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      Situation of Pediatric Patients with Testicular Torsion in Times of COVID-19


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          Purpose. To assess whether the COVID-19 pandemic had an influence on presentation of testicular torsion and/or increase in the frequency of orchiectomy. Patients and Methods. This retrospective study included boys under 18 years of age with testicular torsion divided in two groups: pre-COVID operated in 2019 vs. COVID-19 group from 2020. We compared demographic data as well as local and general symptoms. We analyzed additional tests, intraoperative findings, length of operation and hospitalization, and followup. Results. We analyzed the data collected from 44 patients (24 boys from first group vs. 20 boys from second group). The median age was 13.4 years vs. 14.5 years in the latter. The median time of symptoms duration was 6.5 hours and 8.5 hours, respectively. The main manifestation was testicular pain without additional signs. The results of the laboratory tests did not reflect local advancement. In the 2019 group, Doppler ultrasound showed absent blood flow in the affected testicle in 62% vs. 80% in 2020. The mean time from admission to surgery was virtually identical: 75 minutes in 2019 vs. 76 minutes in 2020. The mean duration of scrotal revision was similar in both groups. There was only one significant difference: the degree of twisting. In 2019, the mean was 360° vs. 540° in 2020. Incidence of orchiectomy also did not significantly vary between the analyzed time periods, with 21% during the pandemic and 35% during the pre-COVID-19 period. Conclusion. We did not observe an increase in the number of testicular torsion cases during the COVID-19 pandemic. Most importantly, the rates of orchiectomy did not significantly differ between the patients with testicular torsion presenting during the COVID-19 outbreak.

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          WHO Declares COVID-19 a Pandemic

