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CHOC-UCI Pediatric Urology study illustrates how COVID-19 delayed emergency care

CHOC’s pediatric urology team, in a partnership with UCI Health, has published the largest study of its kind on an emergency condition that afflicts young males, adding to the emerging body of data on how the COVID-19 pandemic has caused patients to delay seeking emergency treatment.

The CHOC/UCI-led study, recently published in the Journal of Pediatric Urology, also marks a first for the Western Pediatric Urology Consortium (WPUC), a group of several leading pediatric healthcare centers that CHOC was instrumental in founding in 2020.

“This study is a good example of CHOC leading the way and bringing together institutions to answer questions that haven’t been answered before,” says Carol Davis-Dao, PhD, a clinical epidemiologist in CHOC’s Department of Pediatric Urology who has a joint appointment in the UC Irvine Department of Urology.

Dr. Davis-Dao leads urology research efforts at CHOC to provide patients and their families with the most current, evidence-based diagnoses and treatments.

The lead author of “A Multicenter Study of Acute Testicular Torsion in the Time of COVID-10,” Dr. Sarah Holzman, a research fellow at UCI-CHOC, says the research paper is the only multicenter urology study and the largest one related to torsion and COVID-19. Most importantly, she adds, it’s the only study that shows patients were delaying presenting to the Emergency Department for testicular torsion.  

The study’s key finding: Patients significantly delayed seeking treatment in the Emergency Department following the onset of symptoms of a testicular torsion during the early months of the pandemic, and, as a result, more of them had to have a testicle removed compared to patients with the same condition who sought care before the pandemic.

“This is the largest study of testicular torsion during COVID-19 and the first to show a significantly longer time from symptom onset to presentation (in the Emergency Department),” the paper states.

“Low baseline awareness of torsion may contribute to delays in care that were present even before the pandemic, making patients and their families less likely to present for emergency care during the pandemic when there is concern for exposure to COVID-19.”

Also participating as authors of the study were CHOC pediatric urologists Dr. Heidi Stephany, Dr. Kai-wen Chuang, Dr. Elias Wehbi, and Dr. Antoine Khoury, chief of pediatric urology at both CHOC and UC Irvine Medical Center. 

Testicular torsion occurs when the spermatic cord that supplies blood to the testicle twists, cutting off the testicle’s blood supply. It presents as acute and severe scrotal pain that quickly worsens, as well as nausea and vomiting.

Testicular torsion occurs when the spermatic cord that supplies blood to the testicle twists, cutting off the blood supply.

It’s a relatively rare surgical emergency, with an incidence rate of around 4 per 100,000 males per year in the United States. It most frequently occurs in males between the ages of 10 and 19, with one peak in the neonatal period and the second peak around puberty.

Surgery is required for all patients with testicular torsion.

When torsion is caught early — typically within the first six hours — a detorsion orchiopexy can be performed. In the detorsion surgery, the spermatic cord is untwisted and the blood flow returns to the testicle. The surgeon then secures the testis to the inner scrotum so it can never twist again. However, if patients delay coming to the hospital and the testicle does not have blood supply for several hours, the testicle may have to be removed in a procedure called an orchiectomy.

The CHOC-UCI led study involved a total of 221 patients enrolled at one of seven hospitals in the WPUC (CHOC, Children’s Hospital Los Angeles, Seattle Children’s, UC San Francisco, UCLA, UC San Diego and Western University in Ontario, Canada).

A total of 84 patients with testicular torsion, ages 2 months to 18 years, made up the first cohort. They were studied from March 2020 through July 2020.

The second cohort totaled 137 patients who were treated from January 2019 through February 2020.

The median time it took patients in the COVID-19 cohort to show up at the Emergency Department from the onset of symptoms was 17.9 hours, the study found. This compares to 7.5 hours for patients in the pre-pandemic cohort.

A total of 42 percent of patients in the COVID-19 cohort underwent an orchiectomy (removal of the twisted testicle), compared to 29 percent in the pre-pandemic population.

