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BACKGROUND: Venous thromboembolism (VTE), encompassing both deep vein thrombosis (DVT) and pulmonary embolism (PE), is a leading cause of morbidity and mortality worldwide. METHODS: GARFIELD-VTE is a prospective, non-interventional observational study of real-world treatment practices. We aimed to capture the 36-month clinical outcomes of 10,679 patients with objectively confirmed VTE enrolled between May 2014 and January 2017 from 415 sites in 28 countries. FINDINGS: A total of 6582 (61.6 %) patients had DVT alone, 4097 (38.4 %) had PE ± DVT. At baseline, 98.1 % of patients received anticoagulation (AC) with or without other modalities of therapy. The proportion of patients on AC therapy decreased over time: 87.6 % at 3 months, 73.0 % at 6 months, 54.2 % at 12 months and 42.0 % at 36 months. At 12-months follow-up, the incidences (95 % confidence interval [CI]) of all-cause mortality, recurrent VTE and major bleeding were 6.5 (7.0-8.1), 5.4 (4.9-5.9) and 2.7 (2.4-3.0) per 100 person-years, respectively. At 36-months, these decreased to 4.4 (4.2-4.7), 3.5 (3.2-2.7) and 1.4 (1.3-1.6) per 100 person-years, respectively. Over 36-months, the rate of all-cause mortality and major bleeds were highest in patients treated with parenteral therapy (PAR) versus oral anti-coagulants (OAC) and no OAC, and the rate of recurrent VTE was highest in patients on no OAC versus those on PAR and OAC. The most frequent cause of death after 36-month follow-up was cancer (n = 565, 48.6 %), followed by cardiac (n = 94, 8.1 %), and VTE (n = 38, 3.2 %). Most recurrent VTE events were DVT alone (n = 564, 63.3 %), with the remainder PE, (n = 236, 27.3 %), or PE in combination with DVT (n = 63, 7.3 %). INTERPRETATION: GARFIELD-VTE provides a global perspective of anticoagulation patterns and highlights the accumulation of events within the first 12 months after diagnosis. These findings may help identify treatment gaps for subsequent interventions to improve patient outcomes in this patient population. ispartof: THROMBOSIS RESEARCH vol:222 pages:31-39 ispartof: location:United States status: published

Background Superficial venous disease of the lower extremity has a significant impact on quality of life. Both truncal and tributary vein reflux contribute to this disease process. Endovenous foam sclerotherapy is a widely used technique throughout the world for the management of superficial venous reflux and ultrasound guidance improves its safety and efficacy. Methods A PubMed search for ultrasound-guided foam sclerotherapy (UGFS) was conducted and all abstracts were reviewed to identify clinical trials and systematic reviews for a full-text analysis. Additional articles were also identified through searching the references of the selected studies. Results The production of foam for sclerotherapy in a 1:3 or 1:4 ratio of air to sclerosant is optimal in a low silicone, low-volume syringe system. Physiologic gas may decrease any side effects, with the trade-off of decreased foam stability. Proper technique with appropriate sterility and cleansing protocols are paramount for safe and effective treatment. The technical success of UGFS for great saphenous vein disease is inferior to endothermal and surgical modalities and retreatment is more common. However, the clinical improvement in patient-reported quality of life is similar between these three modalities. When used for tributary veins in combination with endothermal approaches of the truncal veins, UGFS has high rates of success with excellent patient satisfaction. UGFS has demonstrated an excellent safety profile comparable with or superior to other modalities. Conclusions With proper technique, UGFS is safe and effective for the management of superficial venous disease.

The coronavirus disease 2019 (COVID-19) global pandemic has resulted in diversion of healthcare resources to the management of patients infected with SARS-CoV-2 virus. Elective interventions and surgical procedures in most countries have been postponed and operating room resources have been diverted to manage the pandemic. The Venous and Lymphatic Triage and Acuity Scale was developed to provide an international standard to rationalise and harmonise the management of patients with venous and lymphatic disorders or vascular anomalies. Triage urgency was determined based on clinical assessment of urgency with which a patient would require medical treatment or surgical intervention. Clinical conditions were classified into six categories of: (1) venous thromboembolism (VTE), (2) chronic venous disease, (3) vascular anomalies, (4) venous trauma, (5) venous compression and (6) lymphatic disease. Triage urgency was categorised into four groups and individual conditions were allocated to each class of triage. These included (1) medical emergencies (requiring immediate attendance), example massive pulmonary embolism; (2) urgent (to be seen as soon as possible), example deep vein thrombosis; (3) semi-urgent (to be attended to within 30-90 days), example highly symptomatic chronic venous disease, and (4) discretionary/non-urgent- (to be seen within 6-12 months), example chronic lymphoedema. Venous and Lymphatic Triage and Acuity Scale aims to standardise the triage of patients with venous and lymphatic disease or vascular anomalies by providing an international consensus-based classification of clinical categories and triage urgency. The scale may be used during pandemics such as the current COVID-19 crisis but may also be used as a general framework to classify urgency of the listed conditions.