          The World Health Organization (WHO) on March 11, 2020, has declared the novel coronavirus (COVID-19) outbreak a global pandemic (1). At a news briefing, WHO Director-General, Dr. Tedros Adhanom Ghebreyesus, noted that over the past 2 weeks, the number of cases outside China increased 13-fold and the number of countries with cases increased threefold. Further increases are expected. He said that the WHO is “deeply concerned both by the alarming levels of spread and severity and by the alarming levels of inaction,” and he called on countries to take action now to contain the virus. “We should double down,” he said. “We should be more aggressive.” Among the WHO’s current recommendations, people with mild respiratory symptoms should be encouraged to isolate themselves, and social distancing is emphasized and these recommendations apply even to countries with no reported cases (2). Separately, in JAMA, researchers report that SARS-CoV-2, the virus that causes COVID-19, was most often detected in respiratory samples from patients in China. However, live virus was also found in feces. They conclude: “Transmission of the virus by respiratory and extrarespiratory routes may help explain the rapid spread of disease.”(3). COVID-19 is a novel disease with an incompletely described clinical course, especially for children. In a recente report W. Liu et al described that the virus causing Covid-19 was detected early in the epidemic in 6 (1.6%) out of 366 children (≤16 years of age) hospitalized because of respiratory infections at Tongji Hospital, around Wuhan. All these six children had previously been completely healthy and their clinical characteristics at admission included high fever (>39°C) cough and vomiting (only in four). Four of the six patients had pneumonia, and only one required intensive care. All patients were treated with antiviral agents, antibiotic agents, and supportive therapies, and recovered after a median 7.5 days of hospitalization. (4). Risk factors for severe illness remain uncertain (although older age and comorbidity have emerged as likely important factors), the safety of supportive care strategies such as oxygen by high-flow nasal cannula and noninvasive ventilation are unclear, and the risk of mortality, even among critically ill patients, is uncertain. There are no proven effective specific treatment strategies, and the risk-benefit ratio for commonly used treatments such as corticosteroids is unclear (3,5). Septic shock and specific organ dysfunction such as acute kidney injury appear to occur in a significant proportion of patients with COVID-19–related critical illness and are associated with increasing mortality, with management recommendations following available evidence-based guidelines (3). Novel COVID-19 “can often present as a common cold-like illness,” wrote Roman Wöelfel et al. (6). They report data from a study concerning nine young- to middle-aged adults in Germany who developed COVID-19 after close contact with a known case. All had generally mild clinical courses; seven had upper respiratory tract disease, and two had limited involvement of the lower respiratory tract. Pharyngeal virus shedding was high during the first week of symptoms, peaking on day 4. Additionally, sputum viral shedding persisted after symptom resolution. The German researchers say the current case definition for COVID-19, which emphasizes lower respiratory tract disease, may need to be adjusted(6). But they considered only young and “normal” subjecta whereas the story is different in frail comorbid older patients, in whom COVID 19 may precipitate an insterstitial pneumonia, with severe respiratory failure and death (3). High level of attention should be paid to comorbidities in the treatment of COVID-19. In the literature, COVID-19 is characterised by the symptoms of viral pneumonia such as fever, fatigue, dry cough, and lymphopenia. Many of the older patients who become severely ill have evidence of underlying illness such as cardiovascular disease, liver disease, kidney disease, or malignant tumours. These patients often die of their original comorbidities. They die “with COVID”, but were extremely frail and we therefore need to accurately evaluate all original comorbidities. In addition to the risk of group transmission of an infectious disease, we should pay full attention to the treatment of the original comorbidities of the individual while treating pneumonia, especially in older patients with serious comorbid conditions and polipharmacy. Not only capable of causing pneumonia, COVID-19 may also cause damage to other organs such as the heart, the liver, and the kidneys, as well as to organ systems such as the blood and the immune system. Patients die of multiple organ failure, shock, acute respiratory distress syndrome, heart failure, arrhythmias, and renal failure (5,6). What we know about COVID 19? In December 2019, a cluster of severe pneumonia cases of unknown cause was reported in Wuhan, Hubei province, China. The initial cluster was epidemiologically linked to a seafood wholesale market in Wuhan, although many of the initial 41 cases were later reported to have no known exposure to the market (7). A novel strain of coronavirus belonging to the same family of viruses that cause severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS), as well as the 4 human coronaviruses associated with the common cold, was subsequently isolated from lower respiratory tract samples of 4 cases on 7 January 2020. On 30 January 2020, the WHO declared that the SARS-CoV-2 outbreak constituted a Public Health Emergency of International Concern, and more than 80, 000 confirmed cases had been reported worldwide as of 28 February 2020 (8). On 31 January 2020, the U.S. Centers for Disease Control and Prevention announced that all citizens returning from Hubei province, China, would be subject to mandatory quarantine for up to 14 days. But from China COVID 19 arrived to many other countries. Rothe C et al reported a case of a 33-year-old otherwise healthy German businessman :she became ill with a sore throat, chills, and myalgias on January 24, 2020 (9). The following day, a fever of 39.1°C developed, along with a productive cough. By the evening of the next day, he started feeling better and went back to work on January 27. Before the onset of symptoms, he had attended meetings with a Chinese business partner at his company near Munich on January 20 and 21. The business partner, a Shanghai resident, had visited Germany between January 19 and 22. During her stay, she had been well with no signs or symptoms of infection but had become ill on her flight back to China, where she tested positive for 2019-nCoV on January 26. This case of 2019-nCoV infection was diagnosed in Germany and transmitted outside Asia. However, it is notable that the infection appears to have been transmitted during the incubation period of the index patient, in whom the illness was brief and nonspecific. The fact that asymptomatic persons are potential sources of 2019-nCoV infection may warrant a reassessment of transmission dynamics of the current outbreak (9). Our current understanding of the incubation period for COVID-19 is limited. An early analysis based on 88 confirmed cases in Chinese provinces outside Wuhan, using data on known travel to and from Wuhan to estimate the exposure interval, indicated a mean incubation period of 6.4 days (95% CI, 5.6 to 7.7 days), with a range of 2.1 to 11.1 days. Another analysis based on 158 confirmed cases outside Wuhan estimated a median incubation period of 5.0 days (CI, 4.4 to 5.6 days), with a range of 2 to 14 days. These estimates are generally consistent with estimates from 10 confirmed cases in China (mean incubation period, 5.2 days [CI, 4.1 to 7.0 days] and from clinical reports of a familial cluster of COVID-19 in which symptom onset occurred 3 to 6 days after assumed exposure in Wuhan (10-12). The incubation period can inform several important public health activities for infectious diseases, including active monitoring, surveillance, control, and modeling. Active monitoring requires potentially exposed persons to contact local health authorities to report their health status every day. Understanding the length of active monitoring needed to limit the risk for missing infections is necessary for health departments to effectively use resources. A recent paper provides additional evidence for a median incubation period for COVID-19 of approximately 5 days (13). Lauer et al suggest that 101 out of every 10 000 cases will develop symptoms after 14 days of active monitoring or quarantinen (13). Whether this rate is acceptable depends on the expected risk for infection in the population being monitored and considered judgment about the cost of missing cases. Combining these judgments with the estimates presented here can help public health officials to set rational and evidence-based COVID-19 control policies. Note that the proportion of mild cases detected has increased as surveillance and monitoring systems have been strengthened. The incubation period for these severe cases may differ from that of less severe or subclinical infections and is not typically an applicable measure for those with asymptomatic infections In conclusion, in a very short period health care systems and society have been severely challenged by yet another emerging virus. Preventing transmission and slowing the rate of new infections are the primary goals; however, the concern of COVID-19 causing critical illness and death is at the core of public anxiety. The critical care community has enormous experience in treating severe acute respiratory infections every year, often from uncertain causes. The care of severely ill patients, in particular older persons with COVID-19 must be grounded in this evidence base and, in parallel, ensure that learning from each patient could be of great importance to care all population,
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            Delayed access to care and late presentations in children during the COVID-19 pandemic: a snapshot survey of 4075 paediatricians in the UK and Ireland