Distribution of patterns in acute testicular torsion presentation by month of the COVID-19 pandemic. Blue bars represent rate of orchiectomy by month, while the navy-blue line represents median time from onset of symptoms to presentation by month.

Other studies have shown that COVID-19 has caused people to delay Emergency Department treatment, including one that examined acute appendicitis from the New York metropolitan region and another similar study in Virginia.

During the last week of June 2020, 41 percent of U.S. adults admitted to avoiding medical care because of COVID-19 exposure concerns and 12 percent avoided urgent or emergent care, according to the Morbidity and Mortality Weekly Report, an epidemiological digest for the United States published by the Centers for Disease Control and Prevention.

Drs. Holzman and Davis-Dao say they plan to continue the study as the pandemic progresses.

Read more about CHOC’s Department of Urology.

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In the spotlight: Dr. Coleen Cunningham

Dr. Coleen Cunningham’s family has long joked that she knew she wanted to be a pediatrician before she was born. By eighth grade, she was certain that she’d work in pediatrics – and she never looked back.

“Kids are just wonderful,” she says. “They’re always a pleasure to be around – how could you ever not want to help a child?”

Today, she serves as both senior vice president and pediatrician-in-chief at CHOC and chair for the UCI Department of Pediatrics. In this unique dual role, which she began in March, Dr. Cunningham acts as a senior clinical leader with oversight responsibility for CHOC’s vast pediatric medical and surgical services, academic advancement, research and teaching programs.

Dr. Coleen Cunningham, senior vice president and pediatrician-in-chief at CHOC and chair for the UCI Department of Pediatrics

“The big job here is integrating our two institutions, CHOC and UCI, and learning how we can align better,” says Dr. Cunningham.

In this role, she explains, she works as a liaison between physicians and administration, which allows her to communicate the patient care needs from the standpoint of a physician to administration, and vice versa. She will also be overseeing the medical education components, so that both entities can ensure they are recruiting and providing the best trainees, residents and fellows.

“As an insider at both CHOC and UCI, I understand what the issues are, but I’m also able to speak for both teams,” she says. “I can take a step back and advocate for the group as a whole. This is a new perspective, but it affords each institution the room to adjust and align.”

Most recently, Dr. Cunningham served as professor with tenure at Duke University in the Division of Pediatric Infectious Diseases and as chief of Global Health and vice chair for research in the Department of Pediatrics. She held secondary appointments in the Department of Pathology at Duke and the Duke Global Health Institute.

She earned her medical degree from the State University of New York Upstate Medical University in Syracuse, NY, where she also did her residency in pediatrics and a fellowship in pediatric infectious diseases. At SUNY, she served as an associate professor of pediatrics and started a pediatric HIV clinic.

Her work on HIV and AIDS in children has been recognized numerous times and is one of the stand-out moments of her career.

“When I started my job, I was telling mothers that their baby had HIV,” she says. “I would be crying alongside them, because at the time, there wasn’t much we could do. Today, when babies are diagnosed, they can be effectively treated – they can live to be 60 or 70, and we get to tell their parents that they’re going to lead a normal life. Seeing that evolve over the course of my career has been very rewarding.”

Dr. Cunningham has published more than 140 manuscripts and led many multicenter clinical trials aimed at the treatment and prevention of HIV infection in children. The progress that has been made in treating HIV, she says, reinforces the importance of integrating clinical care and research.

“Driving the best care for tomorrow requires integrating research and data analysis into our patient care environment, saying ‘Can I improve? Can I do it better?’” says Dr. Cunningham.

Her goal at CHOC, she says, is making research visible.

“CHOC already provides exceptional, top-notch medical care to children,” says Dr. Cunningham. “And if people heard about some of the incredible things we’re doing here, they’d be amazed. We want to lead the nation in care, but we also need to make that care more visible and teach others how to follow suit.”

