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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0001" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0007">Introduction</span><p id="para0005" class="elsevierStylePara elsevierViewall">Ovarian lesions&#44; although rare in the pediatric population&#44; display clinical features and pathology distinct from those of adults&#46; They constitute 1 &#37; to 5 &#37; of all pediatric and adolescent cases&#44; with some studies noting approximately 2&#46;6 instances of ovarian complications per 100&#44;000 female pediatrics&#46;<a class="elsevierStyleCrossRef" href="#bib0001"><span class="elsevierStyleSup">1</span></a> One particular concern is ovarian torsion &#40;OT&#41;&#44; an ovarian lesion that can affect females of all ages&#46;<a class="elsevierStyleCrossRef" href="#bib0002"><span class="elsevierStyleSup">2</span></a> The incidence of OT among children varies from 4&#46;9&#47;100&#44;000 to 20-30&#47;100&#44;000&#44; with an average age of 13 years&#46;<a class="elsevierStyleCrossRef" href="#bib0003"><span class="elsevierStyleSup">3</span></a></p><p id="para0006" class="elsevierStylePara elsevierViewall">Ovarian torsion is a severe condition where the ligament support of the ovary or its appendages twist&#44; obstructing the ovarian parenchymal veins and lymph nodes&#46;<a class="elsevierStyleCrossRef" href="#bib0004"><span class="elsevierStyleSup">4</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">5</span></a> If not diagnosed and treated promptly&#44; it can escalate to congestion and hemorrhagic necrosis&#44; arterial obstruction&#44; and potentially ovarian necrosis&#46; This sequence of events can further impact growth&#44; development&#44; reproduction&#44; and endocrine function&#46; The pathophysiology of OT involves various factors&#44; such as changes in intra-abdominal pressure&#44; tubal spasms&#44; ligament overactivity&#44; and hormonal activity during the premenstrual and peripartum periods&#46;<a class="elsevierStyleCrossRef" href="#bib0003"><span class="elsevierStyleSup">3</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">5</span></a></p><p id="para0007" class="elsevierStylePara elsevierViewall">Diagnosing OT in children is complex&#44; as it often presents with varying degrees of lower abdominal pain&#44; nausea&#44; vomiting&#44; fever&#44; and other symptoms that lack specificity&#46; Previous research showed that only 38 &#37; of preoperative diagnoses were correct&#44; emphasizing the challenge of early detection&#46;<a class="elsevierStyleCrossRef" href="#bib0006"><span class="elsevierStyleSup">6</span></a> Furthermore&#44; infantile OT presents more variability on ultrasound than in older children and adolescents due to the possibility of prenatal occurrence and asymptomatic presentation&#46;<a class="elsevierStyleCrossRef" href="#bib0007"><span class="elsevierStyleSup">7</span></a> As such&#44; potential signs of OT detected during prenatal exams should be considered when diagnosing ovarian conditions in children&#46;</p><p id="para0008" class="elsevierStylePara elsevierViewall">Historically&#44; blood tests and biomarkers&#44; including interleukin-6 &#40;IL-6&#41;&#44; D-dimer&#44; C-reactive protein &#40;CRP&#41;&#44; white blood cell &#40;WBC&#41; count&#44; and neutrophil-lymphocyte ratio &#40;NLR&#41;&#44; have been used to assist OT diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0008"><span class="elsevierStyleSup">8</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0009"><span class="elsevierStyleSup">9</span></a> These biomarkers change in response to the systemic inflammatory reaction induced by ovarian damage and necrosis from torsion&#46; Of these&#44; the NLR has been noted for its quick and accurate response to inflammatory changes&#44; making it a significant inflammatory marker for various diseases&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">10</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0011"><span class="elsevierStyleSup">11</span></a></p><p id="para0009" class="elsevierStylePara elsevierViewall">Despite the fact that ultrasound has been used as a useful diagnostic tool&#44; its limitations&#44; such as missed swirl signs or misleading Doppler flow patterns&#44; have raised concerns over its sensitivity and accuracy&#46;<a class="elsevierStyleCrossRefs" href="#bib0012"><span class="elsevierStyleSup">12-14</span></a> Therefore&#44; there is a growing interest in incorporating additional clinical parameters and exploring alternative imaging techniques&#44; such as computed tomography &#40;CT&#41; scans or magnetic resonance imaging &#40;MRI&#41;&#44; to enhance diagnostic precision&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">15</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0016"><span class="elsevierStyleSup">16</span></a></p><p id="para0010" class="elsevierStylePara elsevierViewall">Moreover&#44; research endeavors are focused on developing novel biomarkers or molecular signatures specific to OT&#46; The discovery of such markers could revolutionize diagnostics&#44; offering rapid and accurate detection before symptoms manifest or when traditional imaging techniques are inconclusive&#46; While ultrasound remains a fundamental diagnostic tool due to its noninvasive nature and widespread availability&#44; its use in conjunction with other diagnostic modalities is recommended for a comprehensive assessment&#46; Collaborative efforts among clinicians and researchers are expected to lead to improved methodologies&#44; enhancing our ability to promptly and accurately diagnose OT&#46;</p><p id="para0011" class="elsevierStylePara elsevierViewall">The importance of preoperative diagnosis of OT in medical practice is well recognized&#46; Regardless of advancements in technology and surgical procedures&#44; direct observation during surgery remains the gold standard for definitive diagnosis&#46; Timely intervention and prevention of further complications are facilitated by accurate preoperative diagnosis&#44; which is essential for ensuring favorable patient outcomes&#46;<a class="elsevierStyleCrossRef" href="#bib0017"><span class="elsevierStyleSup">17</span></a></p><p id="para0012" class="elsevierStylePara elsevierViewall">Despite extensive research&#44; OT diagnosis remains challenging&#46; This paper aims to provide a comprehensive analysis of sonographic&#44; clinical&#44; and laboratory features of OT in children&#46; By doing so&#44; the authors hope to shed light on new perspectives that can enhance preoperative diagnosis and thereby improve patient care&#46;</p></span><span id="sec0002" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0008">Methods</span><span id="sec0003" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0009">Study design and patient enrollment</span><p id="para0013" class="elsevierStylePara elsevierViewall">This study employed a retrospective design approved by institutional review boards to evaluate clinical&#44; ultrasound&#44; and laboratory features for their potential in diagnosing ovarian torsion &#40;OT&#41; among female pediatric patients who presented to the emergency department&#46; Between August 2017 and March 2022&#44; the authors enrolled 326 female pediatric patients who required laparoscopy due to suspected ovarian disease&#46; Post-laparoscopy&#44; the authors categorized patients into the ovarian torsion &#40;OT&#41; group&#44; consisting of 79 patients with ovarian torsion&#44; and the non-ovarian torsion &#40;N-OT&#41; group&#44; which included 247 patients without ovarian torsion&#46;</p><p id="para0014" class="elsevierStylePara elsevierViewall">Patients under 12 years of age and for whom complete abdominal ultrasound imaging data with good image quality was available were included in the study&#46; The exclusion criteria were&#58; &#40;1&#41; Premature infants&#44; macrosomia infants&#44; and low-weight birth infants&#59; &#40;2&#41; Secondary ovarian torsion&#59; &#40;3&#41; No abdominal ultrasound imaging examination was performed before surgery&#46; &#40;4&#41; Patients younger than 1 year were excluded because of the high prevalence of fetal ovarian cysts in this age group&#59; &#40;5&#41; The authors also excluded cases of prenatal ovarian torsion because the condition has significant differences in presentation and physical examination&#46;</p><p id="para0015" class="elsevierStylePara elsevierViewall">A flow chart of the study design is shown in Supplemental Fig&#46; 1&#46;</p></span><span id="sec0004" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0010">Demographic and clinical data collection</span><p id="para0016" class="elsevierStylePara elsevierViewall">An in-depth demographic study was conducted for all the participants&#44; focusing on aspects such as age and the location of ovarian masses&#46; Other clinical characteristics were also noted&#44; such as body mass index&#44; duration of pain&#44; vomiting&#44; lower abdominal pain&#44; absence of leukorrhea and metrorrhagia&#44; vaginal bleeding&#44; history of ovarian cyst&#44; and palpable abdominal mass as well as the incidence of ovarian masses detected before birth and the prevalence of precocious puberty&#46;</p></span><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0011">Sonographic and laboratory analysis</span><p id="para0017" class="elsevierStylePara elsevierViewall">The authors undertook a comprehensive comparison of clinical symptoms&#44; ultrasound features&#44; and laboratory parameters between the OT and N-OT groups&#46; The authors compared abdominal ultrasound examination i&#46;e&#46;&#44; transabdominal sonography &#40;TAS&#41;&#44; C-reactive protein level &#40;CRP&#41;&#44; white blood cell count&#44; absolute neutrophil count &#40;ANC&#41;&#44; and NLR between two groups of patients to determine whether ovarian torsion occurred&#46; Referring to relevant articles&#44; different studies often use NLR &#62; 3 as the threshold to analyze the relationship between NLR and diseases&#46;<a class="elsevierStyleCrossRef" href="#bib0018"><span class="elsevierStyleSup">18</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0019"><span class="elsevierStyleSup">19</span></a> Therefore&#44; in the present study&#44; the authors used the diagnostic value of NLR as NLR &#62; 3 for predicting patients with OT&#46;</p><p id="para0018" class="elsevierStylePara elsevierViewall">The Siemens S2000 and Philips EPIQ5 color Doppler ultrasound diagnostic instruments were used for an abdominal ultrasound&#46; Convex array probe&#44; frequency 2&#8211;6 MHz&#59; Linear array probe&#44; frequency 5&#8211;12 MHz&#46; All patients were placed in a supine position&#44; and the pelvic cavity was scanned to find the ovaries&#46; The bladder was filled as much as possible&#46; Routine abdominal and pelvic examinations were performed&#44; with a focus on scanning the uterus and bilateral appendages&#46; The size of the uterus and bilateral ovaries was measured&#44; and the morphology&#44; structure&#44; volume&#44; internal echo&#44; blood flow changes&#44; and pelvic fluid accumulation of the bilateral ovaries were observed&#46; At the same time&#44; the appendix area was also scanned to exclude other acute abdominal conditions such as appendicitis&#46; If the ultrasound imaging shows significant ovarian enlargement and is located in an uncommon area&#44; with uneven echo&#44; no blood flow signal in the ovary&#44; and torsion of the ovarian vascular pedicle&#44; it can be determined as ovarian torsion&#46; The evaluation of abdominal ultrasound was performed by two board-certified radiologists&#46;</p></span><span id="sec0006" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0012">Statistical analysis</span><p id="para0019" class="elsevierStylePara elsevierViewall">Descriptive statistics &#40;mean &#177; SD for continuous data and frequencies for categorical data&#41; were used to present the demographic and health aspects of the two groups&#46; To compare clinical&#44; sonographic&#44; and laboratory variables between the OT and N-OT groups&#44; the authors utilized the chi-square test or Fisher&#39;s exact test for categorical variables and the Mann-Whitney test for continuous variables&#46; Variables that were associated with ovarian torsion in the multivariate analysis and were of clinical significance&#44; including lower abdominal pain&#44; CRP&#44; prenatal detection of ovarian mass&#44; NLR &#62; 3&#44; and suspected torsion by TAS&#44; were incorporated into a logistic regression model&#46; To refine this model&#44; the authors employed backward selection to eliminate variables that didn&#39;t significantly contribute information&#44; given the other factors in the model&#46; After establishing the final model&#44; the