Prospective pilot derivation of a decision tool for children at low risk for testicular torsion.

Objective The purpose of this study was to derive a pilot clinical decision tool with 100% negative predictive value for testicular torsion based on prospectively collected data in children with acute scrotal pain. Methods This was a prospective cohort study of a convenience sample of newborn to 21-year-old males evaluated for acute (72 hours or less) scrotal pain at an urban children's hospital emergency department (ED). A pediatric emergency medicine fellow or attending physician documented history and examination findings on a standardized data collection form. The study investigators used ultrasound (US), operative reports, or clinical follow-up to identify patients who had testicular torsion. Pearson's chi-square test and odds ratios (OR) were used to identify factors associated with the diagnosis of testicular torsion. The authors also used a recursive partitioning model to create a low-risk decision tool for testicular torsion. Results Of the 450 eligible patients, 228 (51%) were enrolled, with a mean (±SD) age of 9.9 (±4.1) years, including 21 (9.2%, 95% confidence interval [CI] = 5.8% to 13.7%) with testicular torsion. The derived clinical decision tool consisted of three variables: horizontal or inguinal testicular lie (OR = 18.17, 95% CI = 6.2 to 53.2), nausea or vomiting (OR = 5.63, 95% CI = 2.08 to 15.22), and age 11 to 21 years (OR = 3.9, 95% CI = 1.27 to 11.97). These variables had a sensitivity of 100% (95% CI = 98% to 100%) and negative predictive value of 100% (95% CI = 98% to 100%) for the diagnosis of testicular torsion. Conclusions Based on a decision tool derived with recursive partitioning, study patients with all of the following characteristics had no risk of testicular torsion: normal testicular lie, lack of nausea or vomiting, and age 0 to 10 years. Future research should focus on externally validating this tool to optimize emergent evaluation when testicular torsion is likely, while minimizing routine sonographic evaluation when patients are unlikely to have a serious condition requiring immediate management. Resumen Derivacion Prospectiva Piloto de una Herramienta de Decision para Ninos con Bajo Riesgo de Torsion Testicular Objetivos El objetivo de este estudio fue derivar una herramienta piloto de decision clinica con un valor predictivo negativo del 100% para descartar la torsion testicular en base a los datos recogidos de forma prospectiva en ninos con dolor testicular agudo. Metodologia Estudio de cohorte prospectivo de una muestra de conveniencia de varones de hasta 21 anos de edad evaluados por dolor testicular agudo (72 horas o menos) en un servicio de urgencias de un hospital pediatrico urbano. Un medico especialista en urgencias pediatricas documento la historia clinica y los hallazgos de la exploracion fisica en un formulario de recogida de datos estandarizado. Los investigadores del estudio utilizaron la ecografia y los informes de las operaciones o seguimiento clinico para identificar a los pacientes que tuvieron torsion testicular. Se usaron el test de la ji-cuadrado de Pearson y las odds ratios (OR) para identificar los factores asociados con el diagnostico de torsion testicular. Tambien se utilizo un modelo de particionamiento recursivo para crear una herramienta de decision de bajo riesgo de torsion testicular. Resultados Se incluyeron 228 (51%) de los 450 pacientes elegibles, con una media de edad de 9,9 (DE ± 4,1) anos, 21 de ellos (9,2%, IC 95% = 5,8% a 13,7%) con torsion testicular. La escala de decision clinica derivada consistia en tres variables: la posicion del testiculo inguinal u horizontal (OR = 18,17; IC 95% = 6,2 a 53,2), las nauseas o vomitos (OR = 5,63, IC95% = 2,08 a 15,22) y la edad entre 11 y 21 anos (OR = 3,9, IC 95% = 1,27 a 11,97). Estas variables tuvieron una sensibilidad del 100% (IC 95% = 98% a 100%) y un valor predictivo negativo del 100% (IC 95% = 98% a 100%) para el diagnostico de torsion testicular. Conclusiones En base a la herramienta de decision derivada con particion recursiva, los pacientes del estudio con todas las siguientes caracteristicas no tuvieron riesgo de torsion testicular: la posicion del testiculo normal, la ausencia de nauseas o vomitos y la edad entre 0 y 10 anos. Futuras investigaciones deberian centrarse en validar externamente esta herramienta para optimizar la evaluacion urgente de una posible torsion testicular, lo que reduciria la evaluacion mediante ecografia de rutina cuando los pacientes tienen poca probabilidad de tener una enfermedad grave que requiera manejo inmediato.