            The UK has witnessed large reductions in children attending emergency departments (ED) and paediatric assessment units (PAU) during the COVID-19 pandemic,1 which began in late January and peaked in mid-April before declining.2 These reductions raised concerns about the late presentation of critical illness in children. To address this, the British Paediatric Surveillance Unit undertook a snapshot electronic survey on 24 April 2020 of 4075 paediatric consultants representing >90% of paediatric consultants in the UK and Ireland, asking whether, during the previous 14 days, they had seen any children who, in their opinion, presented later than they would have expected prior to the COVID-19 pandemic (ie, delayed presentation). Over the next 7 days, 2433 (60%) paediatricians responded. Overall, 241 (32%) of 752 paediatricians working in ED/PAU had witnessed delayed presentations, with 57 (8%) reporting ≥3 patients with delayed presentation. Delayed presentation reports ranged between 14% in Wales and 47% in the Midlands (figure 1). Free text responses revealed diabetes mellitus (new diagnosis/diabetic ketoacidosis) as by far the most common delayed presentation,3 but also sepsis and malignancy (table 1). There were also nine deaths where delayed presentation was considered a contributing factor, resulting mainly from sepsis and malignancy. Figure 1 Number of paediatricians working in different clinical areas by region in the UK and Ireland who responded to the survey and the proportion who reported delayed presentation in children during the previous 14 days. ED, emergency department; PAU, paediatric assessment unit. Table 1 Summary of the main conditions reported in children and the perinatal period and deaths where delayed presentation was considered by the reporting paediatrician to be a contributing factor n Top 5 delayed diagnoses reported  Diabetes mellitus (diabetic ketoacidosis) 44 (23)  Sepsis 21  Child protection 14  Malignancy 8  Appendicitis 6 Delayed perinatal presentations  Pregnant women presenting late in labour 2  Hypoxic ischaemic encephalopathy 1  Unbooked pregnancy resulting in adverse outcomes 1  Poor feeding after early hospital discharge 2  Dehydration following poor feeding 4 Reported deaths associated with delayed presentation  Sepsis 3  New diagnosis of malignancy 3  Cause not reported 2  New diagnosis of metabolic disease 1 Of the paediatricians working on hospital wards and in clinics, 18% (178 of 997) had also witnessed delayed presentations. Neonatologists’ concerns included late presentations during labour resulting in adverse maternal/neonatal outcomes and early hospital discharges after birth due to COVID-19 concerns before feeding had been established and infants then returning with feeding difficulties and severe dehydration (table 1). Community paediatricians and oncologists were particularly concerned by the fall in referral rates for child protection and cancer assessment, respectively. A 60% response rate in 7 days highlights the importance given to the survey by paediatricians in the UK and Ireland and the widespread professional concern about delayed presentations. Elsewhere, others have raised concerns about declining immunisation rates,4 and the mental health and well-being of children during lockdown.5 While the information collected in the survey was subjective and based on the opinion of individual paediatricians, and although we do not have baseline data for comparison, our findings highlight an urgent need to improve public health messaging for parents, which until recently instructed everyone to stay at home. Children attending primary care and hospitals remain at very low risk for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Parents should continue to access medical care if they are concerned and must not delay getting emergency treatment if their child appears seriously ill. Otherwise, the unintended consequences of the lockdown will do more harm and claim more children’s lives than COVID-19. BPSU Scientific Committee: Nick Bishop, Dr Gavin Dabrera, David Elliman, Lamiya Samad, Ellen Pringle, Simon Nadel, Marc Tebruegge, Hani Ayyash, Sarah Clarke, Chenqu Suo, Jane Sutton, Madeleine Wang, Peter Davis, Ifeanyichukwu Okike, Robert Negrine, Arlene Reynolds.
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              Testicular torsion: epidemiological risk factors for orchiectomy in pediatric and adult patients

              Testicular torsion is a known cause of morbidity in pediatric patients, but the burden in the adult population is poorly understood. We sought to determine the incidence of testicular torsion and risk factors for orchiectomy in a population encompassing all ages. A cohort analysis of 1625 males undergoing surgery for torsion was performed using the 2011 and 2012 Healthcare Cost and Utilization Project Nationwide Emergency Departments Sample. Patient and hospital factors were examined for association with orchiectomy vs. testicular salvage. The estimated yearly incidence of testicular torsion was 5.9 per 100,000 males ages 1-17 years and 1.3 per 100,000 males ≥18 years. Among those undergoing surgical intervention, orchiectomy was performed in 33.6%. The risk of orchiectomy was highest in patients 1-11 years of age and patients over 50 years of age (46.0% and 69.7% of patients, respectively). Orchiectomy was also associated with public insurance (Medicaid/Medicare) or self-pay as primary payer. While testicular torsion is less common in the adult population, the rate of orchiectomy is high. Those with disadvantaged payer status are also at increased risk for testicular loss.

                Author and article information

                Emerg Med Int
                Emerg Med Int
                Emergency Medicine International
                8 May 2023
                : 2023
                : 9960452
                1Department of Pediatric Surgery and Urology, Medical University of Bialystok, Bialystok, Poland
                2Department of Regenerative Medicine and Immune Regulation, Medical University of Bialystok, Bialystok, Poland
                Author notes

                Academic Editor: Guangtao Xu

                Author information
                Copyright © 2023 Marta Komarowska et al.

                This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                : 29 December 2022
                : 23 March 2023
                : 23 April 2023
                Research Article

                Emergency medicine & Trauma
                Emergency medicine & Trauma


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