the number of hospitalizations and compare it to the pre-pandemic and post-pandemic periods. Materials and Methods: The subjects were patients under 18 years of age who were regularly admitted for selected elective procedures in a single tertiary center in Croatia from 1 March to 31 August of 2019, 2020, 2021, and 2022. Data were collected from the electronic logs of surgical procedures and hospital admissions, logs of one-day surgeries, patients' medical records, and discharge letters. The primary outcome of this study was to determine the evolution of the number of elective surgical procedures before, during, and after the peak of the COVID-19 pandemic; also, we aimed to confirm and objectify global data and statements about the decrease in the number of hospital admissions and surgical procedures. Secondary outcome measures included the length of hospitalization, the number and types of complications, and readmissions. Results: In 2020, the number of elective procedures decreased by 28.3% and the number of hospitalizations decreased by 36.2%; in 2021, the number of elective procedures decreased by 30.8% and the number of hospitalizations decreased by 14.2% compared to the pre-pandemic period (2019). In 2022, there was a 22.8% increase in elective procedures and a 2.9% decrease in hospitalizations compared to 2019. No statistical difference was found in the rates of complications between the individual years studied in terms of complications (p = 0.869). Conclusions: The number of elective procedures and hospitalizations during the COVID-19 pandemic has decreased significantly compared to the pre-pandemic period. After the healthcare system adapted to the conditions of the pandemic, the number of elective procedures increased significantly despite COVID-19, while the number of hospitalizations remained approximately the same as before the pandemic.

Evidence linking COVID-19 and the health/well-being of children and adolescents: an umbrella review

BACKGROUND

Experiences during childhood and adolescence have enduring impacts on physical and mental well-being, overall quality of life, and socioeconomic status throughout one's lifetime. This underscores the importance of prioritizing the health of children and adolescents to establish an impactful healthcare system that benefits both individuals and society. It is crucial for healthcare providers and policymakers to examine the relationship between COVID-19 and the health of children and adolescents, as this understanding will guide the creation of interventions and policies for the long-term management of the virus.

METHODS

In this umbrella review (PROSPERO ID: CRD42023401106), systematic reviews were identified from the Cochrane Database of Systematic Reviews; EMBASE (OvidSP); and MEDLINE (OvidSP) from December 2019 to February 2023. Pairwise and single-arm meta-analyses were extracted from the included systematic reviews. The methodological quality appraisal was completed using the AMSTAR-2 tool. Single-arm meta-analyses were re-presented under six domains associated with COVID-19 condition. Pairwise meta-analyses were classified into five domains according to the evidence classification criteria. Rosenberg's FSN was calculated for both binary and continuous measures.

RESULTS

We identified 1551 single-arm and 301 pairwise meta-analyses from 124 systematic reviews that met our predefined criteria for inclusion. The focus of the meta-analytical evidence was predominantly on the physical outcomes of COVID-19, encompassing both single-arm and pairwise study designs. However, the quality of evidence and methodological rigor were suboptimal. Based on the evidence gathered from single-arm meta-analyses, we constructed an illustrative representation of the disease severity, clinical manifestations, laboratory and radiological findings, treatments, and outcomes from 2020 to 2022. Additionally, we discovered 17 instances of strong or highly suggestive pairwise meta-analytical evidence concerning long-COVID, pediatric comorbidity, COVID-19 vaccines, mental health, and depression.

CONCLUSIONS

The findings of our study advocate for the implementation of surveillance systems to track health consequences associated with COVID-19 and the establishment of multidisciplinary collaborative rehabilitation programs for affected younger populations. In future research endeavors, it is important to prioritize the investigation of non-physical outcomes to bridge the gap between research findings and clinical application in this field.

