Increasing utilization of the TWIST score in workup of patients with acute scrotal pain: Role in diagnosis and risk stratification.

INTRODUCTION: The TWIST score is a 5-component physical examination score used to aid in diagnosis of testicular torsion (TT) and could lessen need for radiologic testing in certain clinical scenarios. OBJECTIVE: TWIST use was not previously widespread at our institution. The primary objective of this quality improvement study was to achieve 100% compliance in TWIST utilization among urology and ED residents and to assess for score concordance between ED and urology assessments. Secondary goals were correlation of TWIST components with need for orchiectomy. METHODS: ED staff were educated about the TWIST score and asked to complete assessment for patients presenting with acute scrotal pain. Simultaneously, an electronic medical record-based dot phrase was introduced for urology trainees to complete an independent TWIST evaluation. Spearman correlation was performed to assess association between ED and Urology TWIST scores. Multivariable logistic regression was performed to assess association of TWIST score components and need for orchiectomy. RESULTS: 103 patients presented to the ED from 3/2018-11/2020 with a complaint of acute scrotal pain; 47 were diagnosed with torsion. As compared to our retrospective cohort, the documentation rate of complete TWIST score components on exam rose from 9% to 98% (P < 0.001) on ED evaluation and 16%-66% on urology evaluation (P < 0.001). Rates of repeat ultrasound for patient's transferred between facilities was similar (58% vs. 63%; p = 0.66) as was median time to OR (160 min vs. 145 min; p = 0.5). Using TWIST cutoff of >5 yielded a specificity of 94.5% for diagnosis of torsion, with corresponding strong correlation between ED and urology scores (rho = 0.71). A firm testicle was noted on urology evaluation in 100% of orchiectomy patients (vs. 61% of salvage patients) with persistent association after controlling for duration of symptoms (OR 28.1; P = 0.016). DISCUSSION: Through two-pronged quality improvement efforts, we significantly improved utilization of the TWIST score by ED and urology staff for workup of patients with acute testicular pain. We confirmed the high sensitivity and specificity of the TWIST score and demonstrated inter-rater reliability between ED and urology assessments. On prospective analysis, testicular firmness on exam was predictive of need for orchiectomy. CONCLUSION: The TWIST score is an accurate diagnostic tool for both ED and urology providers in workup of children with acute scrotal pain, with a normal score essentially ruling out the condition. Future work should aim at minimizing unnecessary testing in patients demonstrated to be at high risk for torsion.

Nebulized albuterol delivery is associated with decreased skeletal muscle strength in comparison with metered-dose inhaler delivery among children with acute asthma exacerbations.

OBJECTIVE: Albuterol is a ß2-agonist and causes an intracellular shift of potassium from the interstitium. Whole-body hypokalemia is known to cause skeletal muscle weakness, but whether this occurs as a result of hypokalemia from the intracellular shift during albuterol treatment is unknown. We sought to determine if albuterol total dose or route of administration (nebulization and/or metered-dose inhaler) is associated with skeletal muscle weakness. METHODS: This was a prospective observational study using convenience sampling. Skeletal muscle strength was measured before and after 1 hour of albuterol treatment using a hand-grip dynamometer in participants aged 5-17 years with acute asthma exacerbation in the emergency department. We examined associations of albuterol dose and route of administration with changes in grip strength. RESULTS: Among 50 participants, 10 received continuous albuterol by nebulizer and 40 received albuterol by metered-dose inhaler. The median (interquartile range) in change of grip was -7.8% (interquartile range, -23.3, +5.1) for those treated with a nebulizer and +2.4% (interquartile range, -5%, +12.7%) for those treated with a metered-dose inhaler (P = 0.036 for the difference). In a multiple linear regression model adjusted for the pretreatment Acute Asthma Intensity Research Score and age, participants treated with a nebulizer had a 12.9% decrease in skeletal muscle strength compared with those treated with a metered-dose inhaler. CONCLUSION: Higher doses of albuterol administered via nebulization result in decreased skeletal muscle strength in patients with acute asthma; whereas, albuterol administration via metered-dose inhalers showed no effect on skeletal muscle strength.

A Rare Case of Cor Triatriatum Leading to Respiratory Failure and Shock in an 8-Month-Old Boy.

An 8-month-old boy presents with 1 week of gradually worsening respiratory distress. After chest radiograph shows bilateral airspace opacities, he is treated for pneumonia with antibiotics and intravenous fluids. Shortly after this, he decompensates requiring intubation, followed by cardiopulmonary support with pressors and eventually extracorporeal membrane oxygenation. Bedside ultrasound then shows an additional congenital membrane in the left atrium obstructing pulmonary venous return and thought to have caused his original presentation and subsequent decompensation. After surgical correction, he is decannulated from extracorporeal membrane oxygenation, makes a quick recovery, and is discharged from the hospital in good condition within 2 weeks. This rare case of cor triatriatum highlights the importance of considering congenital heart disease even with common presentations in the pediatric population.