Her drive to teach extends beyond her role with CHOC and has long been one of her passions. A few years ago, she was recognized as a top mentor by Duke, and she continues to actively mentor several junior faculty at the university.

“I love watching my mentees come into their own, fly and go beyond what I can do – it’s like having more kids,” says the mother of five. “I get excited to watch them grow and move their career in the direction they want it to go.”

Dr. Cunningham’s ultimate goals at CHOC are to fully and successful integrate the health system and UCI; develop the physicians, including the physician-scientists at both institutions; and enhance CHOC’s national reputation.

Once she has accomplished that, she says, she has only two things she wants to focus on: her garden and her grandchildren.

Virtual pediatric lecture series: The scope of a fetal center

CHOC’s virtual pediatric lecture series continues with “The scope of a fetal center.”

This online discussion will be held Tuesday, June 8 from 12:30 to 1:30 p.m. and is designed for general practitioners, family practitioners, obstetrician-gynecologists, perinatologists and other healthcare providers.

Dr. Jennifer Jolley, associate clinical professor of the department of obstetrics and gynecology at University of California, Irvine, will discuss several topics, including:

  • Recognizing indications for referral to a fetal center.
  • Augmenting patient care with a multidisciplinary approach to management of high-risk pregnancies.

This virtual lecture is part of a series provided by CHOC that aims to bring the latest, most relevant news to community providers. You can register here.

CHOC is accredited by the California Medical Association (CMA) to provide continuing medical education for physicians and has designated this live activity for a maximum of one AMA PRA Category 1 Credit™. Continuing Medical Education is also acceptable for meeting RN continuing education requirements, as long as the course is Category 1, and has been taken within the appropriate time frames.

Please contact CHOC Business Development at 714-509-4291 or BDINFO@choc.org with any questions.

CHOC surgeons thriving as productive researchers outside the operating room

CHOC surgeons are known for performing the latest procedures, no matter how complex, in areas including heart, trauma, gastrointestinal, urology and neurosurgery.

Outside the operating room, the seven physicians who make up CHOC’s pediatric general and thoracic surgery team also are excelling in another realm that is critical to CHOC’s mission of developing into one of the nation’s leading pediatric healthcare systems —

Research.

In the last five years, the surgery team has published some 35 papers, bolstered by recent new hires and a renewed commitment to dramatically transform CHOC from its roots as a community children’s hospital to an academic institution.

“It’s unprecedented in the history of pediatric surgery at CHOC – there’s no question about that,” pediatric surgeon Dr. Peter Yu says of the volume of research going on with his team.

“We are proud to be one of the most academically productive divisions at the hospital, and we have some impressive partners in other specialties here,” Dr. Yu says. He calls fellow pediatric surgeon Dr. Yigit S. Guner  the leader behind the recent flurry of research.

“The number of papers that we’ve published in the last several years would be something to be proud of at any children’s health system, even the ones that have a longstanding academic tradition,” Dr. Yu says.

Dr. Yu also cites two more recent hires as critical players: John Schomberg, PhD, a biostatistician in nursing administration and trauma, and Elizabeth Wallace, MPH, a clinical research coordinator in the trauma department in Research Administration.

Schomberg has been instrumental in the team’s research efforts, providing statistical expertise to help investigators, both experienced and new to research, formulate and refine their research questions, Wallace says.

“The research team’s accomplishments are due in large part to the progressive leadership of CHOC executives and the CHOC Research Institute for prioritizing research and providing support needed to make these research endeavors possible,” she adds.

“Though we rarely think of it when we’re waiting for our child to be seen by their physician, ultimately research is the foundation for providing our pediatric patients with leading, innovative and excellent care,” Wallace says. “This group’s research has potential to inform best practices, policy and advocacy that addresses the needs of our community and to advance pediatric care on a more global level. I’m excited to see what the future brings.”

Dr. Guner says conducting research is a central part of his effort to care for children. “We always strive to provide great care, but research raises the bar on what can be done to help our patients,” he says.

