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.