authors evaluated the diagnostic ability of a combination of prenatal examination of ovarian mass&#44; suspected torsion by TAS&#44; and NLR &#62; 3 &#40;referred to as the &#39;triad&#39;&#41; to predict ovarian torsion&#46; To determine the sensitivity&#44; specificity&#44; and cutoff values for the &#39;triad&#39; and the presence of at least two of these features&#44; the authors constructed a receiver operating characteristic &#40;ROC&#41; curve and calculated the area under this curve&#46;</p></span></span><span id="sec0007" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0013">Results</span><span id="sec0008" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0014">Demographic and clinical characteristics</span><p id="para0020" class="elsevierStylePara elsevierViewall">A total of 326 female pediatric patients were included in the study&#46; Among them&#44; approximately 24&#46;23 &#37; &#40;79 cases&#41; were diagnosed with ovarian torsion &#40;OT&#41;&#44; while the remaining 75&#46;77 &#37; &#40;247 cases&#41; had no ovarian torsion &#40;N-OT&#41;&#46; The ages of the participants in the OT group and N-OT group were 3155&#177;1637 days and 3436 &#177; 1269 days&#44; respectively&#46; There was no significant difference in age between the two groups &#40;<span class="elsevierStyleItalic">p</span> &#61; 0&#46;5761&#41;&#46; Moreover&#44; no significant differences were observed in the BMI&#44; duration of pain&#44; vomiting&#44; lower abdominal pain&#44; absence of leukorrhea and metrorrhagia&#44; vaginal bleeding&#44; and history of ovarian cyst between the two groups &#40;<span class="elsevierStyleItalic">p</span> &#62; 0&#46;05&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0001">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0001"></elsevierMultimedia></span><span id="sec0009" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0015">Prevalence of ovarian masses and precocious puberty</span><p id="para0021" class="elsevierStylePara elsevierViewall">The study revealed a significant disparity in the occurrence of ovarian masses detected before birth between the OT and N-OT groups&#46; The OT group had a higher incidence of such masses than the N-OT &#40;22 cases versus 7 cases&#44; respectively&#41;&#44; and statistical analysis confirmed this discrepancy as highly significant &#40;<span class="elsevierStyleItalic">p</span> &#60; 0&#46;0001&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0001">Table 1</a>&#41;&#46;</p><p id="para0022" class="elsevierStylePara elsevierViewall">Moreover&#44; there was a significant difference in the prevalence of precocious puberty between the two groups&#46; The OT group had lower rates of early-onset puberty than the N-OT group &#40;5 cases versus 72 cases&#44; respectively&#41;&#44; and statistical analysis again confirmed these results as highly significant &#40;<span class="elsevierStyleItalic">p</span> &#60; 0&#46;0001&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0001">Table 1</a>&#41;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0016">Clinical&#44; sonographic and laboratory parameters</span><p id="para0023" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0002">Table 2</a> presents the comparison of clinical presentation&#44; ultrasound features&#44; and laboratory parameters between the OT and N-OT groups&#46; The OT group had a higher proportion of children with lower abdominal pain &#40;55&#46;67&#37; vs&#46; 35&#46;22 &#37;&#44; <span class="elsevierStyleItalic">p</span> &#60; 0&#46;001&#41; and a higher proportion of children with suspected torsion according to the TAS &#40;54&#46;53&#37; vs&#46; 10&#46;5 &#37;&#44; <span class="elsevierStyleItalic">p</span> &#60; 0&#46;001&#41;&#46; There were more patients in the OT group with lower abdominal pain than in the N-OT group and the difference was significant &#40;<span class="elsevierStyleItalic">p</span> &#60; 0&#46;001&#41;&#46; Additionally&#44; the OT group had significantly higher levels of CRP&#44; WBC count&#44; and ANC &#40;<span class="elsevierStyleItalic">p</span> &#60; 0&#46;001&#41;&#46; The NLR was also higher in the OT group&#44; with 41&#46;77 &#37; of patients in the OT group having an NLR &#62; 3 compared to only 3&#46;64 &#37; in the N-OT group &#40;<span class="elsevierStyleItalic">p</span> &#60; 0&#46;001&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0002">Table 2</a>&#41;&#46; Moreover&#44; the authors found that NLR &#62; 3 had a sensitivity of 82&#46;3 &#37; and a specificity of 85 &#37; for predicting ovarian torsion &#40;Supplemental Fig&#46; 2&#41;&#46;</p><elsevierMultimedia ident="tbl0002"></elsevierMultimedia></span><span id="sec0011" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0017">Predictors of ovarian torsion</span><p id="para0024" class="elsevierStylePara elsevierViewall">A multivariate analysis was performed for different factors associated with ovarian torsion&#46; The odds ratios for different factors associated with ovarian torsion are presented in Supplemental Table 1&#46; Patients with suspected torsion identified by TAS were 9&#46;17 times more likely to have adnexal torsion than those without &#40;95 &#37; CI&#58; 4&#46;434&#8211;18&#46;965&#41;&#46; Notably&#44; patients with NLR &#62; 3 had a higher incidence of ovarian torsion than those with NLR &#60; 3&#44; and the odds ratio was 10&#46;847 &#40;95 &#37; CI&#58; 4&#46;283&#8211;27&#46;474&#41;&#46; In addition&#44; patients with ovarian masses detected by prenatal examination were 20&#46;377 times more likely to have adnexal torsion than those without &#40;95 &#37; CI&#58; 7&#46;295&#8211;56&#46;915&#41;&#46;</p></span><span id="sec0012" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0018">Predictive value of triad and combination features</span><p id="para0025" class="elsevierStylePara elsevierViewall">Prenatal examination of the ovarian mass&#44; suspected torsion by TAS&#44; and NLR &#62; 3 were combined as a triad&#46; <a class="elsevierStyleCrossRefs" href="#tbl0003">Tables 3 and 4</a> show the sensitivity&#44; specificity&#44; cutoff values&#44; and area under the curve &#40;AUC&#41; for the triad and combinations of at least two features&#46; When all features of the triad were present&#44; the probability of predicting ovarian torsion had a sensitivity of 82&#46;3 &#37;&#44; a specificity of 85 &#37;&#44; a cutoff value of 0&#46;673&#44; and an AUC of 0&#46;868&#46; In the presence of at least two features&#44; sensitivity ranged from 65&#46;8 &#37; to 82&#46;3 &#37;&#44; and specificity ranged from 85 &#37; to 87 &#37;&#44; depending on the combination of signs&#46;</p><elsevierMultimedia ident="tbl0003"></elsevierMultimedia><elsevierMultimedia ident="tbl0004"></elsevierMultimedia></span></span><span id="sec0013" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0019">Discussion</span><p id="para0026" class="elsevierStylePara elsevierViewall">Childhood ovarian torsion studies are relatively scarce&#44; as the current literature primarily focuses on adult cases&#46; Ovarian torsion in pediatric patients predominantly originates from congenital or physiological factors such as hormonal changes causing ovary enlargement or ligament elongation&#46; Given children&#39;s long life expectancy&#44; the risks posed by ovarian torsion are especially pronounced&#44; potentially leading to severe complications such as ovarian necrosis and peritonitis&#46; Therefore&#44; it is critical to diagnose this condition early and correctly to enhance ovarian salvage rates&#44; which currently range from 27 &#37; to 99 &#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">20</span></a></p><p id="para0027" class="elsevierStylePara elsevierViewall">The present study involved 326 children who underwent laparoscopic surgery for ovarian masses&#44; out of whom 79 had ovarian torsion&#46; The key predictors of adnexal torsion were suspected torsion via abdominal ultrasound&#44; and prenatal examination revealing an ovarian mass&#44; with NLR &#707; 3&#46; Ultrasonography revealed multiple follicles surrounding the enlarged ovaries&#44; as well as abnormal blood flow signals&#44; indicating a series of ovarian torsion sonograms&#46; However&#44; as ultrasound results hinge on the examiner&#39;s skill and experience&#44; disparities inevitably arise&#44; exposing a drawback of this diagnostic method&#46; Hence&#44; there is a need for a collective diagnosis considering prenatal ovarian mass detection&#44; NLR &#62; 3&#44; and ultrasound results&#46; Combining these three parameters for diagnosing and predicting ovarian torsion resulted in a low sensitivity yet an impressive specificity of 95&#46;1 &#37;&#46; When at least two of these features were present&#44; this model predicted torsion with a probability ranging from 88&#46;23 &#37; to 99&#46;35 &#37;&#46; The present research concurs with other studies reporting that approximately 40 &#37; of surgically confirmed ovarian torsion cases were preoperatively diagnosed based on clinical and ultrasound characteristics&#46;<a class="elsevierStyleCrossRef" href="#bib0021"><span class="elsevierStyleSup">21</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0022"><span class="elsevierStyleSup">22</span></a> Despite the reliance on TAS for ovarian torsion diagnosis&#44; the authors observed a low sensitivity of 54&#46;4 &#37; for TAS alone&#46; This corresponds with other findings revealing normal ultrasounds in approximately 50 &#37; of ovarian torsion cases&#46;<a class="elsevierStyleCrossRef" href="#bib0023"><span class="elsevierStyleSup">23</span></a> These discrepancies challenge the exclusive reliance on ultrasound for preoperative diagnosis&#46;</p><p id="para0028" class="elsevierStylePara elsevierViewall">Further analysis of the present data demonstrated that lower abdominal pain was significantly more common in patients with ovarian torsion than in those without &#40;55&#46;67&#37; vs&#46; 35&#46;22 &#37;&#44; <span class="elsevierStyleItalic">p</span> &#60; 0&#46;001&#41;&#46; This aligns with previous findings linking lower abdominal pain and adnexal torsion&#46;<a class="elsevierStyleCrossRef" href="#bib0024"><span class="elsevierStyleSup">24</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">25</span></a> Likewise&#44; several studies show the same symptom as a potential indicator of gynecological inflammation and malignancies&#46;<a class="elsevierStyleCrossRef" href="#bib0008"><span class="elsevierStyleSup">8</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0024"><span class="elsevierStyleSup">24</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0026"><span class="elsevierStyleSup">26</span></a></p><p id="para0029" class="elsevierStylePara elsevierViewall">The present research also established a significantly higher NLR in patients with ovarian torsion than in those without &#40;3&#46;769 &#177; 4&#46;475 vs&#46; 0&#46;9171 &#177; 0&#46;9147&#44; <span class="elsevierStyleItalic">p</span> &#60; 0&#46;001&#41;&#44; confirming prior research&#46;<a class="elsevierStyleCrossRef" href="#bib0018"><span class="elsevierStyleSup">18</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0027"><span class="elsevierStyleSup">27</span></a> The rise in NLR stems from the inflammatory and immune response triggered by ischemia and necrosis in ovarian torsion&#44; making it a potential early diagnostic and assessment tool for this condition&#46;</p><p id="para0030" class="elsevierStylePara elsevierViewall">Currently&#44; no universally accepted predictive rule exists for adnexal torsion detection&#46; Given the insufficiency of any single tool for a reliable diagnosis&#44; the authors propose a simple prediction model for ovarian torsion based on symptoms and laboratory and ultrasound findings&#46; The authors report a specificity of 95&#46;1 &#37; and an AUC of 0&#46;795 for the combination of NLR &#62; 3&#44; prenatal examination revealing ovarian mass&#44; and suspected torsion on abdominal ultrasound&#46; Despite its low sensitivity&#44; the model&#39;s high specificity indicates its importance&#46; Thus&#44; the presence of at least two of these three features should heighten the clinical suspicion of ovarian torsion in children with ovarian masses&#46;</p><span id="sec0014" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0020">Strengths and limitations</span><p id="para0031" class="elsevierStylePara elsevierViewall">This study possesses a number of notable strengths&#46; To our knowledge&#44; this is the first study to investigate the clinical symptoms&#44; NLR&#44; and ultrasound characteristics of pediatric ovarian torsion both independently and in combination&#46; The study is further distinguished by its substantial sample size&#44; constituting the largest single-institutional cohort of