Management of Pediatric Foreign Body Injuries during the COVID-19 Pandemic: Results of an International Survey

The COVID-19 pandemic has had direct and indirect effects on daily life. In hospitals, the impact of the pandemic was observed in the diagnostic and therapeutic workflow. In this work, we explored potential changes in activities related to the treatment of foreign body injuries (FBIs) in children and the behavioral habits of physicians during the first wave of the pandemic. An online survey was conducted among physicians of the Susy Safe network. The survey comprised items related to respondent information, reference center characteristics, the treatment of FBIs during the COVID-19 pandemic, and a modified COVID-19 Anxiety Scale (CAS). The survey was distributed among the Susy Safe project international network surveillance registry for FBIs. A total of 58 physicians responded to the survey, including 18 (32%) from Europe and 16 (28%) from South America. The respondents indicated that the estimated number of aspirated foreign bodies during the pandemic was lower than or the same as that before the pandemic (43, 74%), and the same was observed for ingested foreign bodies (43, 74%). In univariable logistic regression, no single predictor was associated with a delay in routine care for children or an increasing tendency of medical personnel to avoid procedures. The workflow of physicians involved in the management of FBIs in children has not changed drastically during the COVID-19 pandemic, especially in emergency departments.

Tackling a Post-COVID-19 Cholecystectomy Waiting List: Are We Meeting the Challenge?

Background and Objectives: The COVID-19 pandemic has led to a tremendous backlog in elective surgical activity. Our hospital trust adopted an innovative approach to dealing with elective waiting times for cholecystectomy during the recovery phase from COVID-19. This study aimed to evaluate trends in overall cholecystectomy activity and the effect on waiting times. Materials and Methods: A prospective observational study was undertaken, investigating patients who received a cholecystectomy at a large United Kingdom hospital trust between February 2021 and February 2022. There were multiple phased strategies to tackle a 533-patient waiting list: private sector, multiple sites including emergency operating, mobile theatre, and seven-day working. The correlation of determination (R2) and Kruskal-Wallis analysis were used to evaluate trends in waiting times across the study period. Results: A total of 657 patients underwent a cholecystectomy. The median age was 49 years, 602 (91.6%) patients had an ASA of 1-2, and 494 (75.2%) were female. A total of 30 (4.6%) patients were listed due to gallstone pancreatitis, 380 (57.8%) for symptomatic cholelithiasis, and 228 (34.7%) for calculous cholecystitis. Median waiting times were reduced from 428 days (IQR 373-508) to 49 days (IQR 34-96), R2 = 0.654, p < 0.001. For pancreatitis specifically, waiting times had decreased from a median of 218 days (IQR 139-239) to 28 (IQR 24-40), R2 = 0.613, p < 0.001. Conclusions: This study demonstrates the methodology utilised to safely and effectively tackle the cholecystectomy waiting list locally. The approach utilised here has potential to be adapted to other units or similar operation types in order to reduce elective waiting times.

Delayed Care Seeking and Outcomes of Testicular Torsion among Children during the COVID-19 Pandemic: A Systematic Review and Meta-Analysis

INTRODUCTION

 Since the onset of coronavirus disease 2019 (COVID-19), stay-at-home orders and fear caused by the pandemic have had a significant effect on the timing and outcomes of testicular torsion. However, the evidence was limited since the study results were inconsistent. This study aims to examine the hospitalization rates, timing, and outcomes of testicular torsion in children before and during the pandemic.

MATERIALS AND METHODS

 Using PubMed, Embase, and Google Scholar databases, we conducted a systematic search and meta-analysis of studies reporting the timing and outcomes of children admitted with testicular torsion before and during the COVID-19 pandemic. Subgroup analyses were conducted to explore possible sources of heterogeneity.

RESULT

 The outcomes of 899 testicular torsion patients from eight studies were evaluated. Our study found an increased hospitalization rate for patients with testicular torsion (incidence rate ratio = 1.60, 95% confidence interval [CI]: 1.27-2.03; p = 0.001). Despite a significant increase in the duration of symptoms during the COVID-19 pandemic (weighted mean difference = 11.04, 95% CI: 2.75-19.33; p = 0.009), orchiectomy rates did not increase (odds ratio = 1.33, 95% CI: 0.85-2.10; p = 0.147).