Three general areas

The research being conducted by doctors in CHOC’s pediatric general and thoracic surgery division falls into three general categories: general pediatric surgery, trauma and extracorporeal membrane oxygenation (ECMO), a critical care technology that can be used to bypass a failing heart or lungs.

One trauma study, expected to be submitted for publication in February 2021, looked at legal intervention — any injury sustained from an encounter with a law enforcement officer. While studies have been conducted in adults, none have focused on the pediatric population. Legal intervention as cause of traumatic injury in the pediatric trauma population is infrequent yet reported.

Schomberg, Wallace, Dr. Guner and Dr. Yu were among the researchers who examined the National Trauma Data Bank (NTDB) for health disparities related to legal intervention in the pediatric population.

The team’s key finding: Legal intervention in children disproportionately affects the African American population.

Of the 1,069,609 pediatric trauma patients identified in the NTDB, according to an abstract of their paper, 622 sustained injuries involving legal intervention. When these patients were compared to the general pediatric NTDB, they were more likely to be older, male and test positive for illegal drugs or alcohol.

They were more likely to be African American (44.37% vs 17%), Latino (22.82% vs 15.10%), or Native American (0.96% vs 0.94%).

Mortality was higher in trauma involving legal intervention than in the general pediatric trauma population (4.82% vs 1.11%,), particularly in African Americans (63.33% vs 36.66%). Understanding the issue can hopefully point to more effective strategies to minimize harm while protecting public safety.

Variety of research papers

Several of the pediatric general and thoracic surgery division’s research papers concern congenital diaphragmatic hernias (CDH), a rare birth defect in which a hole in the diaphragm allows the intestines, stomach, liver and other abdominal organs to enter the chest, impairing typical lung development.

In another research project in collaboration with St. Louis Children’s Hospital-Washington University and The Children’s Hospital of Philadelphia, Dr. Yu looked at the incidence and length of stay for pediatric appendicitis during the initial days of the COVID-19 pandemic.

Dr. Yu is also currently working on a model to predict a rare traumatic injury referred to as blunt cerebrovascular injury (BCVI) and an interactive web app that would allow a trauma team to better understand their patient’s risk for BCVI.

Dr. Mustafa Kabeer, a CHOC pediatric surgeon, has published work in trauma and neonatology as well as basic science research on the stress response following splenectomy in mice. Dr. Kabeer’s most notable work includes research on the pioneering use of newborn umbilical cords to repair congenital birth defects such as gastroschisis.

Dr. David Gibbs, director of trauma services at CHOC, has been a staunch advocate for research, pushing CHOC to become the leading institution for pediatric trauma research in Orange County while pursuing a Pediatric Level 1 Trauma Center designation.

Dr. Gibbs’ published work includes developing prediction models in the trauma population to better understand prolonged hospital stays and return visits to the emergency department, revisiting the practice of X-rays post chest tube removal, and trauma case reports.

A true team effort

Dr. Yu  says the surgeons in his division work as a team on many research projects.

“Just like you can be a great surgeon,” he explains, “if you go in to operate and you don’t have any anesthesiologists or a nurse or a scrub tech to hand you instruments, there’s only so much that you can do by yourself.”

Dr. Guner says he enjoys understanding as much as possible about the diseases that he treats, and that research is an ideal vehicle to deepen that understanding.

“I really respect people who come here to work and take care of patients – it’s a vital service that people need,” he says. “In addition, I’ve always felt that I really wanted to know about the diseases themselves. Conducting research allows me to contribute to my field and to society at large.”

Another important aspect of research, Dr. Guner adds, is that it helps residents.

“Part of their training is more than taking care of patients,” Dr. Guner explains. “Learning and research go hand in hand. Research makes residents more motivated to work with their mentors and gives them something to do in the early stages of their career by increasing the energy they devote to academia.”