children with torsion diagnosed via laparoscopic findings&#46; Moreover&#44; the urgency and real-world applicability of the present research are emphasized by the fact that most abdominal sonograms were carried out in emergency room settings&#44; reflecting the critical need for timely diagnosis of suspected adnexal torsion&#46;</p><p id="para0032" class="elsevierStylePara elsevierViewall">However&#44; the authors recognize several limitations inherent in the research design&#46; Primarily&#44; the retrospective nature of the study could introduce bias&#44; potentially affecting the results&#46; Furthermore&#44; the authors did not comprehensively document the ultrasound features of adnexal torsion&#44; limiting descriptions to a binary categorization of torsion suspected or not suspected&#46; The present sample is also exclusively composed of female pediatric patients who underwent surgical treatment&#44; possibly excluding cases of adnexal torsion that did not receive surgery&#46; However&#44; given the status as a regional national medical center&#44; the authors often receive referrals from other institutions&#44; which likely reduces the number of missed cases&#46;</p><p id="para0033" class="elsevierStylePara elsevierViewall">Despite these limitations&#44; the present findings underscore the importance of ultrasound&#44; clinical symptoms&#44; and laboratory features as first-line evaluative tools for children suspected of having ovarian torsion&#46; The presence of an ovarian mass upon prenatal examination&#44; an NLR &#62; 3&#44; and indicative findings from TAS should raise a high suspicion of torsion&#46;</p><p id="para0034" class="elsevierStylePara elsevierViewall">In light of these findings&#44; the authors developed a predictive model incorporating these three features to aid in the preoperative diagnosis of torsion in children&#46; This tool can expedite diagnosis&#44; enabling prompt surgical intervention and potentially mitigating the risk of ovarian damage&#46;</p><p id="para0035" class="elsevierStylePara elsevierViewall">Nevertheless&#44; the retrospective design of this study restricts the ability to draw definitive conclusions&#46; As such&#44; further prospective studies are warranted to corroborate the present findings and refine the predictive model&#46; As medical professionals&#44; the goal is to continually improve diagnostic capabilities to increase the chances of preserving ovarian function and improving patient outcomes&#46;</p></span></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0021">Conclusions</span><p id="para0036" class="elsevierStylePara elsevierViewall">This study presents a prediction model that combines clinical&#44; laboratory&#44; and ultrasound findings to assist in the preoperative diagnosis of children with ovarian torsion&#44; thus proving its usefulness in the emergency department&#46;</p></span></span>"
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              "titulo" => "Demographic and clinical characteristics"
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              "titulo" => "Prevalence of ovarian masses and precocious puberty"
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    "fechaRecibido" => "2023-08-24"
    "fechaAceptado" => "2024-01-22"
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            0 => "Ovarian torsion"
            1 => "Children"
            2 => "Immune cells"
            3 => "Prenatal examination"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abss0001" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0002">Objective</span><p id="spara009" class="elsevierStyleSimplePara elsevierViewall">Ovarian torsion &#40;OT&#41; represents a severe gynecological emergency in female pediatric patients&#44; necessitating immediate surgical intervention to prevent ovarian ischemia and preserve fertility&#46; Prompt diagnosis is&#44; therefore&#44; paramount&#46; This retrospective study set out to assess the utility of combined clinical&#44; ultrasound&#44; and laboratory features in diagnosing OT&#46;</p></span> <span id="abss0002" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0003">Methods</span><p id="spara010" class="elsevierStyleSimplePara elsevierViewall">The authors included 326 female pediatric patients aged under 14 years who underwent surgical confirmation of OT over a five-year period&#46; Logistic regression analysis was employed to pinpoint factors linked with OT&#44; and the authors compared clinical presentation&#44; laboratory results&#44; and ultrasound characteristics between patients with OT &#40;OT group&#41; and without OT &#40;N-OT group&#41;&#46; The authors conducted receiver operating characteristic &#40;ROC&#41; curve analysis to gauge the predictive capacity of the combined features&#46;</p></span> <span id="abss0003" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0004">Results</span><p id="spara011" class="elsevierStyleSimplePara elsevierViewall">Among 326&#44; OT was confirmed in 24&#46;23 &#37; &#40;79 cases&#41; of the patients&#46; The OT group had a higher incidence of prenatal ovarian masses than the N-OT &#40;22 cases versus 7 cases&#41; &#40;<span class="elsevierStyleItalic">p</span> &#60; 0&#46;0001&#41;&#46; Similarly&#44; the authors observed significant differences in the presence of lower abdominal pain&#44; suspected torsion on transabdominal ultrasound&#44; and a high neutrophil-lymphocyte ratio &#40;NLR &#62; 3&#41; between the OT and non-OT groups &#40;p &#706; 0&#46;05&#41;&#46; Furthermore&#44; when these parameters were combined&#44; the resulting area under the curve &#40;AUC&#41; was 0&#46;868&#44; demonstrating their potential utility in OT diagnosis&#46;</p></span> <span id="abss0004" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0005">Conclusion</span><p id="spara012" class="elsevierStyleSimplePara elsevierViewall">This study demonstrates a prediction model integrating clinical&#44; laboratory&#44; and ultrasound findings that can support the preoperative diagnosis of ovarian torsion&#44; thereby enhancing diagnostic precision and improving patient management&#46; Future prospective studies should concentrate on developing clinical predictive models for OT in pediatric patients&#46;</p></span>"
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          "leyenda" => "<p id="spara002" class="elsevierStyleSimplePara elsevierViewall">BMI&#44; Body-mass index&#59; PE&#44; Prenatal examination revealed ovarian mass&#59; PP&#44; Precocious puberty&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><a name="en0001"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Parameters&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">OT group&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0003"></a><th class="td" title="\n
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                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">N-OT group&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="top">Cases &#40;<span class="elsevierStyleItalic">N</span> &#61; 326&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="top">79&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="top">247&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0008"></a><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0009"></a><td class="td" title="\n
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                  \t\t\t\t</td><a name="en0011"></a><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="top">3436&#177;1269&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0012"></a><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="top">0&#46;5761&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="top">Race&#47;ethnicity &#40;Han Chinese&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="top">79 &#40;100 &#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0015"></a><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="top">242 &#40;97&#46;9 &#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0016"></a><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="top">0&#46;963&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="top">BMI &#40;kg&#47;m<span class="elsevierStyleSup">2</span>&#41; &#40;main&#41; &#177; SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0018"></a><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="top">19&#46;26&#177;2&#46;32&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0019"></a><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="top">18&#46;90&#177;1&#46;92&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0020"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#46;174&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0021"></a><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="top">Duration of pain &#40;d&#41;&#40;mean&#41; &#177; SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0022"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">5&#46;59&#177;1&#46;48&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0023"></a><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="top">5&#46;40&#177;1&#46;63&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0024"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#46;337&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="top">Vomiting &#40;N&#41; &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0026"></a><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="top">6 &#40;7&#46;59 &#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0027"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">13 &#40;5&#46;26 &#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0028"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#46;4184&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0029"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Absence of leukorrhea &#38; metrorrhagia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0030"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">75 &#40;94&#46;9 &#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0031"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">247 &#40;100 &#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0032"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#46;23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0033"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Vaginal bleeding&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0034"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">6 &#40;7&#46;6 &#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0035"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">25 &#40;10&#46;1 &#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0036"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#46;77&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0037"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">History of ovarian cyst&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0038"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0 &#40;0&#46;0 &#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0039"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">1 &#40;2&#46;6 &#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0040"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">1&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0041"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">PE N &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0042"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">22 &#40;27&#46;85 &#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0043"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">7 &#40;2&#46;83 &#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0044"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#60;0&#46;0001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0045"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">PP N &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0046"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">5 &#40;6&#46;33 &#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0047"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">72 &#40;29&#46;15 &#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0048"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#60;0&#46;0001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab3558728.png"
              ]
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          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spara001" class="elsevierStyleSimplePara elsevierViewall">Demographic and clinical characteristics of patients who underwent laparoscopy&#46;</p>"
        ]
      ]
      1 => array:8 [
        "identificador" => "tbl0002"
        "etiqueta" => "Table 2"
        "tipo" => "MULTIMEDIATABLA"
