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Perysinakis I, Vassalou EE. Non-traumatic lower abdominal pain: ultrasonographic and clinical differential diagnosis. Ultrasonography 2024; 43:151-168. [PMID: 38443147 PMCID: PMC10915120 DOI: 10.14366/usg.23227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 01/25/2024] [Accepted: 01/27/2024] [Indexed: 03/07/2024] Open
Abstract
Lower abdominal pain is frequently reported and has a diverse differential diagnosis. In cases with atypical presentation and nonspecific findings, further imaging evaluation is required to confirm the clinical suspicion and to distinguish between self-limiting disorders and those requiring immediate intervention. In line with European guidelines, transabdominal ultrasonography is recommended as a first-line imaging modality for clinically suspected acute appendicitis and acute diverticulitis, which respectively represent the predominant causes of right and left lower quadrant abdominal pain. It is similarly the preferred method for evaluating suspected obstetric/gynecologic and genitourinary diseases. Computed tomography is utilized as a secondary option when ultrasonography results are inconclusive. This pictorial essay illustrates the sonographic features of the most common conditions associated with lower abdominal pain and outlines the clinical characteristics of each entity.
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Affiliation(s)
- Iraklis Perysinakis
- Department of Surgical Oncology, University Hospital of Heraklion, Heraklion, Crete, Greece
| | - Evangelia E. Vassalou
- Department of Medical Imaging, University Hospital of Heraklion, Heraklion, Crete, Greece
- Department of Medical Imaging, General Hospital of Sitia, Sitia, Crete, Greece
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Theilen TM, Rolle U. [The acute abdomen in children]. Med Klin Intensivmed Notfmed 2023; 118:619-625. [PMID: 37294351 PMCID: PMC10252174 DOI: 10.1007/s00063-023-01030-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 05/03/2023] [Indexed: 06/10/2023]
Abstract
BACKGROUND Because 8-10% of children in the emergency room present with acute abdominal pain, a systematic work-up is essential to rule out acute abdomen. OBJECTIVES This article highlights the etiology, symptoms, diagnostic workup, and treatment of acute abdomen in children. MATERIALS AND METHODS Review of the current literature. RESULTS Abdominal inflammation, ischemia, bowel and ureteral obstruction, or abdominal bleeding are causes of acute abdomen. Extra-abdominal diseases such as otitis media in toddlers or testicular torsion in adolescent boys can also lead to symptoms of acute abdomen. Abdominal pain, (bilious) vomiting, abdominal guarding, constipation, blood-tinged stools, abdominal bruise marks, and poor condition of the patient with symptoms such as tachycardia, tachypnea, and hypotonia up to shock are leading symptoms of acute abdomen. In some cases, emergent abdominal surgery is needed to treat the cause of the acute abdomen. However, in patients with pediatric inflammatory multisystem syndrome temporarily associated with SARS-CoV‑2 infection (PIMS-TS), a new disease causing an acute abdomen, surgical treatment is rarely needed. CONCLUSIONS Acute abdomen can lead to nonreversible loss of an abdominal organ, such as bowel or ovary, or develop into acute deterioration of the patient's condition up to the state of shock. Therefore, a complete history and thorough physical examination are needed to timely diagnose acute abdomen and initiate specific therapy.
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Affiliation(s)
- Till-Martin Theilen
- Klinik für Kinderchirurgie und Kinderurologie, Universitätsklinikum Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Deutschland
| | - Udo Rolle
- Klinik für Kinderchirurgie und Kinderurologie, Universitätsklinikum Frankfurt, Theodor-Stern-Kai 7, 60590, Frankfurt am Main, Deutschland.