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Personalized medicine, surgical innovations advance pediatric brain tumor care

The Neuro-Oncology Treatment Program at the Hyundai Cancer Institute at CHOC is doing more than providing the most advanced care for pediatric brain tumors — it’s also helping to shape the future of personalized medicine and surgical innovations.

CHOC offers a full range of standard treatments for brain tumors, as well as personalized therapies for many tumor types, such as medulloblastomas, based on genetic subtyping. Experimental treatments are available through Children’s Oncology Group and other consortium and industry-driven clinical trials. Some of these studies — including a trial developed by a CHOC neuro-oncologist to investigate a vaccine for diffuse intrinsic pontine glioma — are part of CHOC’s robust early-phase clinical trials program, according to Dr. Chenue Abongwa, pediatric neuro-oncologist at CHOC.

Dr. Chenue Abongwa
Dr. Chenue Abongwa, pediatric neuro-oncologist at CHOC

CHOC also partners with some of the country’s foremost healthcare institutions, including Mayo Clinic, to apply the latest genomic sequencing and molecular studies in studying each individual tumor.

When a patient presents with a brain tumor, a wide range of specialists are involved from the beginning. “We have a multidisciplinary neuro-oncology tumor board that includes neurologists, neurosurgeons, neuroradiologists, radiation oncologists, pathologists and a neuro-oncologist, and we involve other specialists as needed,” says Dr. Abongwa. “This expertise allows us to select the treatment likely to be the best option for each child while minimizing the risk of side effects.”

Each patient at CHOC is treated via an individualized, precision medicine approach. When surgery is necessary, CHOC has four highly experienced, board-certified pediatric neurosurgeons who can apply some of the most advanced surgical capabilities. “We have the latest in surgical navigation, and we partner with neurologists at CHOC to offer surgical neuromonitoring to track certain nerve potentials during resections,” says Dr. Suresh Magge, medical director of neurosurgery at CHOC and co-medical director of the CHOC Neuroscience Institute. “If we’re operating near the brain stem, it’s important to know if there’s potential for damage in surrounding structures.”

Dr. Suresh Magge
Dr. Suresh Magge, medical director of neurosurgery at CHOC and co-medical director of the CHOC Neuroscience Institute

Several of the surgical therapies CHOC offers are minimally invasive alternatives to craniotomy. One example is endoscopic surgery, which may be appropriate for tumors located in the ventricles. Neurosurgeons can visualize and resect these tumors using an endoscope inserted through a small incision.

“Certain tumors, especially those located deep in the brain, are amenable to laser interstitial thermal therapy (laser ablation),” Dr. Magge says. “This has revolutionized the treatment of certain types of lesions. We can insert a catheter through a small incision down to the deep part of the brain and ablate the tumor without harming surrounding structures. A ROSA™ (robotic stereotactic assistance) robot allows us to insert the laser with a high degree of precision. Patients experience minimal blood loss and typically go home within a day.”

Once treatment concludes, patients ultimately enter the Neuro-Oncology Treatment Program’s longstanding late effects program. This multidisciplinary program provides long-term follow-up of patients and connects them with specialists who can treat endocrine, neurocognitive, psychosocial and other side effects of treatment.

“For some tumors, such as medulloblastomas, we’ve reached the point where we’re achieving good rates of cure, as high as 80% or more,” Dr. Abongwa says. “So now we’re focused on minimizing the long-term effects of treatment. Most institutions don’t have a strong, long-term follow-up program for pediatric patients. Over time, our program has become quite robust and multidisciplinary. That’s another area of benefit that we offer our patients. We’re a child- and family-focused institution. That focus is evident in all the programs and services that are available to our patients.”

Our Care and Commitment to Children Has Been Recognized

CHOC Hospital was named one of the nation’s best children’s hospitals by U.S. News & World Report in its 2020-21 Best Children’s Hospitals rankings and ranked in the cancer specialty.

Learn how CHOC’s pediatric oncology treatments, expertise and support programs preserve childhood for children in Orange County, Calif., and beyond.