Improving testicular examinations on paediatric patients in the emergency department: A quality improvement study to improve early diagnosis of testicular torsion

Cheng, Ernest; Chui, Juanita N; Crowe, Murray; Cooke, Andrew

doi:10.1016/j.ajur.2021.07.002

Cited by 3 publications

(5 citation statements)

References 14 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Full texts were reviewed for 17 articles. Four were removed as they did not report diagnostic outcomes, 14 evaluated the same cohort as another included study, 15 conducted a narrative review 16 and used TWIST in an unsuitable cohort of middle-aged males. 17 The remaining 13 articles met the inclusion criteria and were included in the final analysis.…”

Section: Resultsmentioning

confidence: 99%

“…A recent Australian study showed that the simple placement of educational posters around the emergency department increased TWIST documentation from 49% to 63% over 3 months. 14 Our review should be considered in the context of the following limitations. First, all studies were observational.…”

Section: Discussionmentioning

confidence: 99%

“…A recent Australian study showed that the simple placement of educational posters around the emergency department increased TWIST documentation from 49% to 63% over 3 months. 14…”

Section: Discussionmentioning

confidence: 99%

See 2 more Smart Citations

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

Qin

2022

Journal of Urology

View full text Add to dashboard Cite

Purpose: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.Materials and Methods: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.Results: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.Conclusions: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.

show abstract

Section: Resultsmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

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

Qin

2022

Journal of Urology

View full text Add to dashboard Cite

show abstract

“…Only 23.8% of TT patients received timely treatment within 6 h after onset of symptoms. Therefore, as a time-sensitive diagnosis, early recognition and definitive management of TT are critical 10 .…”

Section: Discussionmentioning

confidence: 99%

Analysis of factors associated with delayed diagnosis and treatment of testicular torsion in 1005 cases from Chongqing city, China: a cross-sectional study

Yi,

Wang,

et al. 2023

Sci Rep

View full text Add to dashboard Cite

This study aimed to investigate the clinical and social factors of delayed treatment for testicular torsion (TT) and to explore the risk factors of testicular excision in China. The clinical data of 1005 patients with TT who were admitted to 48 medical institutions in Chongqing city (China) from January 2012 to December 2021 were retrospectively analyzed. It was revealed that the misdiagnosis rates of non-senior (junior and middle) grade doctors and senior doctors were 25.1% and 9.6%, respectively. The proportion of TT patients who received timely treatment (within 6 h after onset of symptoms) was 23.8%. The results of the multivariable logistic regression analysis indicated that absent cremasteric reflex was a protective factor for delayed surgery of more than 6 h from onset of symptoms to surgery. Misdiagnosis, consultation with a non-urologist as the first consultant doctor, absence blood flow in color Doppler ultrasound, negative high-riding testis findings, the presence of fever, and non-manual detorsion were identified as risk factors associated with delayed surgery (more than 6 h from the onset of symptoms) for TT. Furthermore, misdiagnosis, non-urologist first-consultant doctor, absent blood flow in DUS, non-manual detorsion, fever, degree of cord twisting > 180, and the initial diagnosis in tertiary hospitals were risk factors for orchidectomy. Having TT on the right side, and the presence of nausea and vomiting were identified as protective factors for orchidectomy. Technical training in the diagnosis and treatment of TT should be extended to primary hospitals and doctors to significantly improve their accuracy in managing this condition.

show abstract

“…One group increased the awareness of testicular torsion and the examination components of the TWIST score by placing educational posters in the emergency department. 13 Increased use of this clinical algorithm offers the opportunity for expediting decision making and standardizing management of the acute scrotum across hospitals. Through shared best practices and a systematic approach, the outcomes of testicular torsion can be optimized, providing all patients with high-quality, rapid care.…”

mentioning

confidence: 99%

Let's Do the TWIST

Finkelstein

2022

Journal of Urology

View full text Add to dashboard Cite

Testicular torsion is a frequently encountered urological emergency that presents a time-sensitive risk to the testicle. Prompt diagnosis and treatment are crucial in the management of this condition, as delays may result in testicular loss. Clinical decision tools can aid in the evaluation and timely diagnosis of patients presenting with an acute scrotum where testicular torsion is suspected. One such tool was introduced by Barbosa and colleagues in 2013, the 7-point Testicular Workup for Ischemia and Suspected Torsion (TWIST) score. 1 Patients are stratified into 3 risk groups based on 5 criteria from the history and clinical examinationdlow, intermediate and high riskdwith recommendations for rule-out, further evaluation with ultrasound and surgical exploration, respectively.Within the last several years, there have been a number of studies evaluating the TWIST algorithm. Most studies have employed the Barbosa stratification system without questioning whether the scoring thresholds are appropriate. In this issue of The Journal, Qin and Qu (page 62) performed a systematic review from pertinent prospective and retrospective studies as well as a meta-analysis to determine the diagnostic utility of TWIST and its role in risk stratification of testicular torsion. 2 The authors specifically examined various TWIST cutoff scores to ascertain the ideal risk stratification system for widespread adoption.One can conclude from this well-conducted study that the TWIST algorithm is an accurate risk stratification instrument for testicular torsion. The authors confirmed that the original scoring system proposed by Barbosa had the greatest overall reliability: the AUC was 0.924, the sensitivity for the low-risk group was 98.4% and specificity in the high-risk group was 97.5%. Application of TWIST to high-risk patients may reduce delays in management caused by unnecessary imaging, potentially improving the time to treatment, leading to better outcomes in patients with testicular torsion and reducing costs. This portends particular significance in resource-limited settings, where waiting for imaging may delay diagnosis and result in unfavorable surgical outcomes.

show abstract

Improving testicular examinations on paediatric patients in the emergency department: A quality improvement study to improve early diagnosis of testicular torsion

Cited by 3 publications

References 14 publications

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

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

Analysis of factors associated with delayed diagnosis and treatment of testicular torsion in 1005 cases from Chongqing city, China: a cross-sectional study

Let's Do the TWIST

Contact Info

Product

Resources

About