This quality improvement study uses Medicare claims data to evaluate the association of a peer-benchmarking intervention with physician variability in the use of endovenous thermal ablation (EVTA) and related costs., Key Points Question Is provision of individualized peer-benchmarking data on performance of endovenous thermal ablation (EVTA) associated with changes in physicians’ practice patterns or costs? Findings In this quality improvement study of 1558 physicians who performed at least 11 EVTAs for a total of 188 976 Medicare patients and were given a performance report of their EVTA use compared with their peers, a significant reduction in the number of EVTAs per patient was found after receipt of the reports, resulting in savings of $6.3 million to Medicare per year. Meaning In this quality improvement study, peer benchmarking was associated with a change in practice patterns of EVTA-performing physicians and with substantial Medicare savings., Importance The frequency of use of endovenous thermal ablation (EVTA) to treat chronic venous insufficiency has increased rapidly in the US. Wide variability in EVTA use among physicians has been documented, and standard EVTA rates were defined in the 2017 Medicare database. Objective To assess whether providing individualized physician performance reports is associated with reduced variability in EVTA use and cost savings. Design, Setting, and Participants This prospective quality improvement study used data from all US Medicare patients aged 18 years or older who underwent at least 1 EVTA between January 1, 2017, and December 31, 2017, and between January 1, 2019, and December 31, 2019. All US physicians who performed at least 11 EVTAs yearly for Medicare patients in 2017 and 2019 were included in the assessment. Intervention A performance report comprising individual physician EVTA use per patient with peer-benchmarking data was distributed to all physicians in November 2018. Main Outcomes and Measures The mean number of EVTAs performed per patient was calculated for each physician. Physicians who performed 3.4 or more EVTA procedures per patient per year were considered outliers. The change in the number of procedures from 2017 to 2019 was analyzed overall and by inlier and outlier status. An economic analysis was also performed to estimate the cost savings associated with the intervention. Results A total of 188 976 patients (102 222 in 2017 and 86 754 in 2019) who had an EVTA performed by 1558 physicians were included in the analysis. The median patient age was 72.2 years (IQR, 67.9-77.8 years); 67.3% of patients were female, and 84.9% were White. Among all physicians, the mean (SD) number of EVTAs per patient decreased from 2017 to 2019 (1.97 [0.85] vs 1.89 [0.77]; P

Varicose veins afflict more than one in five Americans, and although varicose veins may be an asymptomatic cosmetic concern in some, many others experience symptoms of pain, aching, heaviness, itching, and swelling. More advanced venous disease can result from untreated venous insufficiency. The complications of chronic venous disease, including bleeding, thrombosis, and ulceration, are seen in up to 2 million Americans annually. Numerous reports have documented venous disease adversely affects quality of life and that treatment of venous disease can improve quality of life. It has previously been documented that private insurers, and Centers for Medicare & Medicaid Services subcontractors for that matter, have disparate policies that in many instances are self-serving, contain mistakes, use outdated evidence, and disregard evidence-based guidelines. The two leading venous medical societies, the American Venous Forum and the American Venous and Lymphatic Society, have come together to review the varicose vein coverage policies of seven major U.S. private medical insurance carriers whose policies cover more than 150 million Americans. The authors reviewed the policies for venous disease and, if significant gaps or inconsistencies are found, we hope to point them out, and, finally, to propose a thoughtful and reasonable policy based on the best available evidence.

