1
|
Unjumbling the TWIST score for testicular torsion: systematic review and meta-analysis. Pediatr Surg Int 2023; 39:137. [PMID: 36811717 DOI: 10.1007/s00383-023-05401-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/31/2023] [Indexed: 02/24/2023]
Abstract
OBJECTIVE 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. METHODS 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. RESULTS 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. CONCLUSION 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.
Collapse
|
2
|
Bermingham HN, Popplewell MA, Naumann DN, Gulamhussein MA, Liaw F, Layton GR, Fernando H, Tucker O, Bowley D, Dilworth MP. Comparing the surgical management of acute paediatric scrotal pain between adult urologists and general surgeons in the UK: an observational study. Ann R Coll Surg Engl 2021; 104:373-379. [PMID: 34939856 DOI: 10.1308/rcsann.2021.0190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Acute scrotal pain is a common paediatric surgical emergency. Assessment and timely exploration are required to rule out testicular torsion (TT) and prevent unnecessary morbidity. METHODS A retrospective observational cohort study was carried out at two district general hospitals in the UK for boys aged ≤16 years presenting with acute scrotal pain between January 2014 and October 2017 managed by adult general surgery (AGS) at one hospital and adult urology (AU) at the other. RESULTS Some 565 patients were eligible for inclusion (n=364 AGS, n=201 AU). A higher proportion of patients underwent surgical exploration at AGS compared with AU (277/346 (80.1%) vs 96/201 (47.8%); p<0.001). Of those who underwent exploration, 101/373 (27.1%) had TT, of whom 25/101 (24.8%) underwent orchidectomy and 125/373 (33.5%) had torted testicular appendage. There was no statistically significant difference in rates of orchidectomy between AGS (19/68, 27.9%) and AU (6/33, 18.2%) with testicular salvage rates of 72.1% and 81.8%, respectively (p=0.334). Patients were twice as likely to be readmitted at AGS as at AU (28/346 (8.1%) vs 8/201 (4.0%); p=0.073). CONCLUSION Although intraoperative findings were similar between adult general surgeons and urologists, there were significant differences in surgical management, with a higher rate of surgical exploration by general surgeons. Testicular salvage and 30-day postoperative morbidity rates at both institutions were acceptable but the readmission rate was high at 6.6%. It is not known why there is a heterogeneity in management of acute scrotal pain between specialist centres, and further prospective investigations are warranted.
Collapse
Affiliation(s)
- H N Bermingham
- University Hospitals Birmingham NHS Foundation Trust, UK
| | - M A Popplewell
- University Hospitals Birmingham NHS Foundation Trust, UK
| | - D N Naumann
- University Hospitals Birmingham NHS Foundation Trust, UK
| | | | - F Liaw
- University Hospital of North Midlands NHS Trust, UK
| | - G R Layton
- University Hospitals Birmingham NHS Foundation Trust, UK
| | - H Fernando
- University Hospital of North Midlands NHS Trust, UK
| | - O Tucker
- University Hospitals Birmingham NHS Foundation Trust, UK
| | - D Bowley
- University Hospitals Birmingham NHS Foundation Trust, UK
| | - M P Dilworth
- University Hospitals Birmingham NHS Foundation Trust, UK
| |
Collapse
|
3
|
Bobillo-Perez S, Sorribes C, Gebellí P, Lledó N, Castilla M, Ramon M, Rodriguez-Fanjul J. Lung ultrasound to predict pediatric intensive care admission in infants with bronchiolitis (LUSBRO study). Eur J Pediatr 2021; 180:2065-2072. [PMID: 33585977 DOI: 10.1007/s00431-021-03978-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/26/2021] [Accepted: 02/02/2021] [Indexed: 01/01/2023]
Abstract
It is extremely difficult to stratify bronchiolitis and predict the need for admission to the pediatric intensive care unit (PICU). We aimed to evaluate the capacity of a new lung ultrasound score (LUSBRO) to predict the need for admission to the PICU compared to a clinical score. This was a prospective observational single-center study that includes infants < 6 month of age admitted to a hospital due to acute bronchiolitis. Both scores were calculated at admission. The main outcome was PICU admission. Second endpoints were the need for mechanical ventilation, respiratory support duration, and the length of stay in the hospital. Eighty patients were included, with a median age of 53 days (IQR 29-115). Forty-four