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        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "alt0002"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spara004" class="elsevierStyleSimplePara elsevierViewall">WBC&#44; White Blood Cells&#59; CRP&#44; C-Reactive Protein&#59; NLR&#44; Neutrophil -Lymphocyte Ratio&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><a name="en0049"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Indicators&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0050"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">OT group&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0051"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">N-OT group&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0052"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">p-value&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><a name="en0053"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Palpable abdominal mass &#40;N&#41; &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0054"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">5 &#40;3&#46;95 &#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0055"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">77 &#40;31&#46;17 &#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0056"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;0001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0057"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Lower abdominal pain &#40;N&#41; &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0058"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">44 &#40;55&#46;67 &#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0059"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">87 &#40;35&#46;22 &#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0060"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">&#60;</span>0&#46;0001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0061"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Fever &#40;N&#41; &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0062"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">7 &#40;8&#46;8 &#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0063"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0 &#40;0&#46;0 &#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0064"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0065"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Ovarian torsion &#40;Left&#41; &#40;N&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0066"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">29&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0067"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">104&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0068"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;396&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0069"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Ovarian torsion &#40;Right&#41; &#40;N&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0070"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0071"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">143&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0068a"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0073"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">WBC &#40;&#42;10&#94;9&#47;L&#41; &#40;main&#41; &#177; SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0074"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">10&#46;73&#177;3&#46;83&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0075"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">7&#46;649&#177;2&#46;965&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0076"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;0001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0077"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Absolute Lymphocytes &#40;&#42;10&#94;9&#47;L&#41; &#40;mean&#41; &#177; SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0078"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">3&#46;368&#177;2&#46;321&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0079"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">2&#46;696&#177;1&#46;174&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0080"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;2949&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0081"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Percentage of Lymphocytes &#40;mean&#41; &#177; SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0082"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">34&#46;25&#177;22&#46;06&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0083"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">37&#46;49&#177;14&#46;54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0084"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;0222&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0085"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Absolute Neutrophils &#40;&#42;10&#94;9&#47;L&#41; &#40;mean&#41; &#177; SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0086"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">6&#46;561&#177;4&#46;354&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0087"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">4&#46;283&#177;2&#46;645&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0088"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;0001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0089"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Percentage of Neutrophils &#40;mean&#41; &#177; SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0090"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">57&#46;55&#177;24&#46;04&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0091"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">53&#46;55&#177;15&#46;85&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0092"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;0143&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0093"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">CRP &#40;mg&#47;L&#41; &#40;mean&#41; &#177; SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0094"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">5&#46;891&#177;14&#46;71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0095"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">1&#46;823&#177;7&#46;838&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0096"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;0001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0097"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">NLR &#40;mean&#41; &#177; SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0098"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">3&#46;769&#177;4&#46;475&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0099"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#46;9171&#177;0&#46;9147&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0100"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;0001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0101"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">NLR &#62; 3 &#40;N&#41; &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0102"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">33 &#40;41&#46;77 &#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">9 &#40;3&#46;64 &#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;0001&nbsp;\t\t\t\t\t\t\n
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                0 => """
                  <table border="0" frame="\n
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                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Signs of torsion&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Predicted probability for torsion&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t</td><a name="en0114"></a><td class="td" title="\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#8722;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="top">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0118"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0119"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#46;44983&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="top">&#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0122"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0123"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#43;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0125"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0126"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#43;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0128"></a><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="top">&#8722;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0132"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#43;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#8722;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#46;88232&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0136"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0137"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0138"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0139"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#46;93371&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0140"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#43;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#43;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#46;94338&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0145"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">3 of 3&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#43;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#43;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#43;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#46;99350&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">95 &#37; CI&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#46;658&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0158"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#46;862&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0159"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#46;52&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0160"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#46;782&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0161"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#46;0714&#8211;0&#46;849&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0162"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">TAS&#43;PE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0163"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#46;747&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0164"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#46;87&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0165"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#46;617&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0166"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#46;818&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0167"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;757&#8211;0&#46;879&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0168"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">NLR&#43;PE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0169"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#46;649&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0170"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#46;951&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0171"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#46;597&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0172"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#46;795&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0173"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;728&#8211;0&#46;861&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0174"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">TAS&#43;NLR&#43;PE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0175"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#46;823&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0176"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#46;85&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0177"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#46;673&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0178"></a><td class="td" title="\n
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Original article
Key clinical predictors in the diagnosis of ovarian torsion in children
Sai Chen, Zhigang Gao, Yunzhong Qian, Qingjiang Chen
Corresponding author
chensai829@zju.edu.cn

Corresponding author.