The coronavirus disease 2019 (COVID-19) global pandemic has resulted in diversion of healthcare resources to the management of patients infected with SARS-CoV-2 virus. Elective interventions and surgical procedures in most countries have been postponed and operating room resources have been diverted to manage the pandemic. The Venous and Lymphatic Triage and Acuity Scale was developed to provide an international standard to rationalise and harmonise the management of patients with venous and lymphatic disorders or vascular anomalies. Triage urgency was determined based on clinical assessment of urgency with which a patient would require medical treatment or surgical intervention. Clinical conditions were classified into six categories of: (1) venous thromboembolism (VTE), (2) chronic venous disease, (3) vascular anomalies, (4) venous trauma, (5) venous compression and (6) lymphatic disease. Triage urgency was categorised into four groups and individual conditions were allocated to each class of triage. These included (1) medical emergencies (requiring immediate attendance), example massive pulmonary embolism; (2) urgent (to be seen as soon as possible), example deep vein thrombosis; (3) semi-urgent (to be attended to within 30–90 days), example highly symptomatic chronic venous disease, and (4) discretionary/non-urgent- (to be seen within 6–12 months), example chronic lymphoedema. Venous and Lymphatic Triage and Acuity Scale aims to standardise the triage of patients with venous and lymphatic disease or vascular anomalies by providing an international consensus-based classification of clinical categories and triage urgency. The scale may be used during pandemics such as the current COVID-19 crisis but may also be used as a general framework to classify urgency of the listed conditions.

On July 20, 2016, a Medicare Evidence Development and Coverage Advisory Committee panel convened to assess the evidence supporting treatment of chronic venous disease. Several societies addressed the questions posed to the panel. A multidisciplinary coalition, representing nine societies of venous specialists, reviewed the literature and presented a consensus opinion regarding the panel questions. The purpose of this paper is to present our coalition's consensus review of the literature and recommendations for chronic venous disease.

Insurance approval for saphenous vein ablation is generally limited to junctional reflux involving the great saphenous vein (GSV) or small saphenous vein. This study was designed to investigate prevalence and disease severity of anterior accessory GSV (AAGSV) compared with GSV disease in patients presenting to dedicated outpatient vein centers.Deidentified data were pulled from the American VeinLymphatic Society PRO Venous Registry for first and second patient encounters. Variables included age, sex, and body mass index (BMI); clinical class of Clinical, Etiology, Anatomy, and Pathophysiology (CEAP) classification; revised Venous Clinical Severity Score (rVCSS); and duplex ultrasound values for each limb. Data were further scrutinized according to duplex ultrasound findings. Patients with normal findings on duplex ultrasound examination or evidence of acute or chronic thrombosis were excluded. Patients were further characterized into two groups. The primary group had no prior vein treatment vs the progressive group, in which patients have had a superficial venous intervention at some point in the past.There were 6836 unique patients with duplex ultrasound patterns of either AAGSV or GSV above the knee or both AAGSV and GSV in either group. This pool contained 2604 patients with recorded CEAP class and rVCSS, representing 2664 patient limbs in the final data set. In comparison to limbs in the progressive group, AAGSV reflux was more common in the primary group (78/563 vs 209/2101; P .01). Demographic features of the groups demonstrated no significant difference. The primary group demonstrated a significantly higher rVCSS (6.95 vs 6.10; P .01) than the progressive group. Patients in the primary group also demonstrated a significantly higher incidence of more advanced disease (CEAP class C4 and above; 43.1% vs 24.8%; P .0001) than those in the progressive group. The primary group demonstrated no significant differences in age, sex proportions, or mean BMI. The mean rVCSS for GSV of these patients (7.22) was significantly higher than that of AAGSV patients (5.63; P .01). The incidence of superficial vein thrombosis for the AAGSV patients (6.41%) was significantly higher than that of the GSV patients (2.17%; P .05) in the progressive group. Patients in the progressive group demonstrated no significant difference in age, sex proportions, mean BMI, or average rVCSS. The proportion of AAGSV limbs with superficial thrombosis events (37/287 [12.9%]) was significantly higher than that for GSV (59/2214 [2.7%]; P .01).AAGSV reflux is common and carries similar morbidity to GSV reflux. It is manifested with an alarming presence of superficial vein thrombosis.