patients (55%) required PICU admission. LUSBRO score showed a better AUC compared to the clinical score to predict PICU admission: 0.932 (95% CI 0.873-0.990) vs. 0.675 (95% CI 0.556-0.794) and a positive correlation with the hospital length of stay. The best cut-off point for predicting the need for PICU admission for LUSBRO score was 6, showing a sensitivity of 90.91% and a specificity of 88.89%.Conclusions: The LUSBRO score is a useful tool to predict the need for admission to the PICU. What is Known • It is extremely difficult to stratify which patients affected by bronchiolitis should be precociously transferred to a third level hospital and will require pediatric intensive care unit (PICU) admission. • Clinical scores have been created but neither of them is accurate. What is New • The LUSBRO score is a useful tool to predict the need for admission to the PICU of patients with bronchiolitis and, consequently, to predict the patients who should be transferred to a tertiary hospital to optimize respiratory support.
Collapse
Affiliation(s)
- Sara Bobillo-Perez
- Disorders of Immunity and Respiration of the Paediatric Critical Patient Research Group, Institut Recerca Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain.,Paediatric Intensive Care Unit, Hospital Sant Joan de Déu, Universitat de Barcelona, Barcelona, Spain
| | - Clara Sorribes
- Pediatric Intensive Care Unit, Paediatric Department, Hospital Joan XXIII, Tarragona, Spain
| | - Paula Gebellí
- Pediatric Intensive Care Unit, Paediatric Department, Hospital Joan XXIII, Tarragona, Spain
| | - Nuria Lledó
- Pediatric Intensive Care Unit, Paediatric Department, Hospital Joan XXIII, Tarragona, Spain
| | - Marta Castilla
- Pediatric Intensive Care Unit, Paediatric Department, Hospital Joan XXIII, Tarragona, Spain
| | - Miquel Ramon
- Pediatric Intensive Care Unit, Paediatric Department, Hospital Joan XXIII, Tarragona, Spain
| | - Javier Rodriguez-Fanjul
- Neonatology Unit, Paediatric Department, Hospital Germans Trias i Pujol, Universitat Autònoma de Barcelona, Carretera de Canyet, s/n, 08916 Badalona, Barcelona, Spain.
| |
Collapse
|
4
|
Rodriguez-Martinez CE, Nino G, Castro-Rodriguez JA, Perez GF, Sossa-Briceño MP, Buendia JA. Cost-effectiveness analysis of phenotypic-guided versus guidelines-guided bronchodilator therapy in viral bronchiolitis. Pediatr Pulmonol 2021; 56:187-195. [PMID: 33049126 PMCID: PMC8850934 DOI: 10.1002/ppul.25114] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 09/10/2020] [Accepted: 10/09/2020] [Indexed: 11/07/2022]
Abstract
OBJECTIVES Although recent evidence suggests that management of viral bronchiolitis requires something other than guidelines-guided therapy, there is a lack of evidence supporting the economic benefits of phenotypic-guided bronchodilator therapy for treating this disease. The aim of the present study was to compare the cost-effectiveness of phenotypic-guided versus guidelines-guided bronchodilator therapy in infants with viral bronchiolitis. METHODS A decision analysis model was developed to compare the cost-effectiveness of phenotypic-guided versus guidelines-guided bronchodilator therapy in infants with viral bronchiolitis. Phenotypic-guided bronchodilator therapy was defined as the administration of albuterol in infants exhibiting a profile of increased likelihood of response to bronchodilators. The effectiveness parameters and costs of the model were obtained from systematic reviews of the literature with meta-analyses and electronic medical records. The main outcome was the avoidance of hospital admission after initial care in the emergency department. RESULTS Compared to guidelines-guided strategy, treating patients with viral bronchiolitis with the phenotypic-guided bronchodilator therapy strategy was associated with lower total costs (US$250.99; 95% uncertainty interval [UI]: US$184.37 to $336.51 vs. US$263.46; 95% UI: US$189.81 to $349.19 average cost per patient) and a higher probability of avoidance of hospital admission (0.7902; 95% UI: 0.7315-0.8356 vs. 0.7638; 95% UI: 0.7062-0.8201), thus leading to dominance. Results were robust to deterministic and probabilistic sensitivity analyses. CONCLUSIONS Compared to guidelines-guided strategy, treating infants with viral bronchiolitis using the phenotypic-guided bronchodilator therapy strategy is a more cost-effective strategy, because it involves a lower probability of hospital admission at lower total treatment costs.