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He KX, Xu L, Ning JZ, Cheng F. MiR-195-5p is involved in testicular ischemia/reperfusion injury by directly targeting PELP1 and regulating spermatogonia pyroptosis. Int Immunopharmacol 2023; 121:110427. [PMID: 37290329 DOI: 10.1016/j.intimp.2023.110427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2023] [Revised: 05/23/2023] [Accepted: 05/30/2023] [Indexed: 06/10/2023]
Abstract
BACKGROUND AND OBJECTIVE Ischemia/reperfusion injury (IRI), which is characterized by testicular torsion and causes permanent impairment of spermatogenic function, is linked with pyroptosis. Studies have implicated endogenous small non-coding RNAs in IRI development across various organs. In this study, we elucidated the mechanism underlying miR-195-5p's action in regulating pyroptosis in testicular IRI. METHODS We established two models, namely a testicular torsion/ detorsion (T/D) mouse model and an oxygen-glucose deprivation/reperfusion (OGD/R)-treated germ cell model. Hematoxylin and eosin staining was performed to evaluate the testicular ischemic injury. The expression of pyroptosis-related proteins and reactive oxygen species production in testis tissues were detected using Western blotting, quantitative real-time PCR, malondialdehyde and superoxide dismutase assay kits and immunohistochemistry. Cell viability and cytotoxicity were evaluated using CCK-8 and LDH assays, whereas expression patterns of inflammatory proteins were measured using ELISA, immunofluorescence, and western blot assays. miR-195-5p interaction with PELP1 was validated by conducting the luciferase enzyme reporter test. RESULTS Pyroptosis-related proteins NLRP3, GSDMD, IL-1β, and IL-18 were significantly upregulated following testicular IRI. A similar pattern was observed in the OGD/R model. miR-195-5p was significantly downregulated in mouse IRI testis tissue and OGD/R-treated GC-1 cells. Notably, miR-195-5p downregulation promoted whereas its upregulation attenuated pyroptosis in OGD/R-treated GC-1 cells. Furthermore, we found that PELP1 is a miR-195-5p target. miR-195-5p attenuated pyroptosis in GC-1 cells by inhibiting PELP1 expression during OGD/R, and this protective effect was blocked upon miR-195-5p downregulation. Collectively, these results indicated that miR-195-5p inhibits testicular IRI-induced pyroptosis by targeting PELP1, suggesting that it has the potential to serve as a novel target for the future development of therapies for testicular torsion.
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Affiliation(s)
- Kai-Xiang He
- Department of Urology, Renmin Hospital of Wuhan University, Wuhan 430060, Hubei Province, PR China
| | - Lizhe Xu
- Department of Urology, Renmin Hospital of Wuhan University, Wuhan 430060, Hubei Province, PR China
| | - Jin-Zhuo Ning
- Department of Urology, Renmin Hospital of Wuhan University, Wuhan 430060, Hubei Province, PR China.
| | - Fan Cheng
- Department of Urology, Renmin Hospital of Wuhan University, Wuhan 430060, Hubei Province, PR China.
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Mao CK, Cao YS, Liu X, Peng B, Chu H, Deng QF, Yu X, Tao CP, Zhang T, Yang C, Peng S. The diagnosis and treatment of testicular torsion in children with non-scrotal initial symptoms. Front Pediatr 2023; 11:1176345. [PMID: 37397154 PMCID: PMC10311083 DOI: 10.3389/fped.2023.1176345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 05/31/2023] [Indexed: 07/04/2023] Open
Abstract
Objective To explore the clinical characteristics of testicular torsion in children with non-scrotal initial symptoms who were misdiagnosed. Methods A retrospective analysis of 73 cases children with testicular torsion and non-scrotal symptoms who were admitted to our department from October 2013 to December 2021 was performed. Patients were divided into misdiagnosis (27 cases) and clear diagnosis at first visit (46 cases) groups. Clinical data, including age at surgery, clinical presentation, physical examination, number of visits (≥2 times), affected side, time from initial symptoms to surgery, and surgical outcomes, were collected. The TWIST (Testicular Workup for Ischemia and Suspected Torsion) score was calculated and analyzed. Results Statistically significant differences between the misdiagnosis and clear diagnosis groups were seen in the time from initial symptoms to surgery, the number of visits, the degree of testicular torsion, and the rate of orchiectomy (P < 0.05). There were no statistically significant differences (P > 0.05) in age, affected side, TWIST score, guardian, direction of testicular torsion, intra-vaginal or extra-vaginal torsion, and Arda classification. Postoperative follow-up was 6-40 months. Of the 36 patients who required an orchiopexy, 1 had testicular atrophy at six months and 2 were lost to follow-up. The contralateral testis of the 37 children who underwent orchiectomies developed normally without torsion. Conclusions The clinical manifestations of testicular torsion in children are diverse and can easily lead to misdiagnosis. Guardians should be aware of this pathology and seek timely medical attention. When the initial diagnosis and treatment of testicular torsion is difficult, the TWIST score during the physical examination may be useful, especially for patients with intermediate-to-high risk scores. Color Doppler ultrasound can assist in making the diagnosis, but when testicular torsion is highly suspected, routine ultrasound is not necessary as it may lead to delayed surgical treatment.