Zhejiang University School of Medicine, The Children's Hospital, National Clinical Research Center for Child Health, Department of Pediatric General Surgery, Zhejiang Province, China
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0001" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0007">Introduction</span><p id="para0005" class="elsevierStylePara elsevierViewall">Ovarian lesions&#44; although rare in the pediatric population&#44; display clinical features and pathology distinct from those of adults&#46; They constitute 1 &#37; to 5 &#37; of all pediatric and adolescent cases&#44; with some studies noting approximately 2&#46;6 instances of ovarian complications per 100&#44;000 female pediatrics&#46;<a class="elsevierStyleCrossRef" href="#bib0001"><span class="elsevierStyleSup">1</span></a> One particular concern is ovarian torsion &#40;OT&#41;&#44; an ovarian lesion that can affect females of all ages&#46;<a class="elsevierStyleCrossRef" href="#bib0002"><span class="elsevierStyleSup">2</span></a> The incidence of OT among children varies from 4&#46;9&#47;100&#44;000 to 20-30&#47;100&#44;000&#44; with an average age of 13 years&#46;<a class="elsevierStyleCrossRef" href="#bib0003"><span class="elsevierStyleSup">3</span></a></p><p id="para0006" class="elsevierStylePara elsevierViewall">Ovarian torsion is a severe condition where the ligament support of the ovary or its appendages twist&#44; obstructing the ovarian parenchymal veins and lymph nodes&#46;<a class="elsevierStyleCrossRef" href="#bib0004"><span class="elsevierStyleSup">4</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">5</span></a> If not diagnosed and treated promptly&#44; it can escalate to congestion and hemorrhagic necrosis&#44; arterial obstruction&#44; and potentially ovarian necrosis&#46; This sequence of events can further impact growth&#44; development&#44; reproduction&#44; and endocrine function&#46; The pathophysiology of OT involves various factors&#44; such as changes in intra-abdominal pressure&#44; tubal spasms&#44; ligament overactivity&#44; and hormonal activity during the premenstrual and peripartum periods&#46;<a class="elsevierStyleCrossRef" href="#bib0003"><span class="elsevierStyleSup">3</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">5</span></a></p><p id="para0007" class="elsevierStylePara elsevierViewall">Diagnosing OT in children is complex&#44; as it often presents with varying degrees of lower abdominal pain&#44; nausea&#44; vomiting&#44; fever&#44; and other symptoms that lack specificity&#46; Previous research showed that only 38 &#37; of preoperative diagnoses were correct&#44; emphasizing the challenge of early detection&#46;<a class="elsevierStyleCrossRef" href="#bib0006"><span class="elsevierStyleSup">6</span></a> Furthermore&#44; infantile OT presents more variability on ultrasound than in older children and adolescents due to the possibility of prenatal occurrence and asymptomatic presentation&#46;<a class="elsevierStyleCrossRef" href="#bib0007"><span class="elsevierStyleSup">7</span></a> As such&#44; potential signs of OT detected during prenatal exams should be considered when diagnosing ovarian conditions in children&#46;</p><p id="para0008" class="elsevierStylePara elsevierViewall">Historically&#44; blood tests and biomarkers&#44; including interleukin-6 &#40;IL-6&#41;&#44; D-dimer&#44; C-reactive protein &#40;CRP&#41;&#44; white blood cell &#40;WBC&#41; count&#44; and neutrophil-lymphocyte ratio &#40;NLR&#41;&#44; have been used to assist OT diagnosis&#46;<a class="elsevierStyleCrossRef" href="#bib0008"><span class="elsevierStyleSup">8</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0009"><span class="elsevierStyleSup">9</span></a> These biomarkers change in response to the systemic inflammatory reaction induced by ovarian damage and necrosis from torsion&#46; Of these&#44; the NLR has been noted for its quick and accurate response to inflammatory changes&#44; making it a significant inflammatory marker for various diseases&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">10</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0011"><span class="elsevierStyleSup">11</span></a></p><p id="para0009" class="elsevierStylePara elsevierViewall">Despite the fact that ultrasound has been used as a useful diagnostic tool&#44; its limitations&#44; such as missed swirl signs or misleading Doppler flow patterns&#44; have raised concerns over its sensitivity and accuracy&#46;<a class="elsevierStyleCrossRefs" href="#bib0012"><span class="elsevierStyleSup">12-14</span></a> Therefore&#44; there is a growing interest in incorporating additional clinical parameters and exploring alternative imaging techniques&#44; such as computed tomography &#40;CT&#41; scans or magnetic resonance imaging &#40;MRI&#41;&#44; to enhance diagnostic precision&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">15</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0016"><span class="elsevierStyleSup">16</span></a></p><p id="para0010" class="elsevierStylePara elsevierViewall">Moreover&#44; research endeavors are focused on developing novel biomarkers or molecular signatures specific to OT&#46; The discovery of such markers could revolutionize diagnostics&#44; offering rapid and accurate detection before symptoms manifest or when traditional imaging techniques are inconclusive&#46; While ultrasound remains a fundamental diagnostic tool due to its noninvasive nature and widespread availability&#44; its use in conjunction with other diagnostic modalities is recommended for a comprehensive assessment&#46; Collaborative efforts among clinicians and researchers are expected to lead to improved methodologies&#44; enhancing our ability to promptly and accurately diagnose OT&#46;</p><p id="para0011" class="elsevierStylePara elsevierViewall">The importance of preoperative diagnosis of OT in medical practice is well recognized&#46; Regardless of advancements in technology and surgical procedures&#44; direct observation during surgery remains the gold standard for definitive diagnosis&#46; Timely intervention and prevention of further complications are facilitated by accurate preoperative diagnosis&#44; which is essential for ensuring favorable patient outcomes&#46;<a class="elsevierStyleCrossRef" href="#bib0017"><span class="elsevierStyleSup">17</span></a></p><p id="para0012" class="elsevierStylePara elsevierViewall">Despite extensive research&#44; OT diagnosis remains challenging&#46; This paper aims to provide a comprehensive analysis of sonographic&#44; clinical&#44; and laboratory features of OT in children&#46; By doing so&#44; the authors hope to shed light on new perspectives that can enhance preoperative diagnosis and thereby improve patient care&#46;</p></span><span id="sec0002" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0008">Methods</span><span id="sec0003" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0009">Study design and patient enrollment</span><p id="para0013" class="elsevierStylePara elsevierViewall">This study employed a retrospective design approved by institutional review boards to evaluate clinical&#44; ultrasound&#44; and laboratory features for their potential in diagnosing ovarian torsion &#40;OT&#41; among female pediatric patients who presented to the emergency department&#46; Between August 2017 and March 2022&#44; the authors enrolled 326 female pediatric patients who required laparoscopy due to suspected ovarian disease&#46; Post-laparoscopy&#44; the authors categorized patients into the ovarian torsion &#40;OT&#41; group&#44; consisting of 79 patients with ovarian torsion&#44; and the non-ovarian torsion &#40;N-OT&#41; group&#44; which included 247 patients without ovarian torsion&#46;</p><p id="para0014" class="elsevierStylePara elsevierViewall">Patients under 12 years of age and for whom complete abdominal ultrasound imaging data with good image quality was available were included in the study&#46; The exclusion criteria were&#58; &#40;1&#41; Premature infants&#44; macrosomia infants&#44; and low-weight birth infants&#59; &#40;2&#41; Secondary ovarian torsion&#59; &#40;3&#41; No abdominal ultrasound imaging examination was performed before surgery&#46; &#40;4&#41; Patients younger than 1 year were excluded because of the high prevalence of fetal ovarian cysts in this age group&#59; &#40;5&#41; The authors also excluded cases of prenatal ovarian torsion because the condition has significant differences in presentation and physical examination&#46;</p><p id="para0015" class="elsevierStylePara elsevierViewall">A flow chart of the study design is shown in Supplemental Fig&#46; 1&#46;</p></span><span id="sec0004" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0010">Demographic and clinical data collection</span><p id="para0016" class="elsevierStylePara elsevierViewall">An in-depth demographic study was conducted for all the participants&#44; focusing on aspects such as age and the location of ovarian masses&#46; Other clinical characteristics were also noted&#44; such as body mass index&#44; duration of pain&#44; vomiting&#44; lower abdominal pain&#44; absence of leukorrhea and metrorrhagia&#44; vaginal bleeding&#44; history of ovarian cyst&#44; and palpable abdominal mass as well as the incidence of ovarian masses detected before birth and the prevalence of precocious puberty&#46;</p></span><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0011">Sonographic and laboratory analysis</span><p id="para0017" class="elsevierStylePara elsevierViewall">The authors undertook a comprehensive comparison of clinical symptoms&#44; ultrasound features&#44; and laboratory parameters between the OT and N-OT groups&#46; The authors compared abdominal ultrasound examination i&#46;e&#46;&#44; transabdominal sonography &#40;TAS&#41;&#44; C-reactive protein level &#40;CRP&#41;&#44; white blood cell count&#44; absolute neutrophil count &#40;ANC&#41;&#44; and NLR between two groups of patients to determine whether ovarian torsion occurred&#46; Referring to relevant articles&#44; different studies often use NLR &#62; 3 as the threshold to analyze the relationship between NLR and diseases&#46;<a class="elsevierStyleCrossRef" href="#bib0018"><span class="elsevierStyleSup">18</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0019"><span class="elsevierStyleSup">19</span></a> Therefore&#44; in the present study&#44; the authors used the diagnostic value of NLR as NLR &#62; 3 for predicting patients with OT&#46;</p><p id="para0018" class="elsevierStylePara elsevierViewall">The Siemens S2000 and Philips EPIQ5 color Doppler ultrasound diagnostic instruments were used for an abdominal ultrasound&#46; Convex array probe&#44; frequency 2&#8211;6 MHz&#59; Linear array probe&#44; frequency 5&#8211;12 MHz&#46; All patients were placed in a supine position&#44; and the pelvic cavity was scanned to find the ovaries&#46; The bladder was filled as much as possible&#46; Routine abdominal and pelvic examinations were performed&#44; with a focus on scanning the uterus and bilateral appendages&#46; The size of the uterus and bilateral ovaries was measured&#44; and the morphology&#44; structure&#44; volume&#44; internal echo&#44; blood flow changes&#44; and pelvic fluid accumulation of the bilateral ovaries were observed&#46; At the same time&#44; the appendix area was also scanned to exclude other acute abdominal conditions such as appendicitis&#46; If the ultrasound imaging shows significant ovarian enlargement and is located in an uncommon area&#44; with uneven echo&#44; no blood flow signal in the ovary&#44; and torsion of the ovarian vascular pedicle&#44; it can be determined as ovarian torsion&#46; The evaluation of abdominal ultrasound was performed by two board-certified radiologists&#46;</p></span><span id="sec0006" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0012">Statistical analysis</span><p id="para0019" class="elsevierStylePara elsevierViewall">Descriptive statistics &#40;mean &#177; SD for continuous data and frequencies for categorical data&#41; were used to present the demographic and health aspects of the two groups&#46; To compare clinical&#44; sonographic&#44; and laboratory variables between the OT and N-OT groups&#44; the authors utilized the chi-square test or Fisher&#39;s exact test for categorical variables and the Mann-Whitney test for continuous variables&#46; Variables that were associated with ovarian torsion in the multivariate analysis and were of clinical significance&#44; including lower abdominal pain&#44; CRP&#44; prenatal detection of ovarian mass&#44; NLR &#62; 3&#44; and suspected torsion by TAS&#44; were incorporated into a logistic regression model&#46; To refine this model&#44; the authors employed backward selection to eliminate variables that didn&#39;t significantly contribute information&#44; given the other factors in the model&#46; After establishing the final model&#44; the authors evaluated the diagnostic ability of a combination of prenatal examination of ovarian mass&#44; suspected torsion by TAS&#44; and NLR &#62; 3 &#40;referred to