Collapse
Affiliation(s)
- Carlos E Rodriguez-Martinez
- Department of Pediatrics, School of Medicine, Universidad Nacional de Colombia, Bogota, Colombia.,Department of Pediatric Pulmonology and Pediatric Critical Care Medicine, School of Medicine, Universidad El Bosque, Bogota, Colombia
| | - Gustavo Nino
- Division of Pediatric Pulmonary and Sleep Medicine, Children's National Hospital, George Washington University, Washington, DC, USA
| | - Jose A Castro-Rodriguez
- Division of Pediatrics, Department of Pediatric Pulmonology and Cardiology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Geovanny F Perez
- Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences, Oishei Children's Hospital, University at Buffalo, Buffalo, New York, USA
| | | | - Jefferson A Buendia
- Department of Pharmacology and Toxicology, School of Medicine, Research Group in Pharmacology and Toxicology (INFARTO), Universidad de Antioquia, Medellín, Colombia
| |
Collapse
|
5
|
Barbosa JABA, de Freitas PFS, Carvalho SAD, Coelho AQ, Yorioka MAW, Pereira MWA, Borges LL, Srougi M, Nahas WC, Arap MA. Validation of the TWIST score for testicular torsion in adults. Int Urol Nephrol 2020; 53:7-11. [PMID: 32844355 DOI: 10.1007/s11255-020-02618-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 08/17/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE The TWIST (Testicular Work-up for Ischemia and Suspected Torsion) score was developed to allow for expedited diagnosis of testicular torsion (TT) in children based on clinical variables: edema (2 points), hard mass (2), absent cremasteric reflex (1), high-riding testis (1) and nausea/vomiting (1). We sought to validate the TWIST Score applied by non-expert physicians for the diagnosis of testicular torsion in an adult population. METHODS We prospectively analyzed all consecutive males presenting to a tertiary hospital with acute scrotum. Patients with previous scrotal pathology or trauma were excluded. Physical examination was performed by a general surgeon and variables of TWIST were recorded. All patients underwent Scrotal Doppler Ultrasound. Measures of accuracy of the TWIST score and ROC curves were generated to evaluate its performance in diagnosing TT in adults. RESULTS Of 68 patients, 34 had TT (50%). Median age was 24.9 years. According to the original cutoffs of TWIST, 23 patients had a score ≤ 2 among which none had TT. Fifteen patients had a score of 3-4, among which seven had TT. Thirty patients had a score ≥ 5, among which 27 had TT. All 18 patients with a score of 6 or greater had TT (100% PPV). ROC curve revealed an AUC of 0.95. CONCLUSION The TWIST Score is valid for the diagnosis of Testicular Torsion in adults, presenting a PPV of 90% for a cutoff of 5 points and 100% for six points. In all patients with a score of 2 or less, the disease could be safely excluded (100% NPV).