Background Parenteral anticoagulants and vitamin K antagonists (VKAs) have constituted the cornerstone of venous thromboembolism (VTE) treatment. Meanwhile, direct oral anticoagulants (DOACs) provide physicians with an alternative. The Global Anticoagulant Registry in the FIELD (GARFIELD)-VTE observes real-world treatment practices. Objectives Describe initial anticoagulation (AC) treatment patterns in VTE patients who received parenteral AC, VKAs, and/or DOACs within ±30 days of diagnosis. Methods VTE patients were categorized into parenteral AC only, parenteral AC with transition to VKA, VKA only, parenteral AC with transition to DOAC, and DOAC only. Results A total of 9647 patients were initiated on AC treatment alone. 4781 (49.6%) patients received DOACs ± parenteral ACs; 3187 (33.0%), VKA ± parenteral ACs; and 1679 (17.4%) parenteral ACs alone. Rivaroxaban was the most frequently used DOAC (79.4%). DOACs were more frequently used in North America/Australia (58.1%), Europe (52.2%), and Asia (47.6%) than in Latin America (29.7%) and the Middle East/South Africa (32.5%). In patients with suspected VTE, most received parenteral AC monotherapy (67.7%). Patients with deep vein thrombosis were more likely to receive DOACs alone than those with pulmonary embolism with or without deep vein thrombosis (36.2% vs 25.9%). Active cancer patients received parenteral AC alone (58.9%), with 25.5% receiving DOAC ± parenteral AC and 12.8% parenteral AC and VKA. A total of 46.5% of pregnant patients received parenteral AC monotherapy, 34.0% were treated with VKA ± parenteral AC, and 19.5% received a DOAC (± parenteral AC). Conclusion AC treatment patterns vary by patient population, geographic region and site of VTE. Guidelines for AC therapy are not always adhered to.

The American College of Phlebology Guidelines Committee performed a systematic review of the literature regarding the clinical impact and treatment of incompetent accessory saphenous veins. Using an accepted process for guideline developments, we developed a consensus opinion that patients with symptomatic incompetence of the accessory great saphenous veins (anterior and posterior accessory saphenous veins) be treated with endovenous thermal ablation (laser or radiofrequency) or ultrasound-guided foam sclerotherapy to eliminate symptomatology (Recommendation Grade 1C).

The feasibility of magnetic resonance venography (MRV) for measuring change in thrombus volume with a novel anticoagulation regimen versus standard anticoagulation in patients with symptomatic deep vein thrombosis (DVT) has not been assessed. Our aim was to study the feasibility of MRV to measure change in thrombus volume in patients with acute symptomatic objectively confirmed proximal DVT in an open-label multicenter trial (edoxaban Thrombus Reduction Imaging Study, eTRIS). We randomized patients in a 2:1 allocation ratio to edoxaban 90 mg/day for 10 days followed by 60 mg/day versus parenteral anticoagulation bridging to warfarin for 3 months. The primary efficacy outcome was a surrogate end point of the relative change in MRV-quantified thrombus volume from baseline to Day 14–21. A total of 85 eligible patients from 26 study sites were randomized to edoxaban monotherapy ( n=56) versus parenteral anticoagulation as a ‘bridge’ to warfarin ( n=29). The mean relative change in MRV-quantified thrombus volume from baseline to Day 14–21 was similar in patients treated with edoxaban and parenteral anticoagulation as a ‘bridge’ to warfarin (−50.1% vs −58.9%; 95% confidence interval of treatment difference, −12.7%, 30.2%). However, thrombus extension was observed in eight patients in the edoxaban monotherapy group and in none in the warfarin group. Rates of recurrent venous thromboembolism (3.6% vs 3.6%, p=0.45) and clinically relevant non-major bleeding (5.4% vs 7.1%, p=0.34) were also similar. No major bleeds occurred in either on-treatment group during the study period. In conclusion, MRV can assess change in thrombus volume in patients with acute DVT randomized to two different anticoagulant regimens. ClinicalTrials.gov Identifier: NCT01662908 Investigational New Drug (IND) Application: Edoxaban IND # 63266

Objective The goal of this American College of Phlebology Patient Reported Outcome Venous Registry analysis was to examine the clinical efficacy of compression stockings using short-form 6D questionnaire (SF-6D). Method SF-6D scores were modeled over time using linear mixed effects model. Changes of SF-6D score from baseline to the last encounter were examined using a paired t-test. Analysis of variance was used to compare changes from baseline in SF-6D scores between C classifications. All analyses were conducted using SAS software, version 9.4 (SAS Institute, Cary NC). Results Baseline mean SF-6D score was 0.83 and at follow-up, 0.85. Mean SF-6D change was +0.02 points (P = .001) over an average time period of 5.5 months. Patients’ SF-6D scores were estimated to increase by +0.03 points (P = .005) per year of usage of compression stockings. SF-6D score changes across C classifications did not demonstrate significant differences (P = .265). Conclusion There was an improvement of SF-6D score in the registry participants who used circular knit compression stockings.