as the &#39;triad&#39;&#41; to predict ovarian torsion&#46; To determine the sensitivity&#44; specificity&#44; and cutoff values for the &#39;triad&#39; and the presence of at least two of these features&#44; the authors constructed a receiver operating characteristic &#40;ROC&#41; curve and calculated the area under this curve&#46;</p></span></span><span id="sec0007" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0013">Results</span><span id="sec0008" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0014">Demographic and clinical characteristics</span><p id="para0020" class="elsevierStylePara elsevierViewall">A total of 326 female pediatric patients were included in the study&#46; Among them&#44; approximately 24&#46;23 &#37; &#40;79 cases&#41; were diagnosed with ovarian torsion &#40;OT&#41;&#44; while the remaining 75&#46;77 &#37; &#40;247 cases&#41; had no ovarian torsion &#40;N-OT&#41;&#46; The ages of the participants in the OT group and N-OT group were 3155&#177;1637 days and 3436 &#177; 1269 days&#44; respectively&#46; There was no significant difference in age between the two groups &#40;<span class="elsevierStyleItalic">p</span> &#61; 0&#46;5761&#41;&#46; Moreover&#44; no significant differences were observed in the BMI&#44; duration of pain&#44; vomiting&#44; lower abdominal pain&#44; absence of leukorrhea and metrorrhagia&#44; vaginal bleeding&#44; and history of ovarian cyst between the two groups &#40;<span class="elsevierStyleItalic">p</span> &#62; 0&#46;05&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0001">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0001"></elsevierMultimedia></span><span id="sec0009" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0015">Prevalence of ovarian masses and precocious puberty</span><p id="para0021" class="elsevierStylePara elsevierViewall">The study revealed a significant disparity in the occurrence of ovarian masses detected before birth between the OT and N-OT groups&#46; The OT group had a higher incidence of such masses than the N-OT &#40;22 cases versus 7 cases&#44; respectively&#41;&#44; and statistical analysis confirmed this discrepancy as highly significant &#40;<span class="elsevierStyleItalic">p</span> &#60; 0&#46;0001&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0001">Table 1</a>&#41;&#46;</p><p id="para0022" class="elsevierStylePara elsevierViewall">Moreover&#44; there was a significant difference in the prevalence of precocious puberty between the two groups&#46; The OT group had lower rates of early-onset puberty than the N-OT group &#40;5 cases versus 72 cases&#44; respectively&#41;&#44; and statistical analysis again confirmed these results as highly significant &#40;<span class="elsevierStyleItalic">p</span> &#60; 0&#46;0001&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0001">Table 1</a>&#41;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0016">Clinical&#44; sonographic and laboratory parameters</span><p id="para0023" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0002">Table 2</a> presents the comparison of clinical presentation&#44; ultrasound features&#44; and laboratory parameters between the OT and N-OT groups&#46; The OT group had a higher proportion of children with lower abdominal pain &#40;55&#46;67&#37; vs&#46; 35&#46;22 &#37;&#44; <span class="elsevierStyleItalic">p</span> &#60; 0&#46;001&#41; and a higher proportion of children with suspected torsion according to the TAS &#40;54&#46;53&#37; vs&#46; 10&#46;5 &#37;&#44; <span class="elsevierStyleItalic">p</span> &#60; 0&#46;001&#41;&#46; There were more patients in the OT group with lower abdominal pain than in the N-OT group and the difference was significant &#40;<span class="elsevierStyleItalic">p</span> &#60; 0&#46;001&#41;&#46; Additionally&#44; the OT group had significantly higher levels of CRP&#44; WBC count&#44; and ANC &#40;<span class="elsevierStyleItalic">p</span> &#60; 0&#46;001&#41;&#46; The NLR was also higher in the OT group&#44; with 41&#46;77 &#37; of patients in the OT group having an NLR &#62; 3 compared to only 3&#46;64 &#37; in the N-OT group &#40;<span class="elsevierStyleItalic">p</span> &#60; 0&#46;001&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0002">Table 2</a>&#41;&#46; Moreover&#44; the authors found that NLR &#62; 3 had a sensitivity of 82&#46;3 &#37; and a specificity of 85 &#37; for predicting ovarian torsion &#40;Supplemental Fig&#46; 2&#41;&#46;</p><elsevierMultimedia ident="tbl0002"></elsevierMultimedia></span><span id="sec0011" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0017">Predictors of ovarian torsion</span><p id="para0024" class="elsevierStylePara elsevierViewall">A multivariate analysis was performed for different factors associated with ovarian torsion&#46; The odds ratios for different factors associated with ovarian torsion are presented in Supplemental Table 1&#46; Patients with suspected torsion identified by TAS were 9&#46;17 times more likely to have adnexal torsion than those without &#40;95 &#37; CI&#58; 4&#46;434&#8211;18&#46;965&#41;&#46; Notably&#44; patients with NLR &#62; 3 had a higher incidence of ovarian torsion than those with NLR &#60; 3&#44; and the odds ratio was 10&#46;847 &#40;95 &#37; CI&#58; 4&#46;283&#8211;27&#46;474&#41;&#46; In addition&#44; patients with ovarian masses detected by prenatal examination were 20&#46;377 times more likely to have adnexal torsion than those without &#40;95 &#37; CI&#58; 7&#46;295&#8211;56&#46;915&#41;&#46;</p></span><span id="sec0012" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0018">Predictive value of triad and combination features</span><p id="para0025" class="elsevierStylePara elsevierViewall">Prenatal examination of the ovarian mass&#44; suspected torsion by TAS&#44; and NLR &#62; 3 were combined as a triad&#46; <a class="elsevierStyleCrossRefs" href="#tbl0003">Tables 3 and 4</a> show the sensitivity&#44; specificity&#44; cutoff values&#44; and area under the curve &#40;AUC&#41; for the triad and combinations of at least two features&#46; When all features of the triad were present&#44; the probability of predicting ovarian torsion had a sensitivity of 82&#46;3 &#37;&#44; a specificity of 85 &#37;&#44; a cutoff value of 0&#46;673&#44; and an AUC of 0&#46;868&#46; In the presence of at least two features&#44; sensitivity ranged from 65&#46;8 &#37; to 82&#46;3 &#37;&#44; and specificity ranged from 85 &#37; to 87 &#37;&#44; depending on the combination of signs&#46;</p><elsevierMultimedia ident="tbl0003"></elsevierMultimedia><elsevierMultimedia ident="tbl0004"></elsevierMultimedia></span></span><span id="sec0013" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0019">Discussion</span><p id="para0026" class="elsevierStylePara elsevierViewall">Childhood ovarian torsion studies are relatively scarce&#44; as the current literature primarily focuses on adult cases&#46; Ovarian torsion in pediatric patients predominantly originates from congenital or physiological factors such as hormonal changes causing ovary enlargement or ligament elongation&#46; Given children&#39;s long life expectancy&#44; the risks posed by ovarian torsion are especially pronounced&#44; potentially leading to severe complications such as ovarian necrosis and peritonitis&#46; Therefore&#44; it is critical to diagnose this condition early and correctly to enhance ovarian salvage rates&#44; which currently range from 27 &#37; to 99 &#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">20</span></a></p><p id="para0027" class="elsevierStylePara elsevierViewall">The present study involved 326 children who underwent laparoscopic surgery for ovarian masses&#44; out of whom 79 had ovarian torsion&#46; The key predictors of adnexal torsion were suspected torsion via abdominal ultrasound&#44; and prenatal examination revealing an ovarian mass&#44; with NLR &#707; 3&#46; Ultrasonography revealed multiple follicles surrounding the enlarged ovaries&#44; as well as abnormal blood flow signals&#44; indicating a series of ovarian torsion sonograms&#46; However&#44; as ultrasound results hinge on the examiner&#39;s skill and experience&#44; disparities inevitably arise&#44; exposing a drawback of this diagnostic method&#46; Hence&#44; there is a need for a collective diagnosis considering prenatal ovarian mass detection&#44; NLR &#62; 3&#44; and ultrasound results&#46; Combining these three parameters for diagnosing and predicting ovarian torsion resulted in a low sensitivity yet an impressive specificity of 95&#46;1 &#37;&#46; When at least two of these features were present&#44; this model predicted torsion with a probability ranging from 88&#46;23 &#37; to 99&#46;35 &#37;&#46; The present research concurs with other studies reporting that approximately 40 &#37; of surgically confirmed ovarian torsion cases were preoperatively diagnosed based on clinical and ultrasound characteristics&#46;<a class="elsevierStyleCrossRef" href="#bib0021"><span class="elsevierStyleSup">21</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0022"><span class="elsevierStyleSup">22</span></a> Despite the reliance on TAS for ovarian torsion diagnosis&#44; the authors observed a low sensitivity of 54&#46;4 &#37; for TAS alone&#46; This corresponds with other findings revealing normal ultrasounds in approximately 50 &#37; of ovarian torsion cases&#46;<a class="elsevierStyleCrossRef" href="#bib0023"><span class="elsevierStyleSup">23</span></a> These discrepancies challenge the exclusive reliance on ultrasound for preoperative diagnosis&#46;</p><p id="para0028" class="elsevierStylePara elsevierViewall">Further analysis of the present data demonstrated that lower abdominal pain was significantly more common in patients with ovarian torsion than in those without &#40;55&#46;67&#37; vs&#46; 35&#46;22 &#37;&#44; <span class="elsevierStyleItalic">p</span> &#60; 0&#46;001&#41;&#46; This aligns with previous findings linking lower abdominal pain and adnexal torsion&#46;<a class="elsevierStyleCrossRef" href="#bib0024"><span class="elsevierStyleSup">24</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">25</span></a> Likewise&#44; several studies show the same symptom as a potential indicator of gynecological inflammation and malignancies&#46;<a class="elsevierStyleCrossRef" href="#bib0008"><span class="elsevierStyleSup">8</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0024"><span class="elsevierStyleSup">24</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0026"><span class="elsevierStyleSup">26</span></a></p><p id="para0029" class="elsevierStylePara elsevierViewall">The present research also established a significantly higher NLR in patients with ovarian torsion than in those without &#40;3&#46;769 &#177; 4&#46;475 vs&#46; 0&#46;9171 &#177; 0&#46;9147&#44; <span class="elsevierStyleItalic">p</span> &#60; 0&#46;001&#41;&#44; confirming prior research&#46;<a class="elsevierStyleCrossRef" href="#bib0018"><span class="elsevierStyleSup">18</span></a><span class="elsevierStyleSup">&#44;</span><a class="elsevierStyleCrossRef" href="#bib0027"><span class="elsevierStyleSup">27</span></a> The rise in NLR stems from the inflammatory and immune response triggered by ischemia and necrosis in ovarian torsion&#44; making it a potential early diagnostic and assessment tool for this condition&#46;</p><p id="para0030" class="elsevierStylePara elsevierViewall">Currently&#44; no universally accepted predictive rule exists for adnexal torsion detection&#46; Given the insufficiency of any single tool for a reliable diagnosis&#44; the authors propose a simple prediction model for ovarian torsion based on symptoms and laboratory and ultrasound findings&#46; The authors report a specificity of 95&#46;1 &#37; and an AUC of 0&#46;795 for the combination of NLR &#62; 3&#44; prenatal examination revealing ovarian mass&#44; and suspected torsion on abdominal ultrasound&#46; Despite its low sensitivity&#44; the model&#39;s high specificity indicates its importance&#46; Thus&#44; the presence of at least two of these three features should heighten the clinical suspicion of ovarian torsion in children with ovarian masses&#46;</p><span id="sec0014" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0020">Strengths and limitations</span><p id="para0031" class="elsevierStylePara elsevierViewall">This study possesses a number of notable strengths&#46; To our knowledge&#44; this is the first study to investigate the clinical symptoms&#44; NLR&#44; and ultrasound characteristics of pediatric ovarian torsion both independently and in combination&#46; The study is further distinguished by its substantial sample size&#44; constituting the largest single-institutional cohort of children with torsion diagnosed via laparoscopic findings&#46; Moreover&#44; the urgency and real-world applicability of the present research are emphasized by the fact that most abdominal sonograms were carried out in emergency room settings&#44; reflecting the critical need for timely diagnosis of suspected adnexal torsion&#46;</p><p id="para0032" class="elsevierStylePara elsevierViewall">However&#44; the authors