Collapse
Affiliation(s)
- João Arthur Brunhara Alves Barbosa
- Hospital das Clínicas da Faculdade de Medicina da USP - Urologia, University of Sao Paulo Medical School, Av Dr Eneas Carvalho Aguiar, 255 - 7o andar (Urologia), São Paulo, CEP, 05403-000, Brazil. .,Hospital Israelita Albert Einstein, Av Albert Einstein, 627. Building A1, Suite 409, Sao Paulo, CEP, 05652-900, Brazil.
| | - Pedro Felipe Silva de Freitas
- Hospital das Clínicas da Faculdade de Medicina da USP - Urologia, University of Sao Paulo Medical School, Av Dr Eneas Carvalho Aguiar, 255 - 7o andar (Urologia), São Paulo, CEP, 05403-000, Brazil
| | - Sergio Andurte Duarte Carvalho
- Hospital das Clínicas da Faculdade de Medicina da USP - Urologia, University of Sao Paulo Medical School, Av Dr Eneas Carvalho Aguiar, 255 - 7o andar (Urologia), São Paulo, CEP, 05403-000, Brazil
| | - Augusto Quaresma Coelho
- Hospital das Clínicas da Faculdade de Medicina da USP - Urologia, University of Sao Paulo Medical School, Av Dr Eneas Carvalho Aguiar, 255 - 7o andar (Urologia), São Paulo, CEP, 05403-000, Brazil
| | - Marco Aurelio Watanabe Yorioka
- Hospital das Clínicas da Faculdade de Medicina da USP - Urologia, University of Sao Paulo Medical School, Av Dr Eneas Carvalho Aguiar, 255 - 7o andar (Urologia), São Paulo, CEP, 05403-000, Brazil
| | - Maykon William Aparecido Pereira
- Hospital das Clínicas da Faculdade de Medicina da USP - Urologia, University of Sao Paulo Medical School, Av Dr Eneas Carvalho Aguiar, 255 - 7o andar (Urologia), São Paulo, CEP, 05403-000, Brazil
| | - Leonardo Lima Borges
- Hospital Israelita Albert Einstein, Av Albert Einstein, 627. Building A1, Suite 409, Sao Paulo, CEP, 05652-900, Brazil
| | - Miguel Srougi
- Hospital das Clínicas da Faculdade de Medicina da USP - Urologia, University of Sao Paulo Medical School, Av Dr Eneas Carvalho Aguiar, 255 - 7o andar (Urologia), São Paulo, CEP, 05403-000, Brazil
| | - William C Nahas
- Hospital das Clínicas da Faculdade de Medicina da USP - Urologia, University of Sao Paulo Medical School, Av Dr Eneas Carvalho Aguiar, 255 - 7o andar (Urologia), São Paulo, CEP, 05403-000, Brazil
| | - Marco Antonio Arap
- Hospital das Clínicas da Faculdade de Medicina da USP - Urologia, University of Sao Paulo Medical School, Av Dr Eneas Carvalho Aguiar, 255 - 7o andar (Urologia), São Paulo, CEP, 05403-000, Brazil.,Hospital Sirio Libanês, Rua Barata Ribeiro 387, Sao Paulo, SP, 01308-050, Brazil
| |
Collapse
|
6
|
Mjaess G, Aoun F, Albisinni S, Vanhaeverbeek M, Roumeguère T. Evidence-based medicine, the number 'three' and its multiples in urological clinical rules. Scand J Urol 2020; 55:86-88. [PMID: 32648513 DOI: 10.1080/21681805.2020.1792978] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Georges Mjaess
- Urology Department, University Clinics of Brussels, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium.,Hôtel Dieu de France, Université Saint Joseph, Beyrouth, Liban
| | - Fouad Aoun
- Hôtel Dieu de France, Université Saint Joseph, Beyrouth, Liban.,Urology Department, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | - Simone Albisinni
- Urology Department, University Clinics of Brussels, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Michel Vanhaeverbeek
- Laboratory of Experimental Medicine, ULB 222, Université Libre de Bruxelles, CHU Charleroi, Charleroi, Belgium
| | - Thierry Roumeguère
- Urology Department, University Clinics of Brussels, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium.,Urology Department, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium.,Laboratory of Experimental Medicine, ULB 222, Université Libre de Bruxelles, CHU Charleroi, Charleroi, Belgium
| |
Collapse
|