CONCLUSION

 During the COVID-19 pandemic, hospitalization rates for testicular torsion and the duration of symptoms among children increased significantly. Moreover, the rate of orchiectomy did not increase during the pandemic, indicating that pediatric emergency services have remained efficient and have prevented an increase in the number of orchiectomies performed despite pandemic-related closures and delays in transporting patients to medical care.

[Effect of the COVID-19 pandemic on the outcome of testicular torsion in children]

INTRODUCTION

The COVID-19 pandemic influenced not only the elective, but the acute surgeries also, all around the world. Some authors found more delayed cases and more orchiectomies performed in childhood because of testicular torsions during the pandemic.

OBJECTIVE

To examine the impact of the COVID-19 pandemic on the treatment of childhood testicular torsion and the frequency of semicastration due to torsion at the first author's institute.

METHODS

A retrospective observational cohort study was performed in a representative Hungarian centre. Boys under 18 years of age operated with testicular torsion were divided into two groups: before COVID-19 (BC; 01/07/2017-31/12/2019) and during COVID-19 (DC; 01/01/2020-30/06/2022) pandemic.

PARAMETERS

elapsed time between the first symptom and arrival at the hospital (<24 h or >24 h), elapsed time to start the surgical procedure since the arrival to the hospital and the rate of semicastration were analysed. For statistical analysis, Mann-Whitney U and chi2 tests were used.

RESULTS

During the study period, altogether, 100 patients (45 BC and 55 DC) were operated on testicular torsion. Statistically significant difference was found between the two timeframes: in the elapsed time from the first symptom and arrival at the hospital (p = 0.048). During the pandemic surgeries started earlier (1.5; 2.5 h) than before the pandemic (1.5; 3.25 h, p = 0.01). No difference was found in the frequency of semicastration between the groups (p = 0.594).

DISCUSSION

Contrary to the literature, during the COVID-19 pandemic, patients with testicular torsion arrived earlier at the hospital, and surgeries were started earlier, than before the pandemic at the investigated institute.

CONCLUSION

The reason behind this accelerated care pathway might be the absence of less severe cases during the COVID-19 period. When people are more prone to stay home, if it does not seem necessary to seek help for any kind of non-urgent medical problem. Orv Hetil. 2023; 164(35): 1367-1372.

Impact of COVID-19 on the associated complications of high-risk conditions in a statewide pediatric emergency network

Background

The COVID-19 pandemic affected the volume and epidemiology of pediatric emergency department (ED) visits. We aimed to determine the rate of associated complications for 16 high-risk conditions in a Michigan statewide network of academic and community EDs during the pandemic.

Methods

We conducted a cross-sectional study of pediatric ED visits among a network of 5 Michigan health systems during the pre-pandemic (March 1, 2019-March 10, 2020) and pandemic (March 11, 2020-March 31, 2021) periods. Data were collected from the medical record and included patient demographics, ED visit characteristics, procedure codes, and final International Classification of Diseases, 10th Revision, Clinical Modification diagnosis codes. Selection of codes for 16 high-risk conditions and diagnostic complications were identified using previously described methods. Characteristics of ED visits were compared before versus during the pandemic using χ2 and Fisher's exact tests. We used multilevel logistic regression to analyze covariates and potential confounders for being diagnosed with a high-risk condition or a complication of a high-risk condition.