recognize several limitations inherent in the research design&#46; Primarily&#44; the retrospective nature of the study could introduce bias&#44; potentially affecting the results&#46; Furthermore&#44; the authors did not comprehensively document the ultrasound features of adnexal torsion&#44; limiting descriptions to a binary categorization of torsion suspected or not suspected&#46; The present sample is also exclusively composed of female pediatric patients who underwent surgical treatment&#44; possibly excluding cases of adnexal torsion that did not receive surgery&#46; However&#44; given the status as a regional national medical center&#44; the authors often receive referrals from other institutions&#44; which likely reduces the number of missed cases&#46;</p><p id="para0033" class="elsevierStylePara elsevierViewall">Despite these limitations&#44; the present findings underscore the importance of ultrasound&#44; clinical symptoms&#44; and laboratory features as first-line evaluative tools for children suspected of having ovarian torsion&#46; The presence of an ovarian mass upon prenatal examination&#44; an NLR &#62; 3&#44; and indicative findings from TAS should raise a high suspicion of torsion&#46;</p><p id="para0034" class="elsevierStylePara elsevierViewall">In light of these findings&#44; the authors developed a predictive model incorporating these three features to aid in the preoperative diagnosis of torsion in children&#46; This tool can expedite diagnosis&#44; enabling prompt surgical intervention and potentially mitigating the risk of ovarian damage&#46;</p><p id="para0035" class="elsevierStylePara elsevierViewall">Nevertheless&#44; the retrospective design of this study restricts the ability to draw definitive conclusions&#46; As such&#44; further prospective studies are warranted to corroborate the present findings and refine the predictive model&#46; As medical professionals&#44; the goal is to continually improve diagnostic capabilities to increase the chances of preserving ovarian function and improving patient outcomes&#46;</p></span></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0021">Conclusions</span><p id="para0036" class="elsevierStylePara elsevierViewall">This study presents a prediction model that combines clinical&#44; laboratory&#44; and ultrasound findings to assist in the preoperative diagnosis of children with ovarian torsion&#44; thus proving its usefulness in the emergency department&#46;</p></span></span>"
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          "titulo" => "Methods"
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              "titulo" => "Study design and patient enrollment"
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              "titulo" => "Demographic and clinical characteristics"
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              "titulo" => "Prevalence of ovarian masses and precocious puberty"
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              "titulo" => "Clinical&#44; sonographic and laboratory parameters"
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          "titulo" => "Discussion"
          "secciones" => array:1 [
            0 => array:2 [
              "identificador" => "sec0014"
              "titulo" => "Strengths and limitations"
            ]
          ]
        ]
        6 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "Conclusions"
        ]
        7 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2023-08-24"
    "fechaAceptado" => "2024-01-22"
    "PalabrasClave" => array:1 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1832375"
          "palabras" => array:5 [
            0 => "Ovarian torsion"
            1 => "Children"
            2 => "Immune cells"
            3 => "Prenatal examination"
            4 => "Precocious puberty"
          ]
        ]
      ]
    ]
    "tieneResumen" => true
    "resumen" => array:1 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abss0001" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0002">Objective</span><p id="spara009" class="elsevierStyleSimplePara elsevierViewall">Ovarian torsion &#40;OT&#41; represents a severe gynecological emergency in female pediatric patients&#44; necessitating immediate surgical intervention to prevent ovarian ischemia and preserve fertility&#46; Prompt diagnosis is&#44; therefore&#44; paramount&#46; This retrospective study set out to assess the utility of combined clinical&#44; ultrasound&#44; and laboratory features in diagnosing OT&#46;</p></span> <span id="abss0002" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0003">Methods</span><p id="spara010" class="elsevierStyleSimplePara elsevierViewall">The authors included 326 female pediatric patients aged under 14 years who underwent surgical confirmation of OT over a five-year period&#46; Logistic regression analysis was employed to pinpoint factors linked with OT&#44; and the authors compared clinical presentation&#44; laboratory results&#44; and ultrasound characteristics between patients with OT &#40;OT group&#41; and without OT &#40;N-OT group&#41;&#46; The authors conducted receiver operating characteristic &#40;ROC&#41; curve analysis to gauge the predictive capacity of the combined features&#46;</p></span> <span id="abss0003" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0004">Results</span><p id="spara011" class="elsevierStyleSimplePara elsevierViewall">Among 326&#44; OT was confirmed in 24&#46;23 &#37; &#40;79 cases&#41; of the patients&#46; The OT group had a higher incidence of prenatal ovarian masses than the N-OT &#40;22 cases versus 7 cases&#41; &#40;<span class="elsevierStyleItalic">p</span> &#60; 0&#46;0001&#41;&#46; Similarly&#44; the authors observed significant differences in the presence of lower abdominal pain&#44; suspected torsion on transabdominal ultrasound&#44; and a high neutrophil-lymphocyte ratio &#40;NLR &#62; 3&#41; between the OT and non-OT groups &#40;p &#706; 0&#46;05&#41;&#46; Furthermore&#44; when these parameters were combined&#44; the resulting area under the curve &#40;AUC&#41; was 0&#46;868&#44; demonstrating their potential utility in OT diagnosis&#46;</p></span> <span id="abss0004" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="cesectitle0005">Conclusion</span><p id="spara012" class="elsevierStyleSimplePara elsevierViewall">This study demonstrates a prediction model integrating clinical&#44; laboratory&#44; and ultrasound findings that can support the preoperative diagnosis of ovarian torsion&#44; thereby enhancing diagnostic precision and improving patient management&#46; Future prospective studies should concentrate on developing clinical predictive models for OT in pediatric patients&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abss0001"
            "titulo" => "Objective"
          ]
          1 => array:2 [
            "identificador" => "abss0002"
            "titulo" => "Methods"
          ]
          2 => array:2 [
            "identificador" => "abss0003"
            "titulo" => "Results"
          ]
          3 => array:2 [
            "identificador" => "abss0004"
            "titulo" => "Conclusion"
          ]
        ]
      ]
    ]
    "apendice" => array:1 [
      0 => array:1 [
        "seccion" => array:1 [
          0 => array:4 [
            "apendice" => "<p id="para0037a" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="ecom0001"></elsevierMultimedia></p>"
            "etiqueta" => "Appendix"
            "titulo" => "Supplementary materials"
            "identificador" => "sec0023"
          ]
        ]
      ]
    ]
    "multimedia" => array:5 [
      0 => array:8 [
        "identificador" => "tbl0001"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "alt0001"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spara002" class="elsevierStyleSimplePara elsevierViewall">BMI&#44; Body-mass index&#59; PE&#44; Prenatal examination revealed ovarian mass&#59; PP&#44; Precocious puberty&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><a name="en0001"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Parameters&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0002"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">OT group&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0003"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">N-OT group&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0004"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">P-value&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><a name="en0005"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Cases &#40;<span class="elsevierStyleItalic">N</span> &#61; 326&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0006"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">79&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0007"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">247&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0008"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#8211;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0009"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Age &#40;d&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0010"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">3155&#177;1637&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0011"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">3436&#177;1269&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0012"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#46;5761&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0013"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Race&#47;ethnicity &#40;Han Chinese&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0014"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">79 &#40;100 &#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0015"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">242 &#40;97&#46;9 &#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0016"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#46;963&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0017"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">BMI &#40;kg&#47;m<span class="elsevierStyleSup">2</span>&#41; &#40;main&#41; &#177; SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0018"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">19&#46;26&#177;2&#46;32&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0019"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">18&#46;90&#177;1&#46;92&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0020"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#46;174&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0021"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Duration of pain &#40;d&#41;&#40;mean&#41; &#177; SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0022"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">5&#46;59&#177;1&#46;48&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0023"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">5&#46;40&#177;1&#46;63&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0024"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#46;337&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0025"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Vomiting &#40;N&#41; &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0026"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">6 &#40;7&#46;59 &#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0027"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">13 &#40;5&#46;26 &#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0028"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#46;4184&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0029"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Absence of leukorrhea &#38; metrorrhagia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0030"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">75 &#40;94&#46;9 &#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0031"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">247 &#40;100 &#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0032"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#46;23&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0033"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Vaginal bleeding&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0034"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">6 &#40;7&#46;6 &#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0035"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">25 &#40;10&#46;1 &#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0036"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#46;77&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0037"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">History of ovarian cyst&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0038"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0 &#40;0&#46;0 &#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0039"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">1 &#40;2&#46;6 &#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0040"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">1&#46;00&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0041"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">PE N &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0042"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">22 &#40;27&#46;85 &#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0043"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">7 &#40;2&#46;83 &#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0044"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#60;0&#46;0001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0045"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">PP N &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0046"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">5 &#40;6&#46;33 &#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0047"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">72 &#40;29&#46;15 &#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0048"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#60;0&#46;0001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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        "descripcion" => array:1 [