Patient registries are beneficial in that they allow the collection of prospective data focused on a specific medical issue. These registries give providers a “real-world” view of patient outcomes. Many medical disciplines have a long history of developing and using patient registries; the first patient registry for chronic venous disease in the United States was launched in 2011, fairly recently in comparison. Registries included in this review were identified by surveying members of major academic societies that focus on the care of chronic venous disease and by searching MEDLINE and Embase databases using Ovid interface. Medical directors of four of the five databases available in the United States completed a standard questionnaire, and the answers served as the basis for this review. This review is not a comparison of registries; it does, however, describe the common and unique features of four venous registries currently available in the United States with the purpose of increasing awareness of and fostering participation in these registries.

Objective Portions of these data were presented in a poster at the XVII World Meeting of the International Union of Phlebology, 8–13 September 2013, Boston, MA, USA. We assessed the incidence of venous thromboembolism following treatment of great saphenous insufficiency by endovenous thermal ablation or foam sclerotherapy using meta-analysis of published randomized controlled trials and case series. Methods Medline, Embase, Cochrane, and Clinical Trials Registry databases were searched from January 2000 through January 2013 for randomized controlled trials and large case series employing endovenous thermal ablation or foam sclerotherapy as a single modality for the treatment of great saphenous insufficiency, with concomitant postoperative duplex scanning. Pooled (stratified) incidence of venous thromboembolism with 95% confidence intervals was estimated using the DerSimonian–Laird procedure for random effects meta-analysis. A bootstrap analysis was performed to examine between-modality differences. Results Twelve randomized controlled trials and 19 case series investigating endovenous thermal ablation (radiofrequency ablation with VNUS/Covidien ClosureFAST™ catheter only, endovenous laser ablation, or both) were included. Data from 12 randomized controlled trials and 6 case series investigating nonproprietary foam preparations were analyzed. Estimated incidence of venous thromboembolism was low (mostly Conclusions Treatment of great saphenous insufficiency by endovenous thermal ablation or foam sclerotherapy is a common vascular intervention. The stratified incidence of venous thromboembolism appears to be low as reported in both randomized controlled trials and case series investigating these modalities. Although duplex scans were obtained postoperatively, a minority of studies specified protocols for venous thromboembolism detection.

Background There has been a substantial increase in the use of procedures to treat lower extremity venous disease in the United States over the past decade. A specialty society-selected metric was applied to evaluate the use of endovenous thermal ablation (EVTA) in Medicare beneficiaries and factors associated with physician practice variations. We used confidential physician reports of this benchmark data to increase physician recognition of individualized usage relative to their peers. Methods We used 100% Medicare fee-for-service claims data to identify all patients 18 years of age and older who underwent at least one lower extremity EVTA over a 1-year period (January 1, 2017, to December 31, 2017). A physician-specific annual rate of EVTA performed per patient was calculated. Individual physician results were shared confidentially with each provider billing Medicare for more than 10 ablations during the study period by mail, benchmarked to the distribution of use by their peers nationally. Hierarchical multivariable linear regression was used to identify patient and provider characteristics associated with high rates of thermal ablations per patient. Results A total of 102,145 Medicare beneficiaries (median age, 72.1 years; 67.8% female) underwent an EVTA by 2462 physicians during the study period. The majority (96.4%) of patients underwent 1 to 5 ablations, 3.3% underwent 6 to 10 ablations, and 0.3% underwent 11 or more ablations. The median and mean physician ablation rates were 1.6 (interquartile range, 1.3-2.2) and 1.9 ± 0.8 ablations per patient annually, respectively. There were 106 physicians (4.3%) who had an ablation rate of 3.4 or greater, which is two or more standard deviations above the national mean. After adjusting for patient-level variables, characteristics independently associated with outlier physicians included specialties other than vascular surgery, fewer years in practice, and higher overall venous ablation practice volume (P ≤ .03). Conclusions Using a physician-generated metric of performance, the physician use EVTA performed annually per patient is highly variable, and this variability correlated with physician discipline, years in practice, and is more common in physicians who perform ablation the most. Our data show that there is considerable variability in the use of EVTA in Medicare beneficiaries, and that outlier physicians performing a high number of venous ablation procedures per patient are identifiable using a peer-benchmarked practice pattern measure via claims-based data.

