Funtabulously Frivolous Friday Five 355
Just when you thought your brain could unwind on a Friday, you realise that it would rather be challenged with some good old fashioned medical trivia FFFF, introducing the Funtabulously Frivolous Friday Five 355
Question 1
What are you trying to measure using a ‘TWIST’ score?
Reveal the funtabulous answer
Likelihood of testicular torsion in children
Developed in 2013 by Barbosa et al. The TWIST score comprises:
| Testicular swelling | 2 points |
| Hard testis | 2 points |
| Absent cremasteric reflex | 1 point |
| High riding testis | 1 point |
| Nausea or vomiting | 1 point |
Grading:
- 0-2 = low risk
- 100% negative predictive value for torsion
- Generally, no ultrasound or urological consultation required
- 3-4: intermediate risk
- ultrasound warranted
- 5 or above: high risk
- 100% positive predictive value for torsion
- ultrasound not required, urgent urological consultation and surgery required to salvage testis.
A 2016 article in The Journal of Urology aimed to aimed to assess the usefulness of the TWIST score in non-urological providers (i.e. ED folk). Retrospective validation in 1 data set showed 66% of patients at low, 16% intermediate and 17% high risk. Negative and positive predictive values for cutoffs of 2 and 5 were 100% (specificity 97%, sensitivity 54%). The second retrospective data set included only torsion cases, none of which was misdiagnosed by the scoring system.
Reference:
- Radiopaedia – TWIST
- Barbosa JA, Tiseo BC, Barayan GA, Rosman BM, Torricelli FC, Passerotti CC, Srougi M, Retik AB, Nguyen HT. Development and initial validation of a scoring system to diagnose testicular torsion in children. J Urol. 2013 May;189(5):1859-64.
- Sheth KR, Keays M, Grimsby GM, Granberg CF, Menon VS, DaJusta DG, Ostrov L, Hill M, Sanchez E, Kuppermann D, Harrison CB, Jacobs MA, Huang R, Burgu B, Hennes H, Schlomer BJ, Baker LA. Diagnosing Testicular Torsion before Urological Consultation and Imaging: Validation of the TWIST Score. J Urol. 2016 Jun;195(6):1870-6
Question 2
Does cold air really help the child with croup?
Reveal the funtabulous answer
Apparently so!
Siebert et al, (2023) investigated the age-old therapy by testing whether 30 mins of exposure to outdoor cold air would improve mild to moderate croup symptoms. All patients (n = 118) were given dexamethasone, then either randomised to wait for 30 mins (time to onset of dexamethasone effect) in indoor room air or outside cold air (<10 degrees Celsius).
49.2% in the outdoor group and 23.7% in the indoor group showed a decrease in croup score (Westley score) of ≥ 2 points from baseline at 30 minutes. Patients with moderate croup benefited the most from the intervention at 30 minutes.
Although I don’t have access to an outside space in my emergency department (short of the ambulance bay), I will be happy if the parents want to take their child outside for a walk! As long as they return for review prior to discharge.
Reference:
- Siebert JN, Salomon C, Taddeo I, Gervaix A, Combescure C, Lacroix L. Outdoor Cold Air Versus Room Temperature Exposure for Croup Symptoms: A Randomized Controlled Trial. Pediatrics. 2023 Sep 1;152(3):e2023061365
Question 3
Does screen time impact your teenager’s ability to recover from concussion?
Reveal the funtabulous answer
Absolutely!
Macnow et al (2021), enrolled 125 patients who were either permitted to engage in their usual screen time or asked to abstain from screen time for 48 hours after injury.
Teenager’s allowed to have their usual screen time average 5.25 hours per day (wow). Teenagers in the intervention/abstinence group average 65 minutes per day (so much better). The screen time group had a significantly longer median recovery time of 8.0 days compared with 3.5 days in the screen time abstinent group.
I do like informing my concussion patients about the study:
‘So, no homework and screen time for school the next two days.’
‘Yay!’
‘…and no TikTok, Insta, SnapChat, PS4 either’
‘WHAT?!’
Reference:
- Macnow T, Curran T, Tolliday C, Martin K, McCarthy M, Ayturk D, Babu KM, Mannix R. Effect of Screen Time on Recovery From Concussion: A Randomized Clinical Trial. JAMA Pediatr. 2021 Nov 1;175(11):1124-1131.