          "en" => "<p id="spara001" class="elsevierStyleSimplePara elsevierViewall">Demographic and clinical characteristics of patients who underwent laparoscopy&#46;</p>"
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      1 => array:8 [
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        "tabla" => array:2 [
          "leyenda" => "<p id="spara004" class="elsevierStyleSimplePara elsevierViewall">WBC&#44; White Blood Cells&#59; CRP&#44; C-Reactive Protein&#59; NLR&#44; Neutrophil -Lymphocyte Ratio&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><a name="en0049"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Indicators&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0050"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">OT group&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0051"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">N-OT group&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0052"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">p-value&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><a name="en0053"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Palpable abdominal mass &#40;N&#41; &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0054"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">5 &#40;3&#46;95 &#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0055"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">77 &#40;31&#46;17 &#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0056"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;0001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0057"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Lower abdominal pain &#40;N&#41; &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0058"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">44 &#40;55&#46;67 &#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0059"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">87 &#40;35&#46;22 &#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0060"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleBold">&#60;</span>0&#46;0001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0061"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Fever &#40;N&#41; &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0062"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">7 &#40;8&#46;8 &#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0063"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0 &#40;0&#46;0 &#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0064"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;34&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0065"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Ovarian torsion &#40;Left&#41; &#40;N&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0066"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">29&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0067"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">104&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0068"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;396&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0069"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Ovarian torsion &#40;Right&#41; &#40;N&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0070"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0071"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">143&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0068a"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0073"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">WBC &#40;&#42;10&#94;9&#47;L&#41; &#40;main&#41; &#177; SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0074"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">10&#46;73&#177;3&#46;83&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0075"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">7&#46;649&#177;2&#46;965&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0076"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;0001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0077"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Absolute Lymphocytes &#40;&#42;10&#94;9&#47;L&#41; &#40;mean&#41; &#177; SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0078"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">3&#46;368&#177;2&#46;321&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0079"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">2&#46;696&#177;1&#46;174&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0080"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;2949&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0081"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Percentage of Lymphocytes &#40;mean&#41; &#177; SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0082"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">34&#46;25&#177;22&#46;06&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0083"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">37&#46;49&#177;14&#46;54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0084"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;0222&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0085"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Absolute Neutrophils &#40;&#42;10&#94;9&#47;L&#41; &#40;mean&#41; &#177; SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0086"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">6&#46;561&#177;4&#46;354&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0087"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">4&#46;283&#177;2&#46;645&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0088"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;0001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0089"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">Percentage of Neutrophils &#40;mean&#41; &#177; SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0090"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">57&#46;55&#177;24&#46;04&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0091"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">53&#46;55&#177;15&#46;85&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0092"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;0143&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0093"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">CRP &#40;mg&#47;L&#41; &#40;mean&#41; &#177; SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0094"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">5&#46;891&#177;14&#46;71&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0095"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">1&#46;823&#177;7&#46;838&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0096"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;0001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0097"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">NLR &#40;mean&#41; &#177; SD&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0098"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">3&#46;769&#177;4&#46;475&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0099"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#46;9171&#177;0&#46;9147&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0100"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;0001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0101"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">NLR &#62; 3 &#40;N&#41; &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0102"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">33 &#40;41&#46;77 &#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0103"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">9 &#40;3&#46;64 &#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0104"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;0001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
              "imagenFichero" => array:1 [
                0 => "xTab3558727.png"
              ]
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spara003" class="elsevierStyleSimplePara elsevierViewall">Clinical&#44; sonographic&#44; and laboratory findings at presentation&#46;</p>"
        ]
      ]
      2 => array:8 [
        "identificador" => "tbl0003"
        "etiqueta" => "Table 3"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "alt0003"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spara006" class="elsevierStyleSimplePara elsevierViewall">TAS&#44; Transabdominal ultrasound&#59; NLR&#44; Neutrophil-lymphocyte Ratio&#58; PE&#44; Prenatal examination revealed ovarian mass&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><a name="en0105"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Signs of torsion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0106"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">TAS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0107"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">NLR &#62;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0108"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">PE&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><a name="en0109"></a><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">Predicted probability for torsion&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><a name="en0110"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0 of 3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0111"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0112"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0113"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0114"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#46;07009&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0115"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">1 of 3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0116"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0117"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0118"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0119"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#46;44983&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0120"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0121"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0122"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0123"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0124"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#46;60567&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0125"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0126"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0127"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0128"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0129"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#46;40871&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0130"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">2 of 3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0131"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0132"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0133"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0134"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">0&#46;88232&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><a name="en0135"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0136"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><a name="en0137"></a><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="top">&#8722;&nbsp;\t\t\t\t\t\t\n
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Article information
ISSN: 00217557
Original language: English
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Jornal de Pediatria (English Edition)
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