Objectives To assess the effect of topically applied nitroglycerin (NTG) ointment (2%) on preoperative targeted venous access site great saphenous vein (GSV) diameter in patients undergoing endovenous laser treatment (ELT). Methods In this double-blinded randomized study design, 75 patients received either (A) treadmill ambulation only, (B) topically applied NTG ointment only, or (C) topically applied NTG ointment + treadmill ambulation. Targeted venous access vein diameters were measured before therapeutic intervention and then repeated after approximately 30 min following pretreatment intervention. Presence of venospasm and the number of ultrasound-guided venous access attempts during each ELT procedure were assessed during the study. Results The mean pretreatment vein diameter was 2.6 mm (range 0.9–4.9 mm). The post-treatment percentage change in vein diameter for group A (treadmill ambulation only) was +2.7% ( P = 0.403), whereas group B (NTG only) and group C (NTG + treadmill ambulation) demonstrated significant venodilatation of +69.0% ( P < 0.0001) and +51.7% ( P < 0.0001), respectively. Statistical analysis of variances and multivariate linear regression model revealed topically applied NTG ointment and ‘C’ classification of clinical, aetiological, anatomical and pathological elements (CEAP) were each significant predictors for venodilatation percentage change ( P < 0.001 and = 0.028, respectively). Conclusion Pretreatment with topically applied NTG ointment (2%) produced a statistically significant, as well as subjective clinically significant venodilatation change in the targeted venous access site diameter of patients undergoing ELT of the GSV in this study.

Chronic venous disorder is one of the most prevalent medical conditions in the US that carries significant economic and health burden. The knowledge into venous pathophysiology, how it develops, and the true quality of life benefits of various treatment options are largely unknown. A truly meaningful clinical data capture system specifically for venous disorder may provide answers to the paucity of data. We describe a modern system to capture research and best practice data using the state of art information technology.

Objectives The emerging model of US healthcare delivery is aimed at reducing costs, standardizing care, and improving outcomes. Although it is necessary for healthcare providers and insurance carriers to work together to achieve those goals, insurers have the added duty of assuring physicians and patients that they comprehend the medical evidence and, based on that understanding, construct policies. Are US insurers meeting that responsibility or are they simply creating policies to serve their own needs? Methods The medical policies of several US health insurers were analysed. The goal was to see whether it could readily be determined if these carriers used evidence-based medicine consistently to create uniform policies for the treatment of patients with symptomatic varicose veins. The literature was also reviewed to determine whether increased insurance documentation requirements have affected cost reduction, standardization of care and/or improvement of outcomes related to chronic vein disease management. Results There is a dramatic lack of uniformity among the insurance policies reviewed. Insurers appear to not choose important papers to create policy but use carefully chosen articles to reinforce what they want their policies to say. In so doing, conflicting policy criteria are being created. Complicating this inconsistency, rules for medical necessity are modified frequently, raising frustration levels among vein providers and their patients. What is clear is that costs are not being lowered, care is not being standardized and little is being done to prevent potential complications resulting from chronic vein disease. Conclusions Patients and physicians are increasingly ill-served by, and frustrated with, the clear lack of consistency in the medical policy criteria being created by US insurance carriers in covering the treatment of patients with symptomatic varicose veins. The contradictory coverage requirements, seemingly based on no understanding of evidence-based medicine guidelines, and total variability in reimbursement for various types of treatment options is particularly worrisome. Collaboration between venous treatment providers and insurance carriers, to create evidence-based standards of care, would be timely and beneficial in creating guidelines for optimal patient care.

The acute pediatric scrotum is a common clinical condition that can present a diagnostic dilemma for even the most experienced physician. The issue of primary importance in each case is to ensure testicular viability through proper evaluation, prompt diagnosis, and surgical intervention if necessary. A review of the various etiologies of acute scrotal disorders in children aids in the formulation of a logical and systematic approach to their accurate diagnosis and management.