Question 4
Which common affliction ailed likes of Christopher Columbus, Henry VIII, Benjamin Franklin, Sir Laurence Olivier and Beethoven?
Reveal the funtabulous answer
Gout.
First documented by the Egyptians in 2640 BC. Podagra (acute gout occurring in the first metatarsophalangeal joint) was later recognized by Hippocrates in the fifth century BC, who referred to it as ‘the unwalkable disease’.
‘Gout’ is derived from the Latin word gutta (or ‘drop’), referring to the prevailing medieval belief that an excess of one of the four ‘humors’ – would, under certain circumstances, ‘drop’ or flow into a joint, causing pain and inflammation.
Throughout history, gout has been associated with rich foods and excessive alcohol consumption. Because it is clearly associated with a lifestyle that, at least in the past, could only be afforded by the affluent, gout has been referred to as the ‘disease of kings’.
Specifically, Gout is caused by the deposition of monosodium urate crystals in articular and non-articular structures. A high serum urate concentration is the most important risk factor. Gout presents as intermittent episodes of severely painful arthritis (gout flares) caused by the innate immune response to deposited monosodium urate crystals.
Reference:
- The disease of Kings – Conversation accessed Dec 2023
Question 5
What is better to rehydrate a child with, Oral Rehydration Solution (ORS) or dilute apple juice?
Reveal the funtabulous answer
Dilute apple juice, every time.
Children very (very) commonly present to emergency with various illness that reduce their oral intake, frequently gastroenteritis and tonsillitis. At home they will have stopped drinking AND eating, thus they will be dehydrated and, often, ketotic – best termed starvation ketosis.
Starvation ketosis is an arguably under-appreciated pathophysiology in emergency paediatrics. There is little good epidemiological data on this element of acute paediatrics, however Millar et al in 2022 prospectively found the prevalence of clinically significant ketosis (beta-hydroxybutyrate 2.5 mmol/L or more) to be approximately 1800 per 100,000 ED presentations (previous retrospective estimates 4 per 100,000), with more than 170 per 100,000 also being hypoglycaemic. Affected patients were 3 months to 9 years of age.
Symptoms of ketosis include abdominal pain, nausea and vomiting, headache, and lethargy. These will be in addition to whichever symptoms the child is experiencing to become ketosis with. Thus trying to rehydrate and feed an unwell child who is now also ketotic adds a layer of complexity and difficulty.
In 2016, Freedman et al prospectively enrolled children with mild gastroenteritis to receive either colour-matched half-strength apple juice/preferred fluids or apple-flavoured electrolyte maintenance solution. Among the 647 randomized children, fewer children administered apple juice/preferred fluids received intravenous rehydration: 2.5% vs 9.0%.
This author is a big fan of measuring ketones when a child presents with a strong history of reduced oral intake and appears quite flat. Common management includes anti-emetics, then analgesia, then a trial of oral intake with sugary solutions (fruit juice icy poles are a big winner), juice, jelly, biscuits, cheese, etc. Paying close attention to ketosis as well as the child’s initial pathology increases the rates of successful discharge from ED.
Reference:
- Freedman SB, Willan AR, Boutis K, Schuh S. Effect of Dilute Apple Juice and Preferred Fluids vs Electrolyte Maintenance Solution on Treatment Failure Among Children With Mild Gastroenteritis: A Randomized Clinical Trial. JAMA. 2016 May 10;315(18):1966-74.
… and finally, quotes
If my life depended upon my ability to cut down a tree in five minutes I would spend three minutes sharpening my axe
Reverend W. H. Alexander 1944
Often misquoted as an Abraham Lincoln quote but the first reference to Lincoln came around 1960 quoting “If I had six hours, I’d spend the first five sharpening my axe”. All well and good but he died in 1865. Regardless, our time is often better spent preparing than swing axes!
… and finally, video
FFFF
Funtabulously Frivolous Friday Five
Dr Mark Corden BSc, MBBS, FRACP. Paediatric Emergency Physician working in Northern Hospital, Melbourne. Loves medical history and trivia...and assumes everyone around him feels the same...| LinkedIn |
Dr Neil Long BMBS FACEM FRCEM FRCPC. Emergency Physician at Kelowna hospital, British Columbia. Loves the misery of alpine climbing and working in austere environments (namely tertiary trauma centres). Supporter of FOAMed, lifelong education and trying to find that elusive peak performance.