Results

A total of 417,038 pediatric ED visits were analyzed. The proportion of patients presenting with 10 of 16 high-risk conditions (including appendicitis, sepsis, and stroke) was higher in the pandemic period compared with pre-pandemic (P < 0.01). Despite this, there was no significant increase in the frequency of complications for any of the 16 high-risk conditions during the pandemic. The adjusted odds of being diagnosed with appendicitis (pre-pandemic 0.23% vs pandemic 0.52%; odds ratio [OR], 1.19 [95% confidence interval, CI, 1.00-1.41]), diabetic ketoacidosis (pre-pandemic 0.16% vs pandemic 0.52%; OR, 2.40 [95% CI, 2.07-2.78]), intussusception (pre-pandemic 0.05% vs pandemic 0.07%; OR, 1.64 [95% CI, 1.22-2.21)], and testicular torsion (pre-pandemic 0.10% vs pandemic 0.14%; OR, 1.64 [95% CI, 1.18-2.28]) was higher during the pandemic.

Conclusions

Despite a higher proportion of ED visits attributed to high-risk conditions, there was no increase in complications, suggesting minimal impact of the pandemic on outcomes of pediatric ED visits.

Testicular torsion during the COVID-19 pandemic: Results of a multicenter study in northern Italy

INTRODUCTION

The literature reported an increased avoidance of the Emergency Department (ED) during COrona VIrus Disease 19 (COVID-19) pandemic, causing a subsequent increase of morbidity and mortality for acute conditions. Testicular torsion is a surgical emergency, which can lead to the loss of the affected testicle if a delayed treatment occurs. As testicular loss is time-related, outcome was hypothesized to be negatively affected by the pandemic.

OBJECTIVE

The aim is to investigate whether presentation, treatment and outcomes of children with testicular torsion were delayed during COVID-19.

STUDY DESIGN

Medical records of pediatric patients operated for testicular torsion of six Paediatric Surgical Units in Northern Italy between January 2019 and December 2020 were retrospectively reviewed. Patients were divided as for ones treated during (dC) or before the pandemic (pC). To reflect possible seasonality, related to lockdown restrictions, winter and summer calendar blocks were also analysed. For all cohorts, demographic data, pre-operative evaluation, operative notes and post-operative outcomes were reviewed. Primary outcomes were referral time, time from diagnosis to surgery and ischemic time, while secondary outcomes were orchiectomy and atrophy rates. Statistic was conducted as appropriate.

RESULTS

A total of 188 patients with acute testicular torsion were included in the study period, 89 in the pre-COVID-19 (pC) period and 99 during COVID-19 (dC). Time from symptom onset to the access to the Emergency Department (T1) was not different among the two populations (pC: 5,5 h, dC: 6 h, p 0.374), and similarly time from diagnosis to surgery (pC: 2,5 h, dC: 2,5 h, p 0.970) and ischemic time (pC: 8,2 h, dC: 10 h, p 0.655). T1 was <6 h in 46/99 patients (46%) pC and 45/89 patients (51%) dC (p = 0.88, Fisher's exact test). Subgroup analysis accounting for different lockdown measures, confirm the absence of any difference. Orchiectomies rate was 23% (23/99) dC and 21% (19/89) pC (p = 0.861, Fisher's exact test) and rate of post-operative atrophy was 9% dC (7/76) and 14% pC (10/70), p = 0,44, Fisher's exact test.

DISCUSSION

Despite worldwide pediatric ED accesses reduction, we reported that neither ischemic time nor the long-term outcomes in children with testicular torsion increased during the COVID-19 pandemic. In the available literature, few studies investigated the topic and are controversial on the results. Similarly to our findings, some studies found that timing and orchiectomy rates were not significantly different during the pandemic, while others reported a correlation to pandemic seasonality. Furthermore, in the recent pediatric literature it has been reported a delayed testicular torsion diagnosis due to shame in informing parents. Strengths of this study are the large numerosity, its multicentric design and a long study period. Its main limitation is being retrospective.

CONCLUSIONS

We reported our large cohort from one of the most heavily COVID-19-affected regions, finding that referral, intra-hospital protocols and ischemic time in testicular torsion were not increased during to the pandemic, as well as orchiectomy rate and atrophy.