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Lacy A, Smith A, Koyfman A, Long B. High risk and low prevalence diseases: Testicular torsion. Am J Emerg Med 2023; 66:98-104. [PMID: 36738571 DOI: 10.1016/j.ajem.2023.01.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 01/17/2023] [Accepted: 01/20/2023] [Indexed: 01/27/2023] Open
Abstract
INTRODUCTION Testicular torsion is a serious condition that carries with it a high rate of morbidity. OBJECTIVE This review highlights the pearls and pitfalls of testicular torsion, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence. DISCUSSION Testicular torsion is a urological emergency that occurs with rotation of the testicle along its supporting ligaments leading to obstruction of vascular flow. A key risk factor is the presence of a bell-clapper deformity. The most common population affected includes children in a bimodal distribution with the most cases occurring in the first year of life and between 12 and 18 years, although cases do occur in adults. Acute, severe, unilateral scrotal pain is the most common presenting symptom. Nausea and vomiting are common, but the presence or absence of a cremasteric reflex is not a reliable indicator of disease. The TWIST score may assist with clinical decision making in patients presenting with acute testicular pain but should not be used in isolation. If torsion is suspected or confirmed, consultation with the urology specialist should not be delayed, as outcomes are time sensitive. Ultrasound can be used for diagnosis, but a normal ultrasound examination cannot exclude the diagnosis. Treatment includes emergent urology consultation for surgical exploration and detorsion, as well as symptomatic therapy in the ED. Manual detorsion can be attempted in the ED while awaiting transfer or consultation. CONCLUSIONS An understanding of testicular torsion can assist emergency clinicians in diagnosing and managing this disease.
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Affiliation(s)
- Aaron Lacy
- Department of Emergency Medicine, Washington University School of Medicine, St Louis, MS, USA.
| | - Amanda Smith
- Department of Emergency Medicine, Vanderbilt University Medical Center, 1211 Medical Center Dr, Nashville, TN, USA.
| | - Alex Koyfman
- Department of Emergency Medicine, UT Southwestern, Dallas, TX, USA
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam, Houston, TX, USA.
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LONG-DEPAQUIT T, CHIRON P, BOURGOUIN S, HARDY J, DELEDALLE FX, LAROCHE J, MOLIMARD B, SAVOIE PH. [Management of testicular torsion by a general surgeon isolated in Africa]. MEDECINE TROPICALE ET SANTE INTERNATIONALE 2022; 2:mtsi.v2i2.2022.230. [PMID: 35685303 PMCID: PMC9128443 DOI: 10.48327/mtsi.v2i2.2022.230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Figures] [Subscribe] [Scholar Register] [Received: 11/12/2021] [Accepted: 03/02/2022] [Indexed: 06/15/2023]
Abstract
The onset of sudden and intense scrotal pain exposes to several problems when it occurs in a young man in Africa. Among the possible etiologies, testicular torsion is the surgical emergency to rule out, because beyond 6 hours of evolution the functional prognosis of the testicle is concerned. The septic evolution towards a purulent melting, in case of exceeded torsion, is also possible. Of slightly lower incidence than in Western countries, lack of awareness of this pathology by local health actors, the precariousness or health isolation of certain populations in certain under-medicalized regions, contribute to diagnostic and therapeutic delays. This often leads to a pejorative development, loss of the testicle being directly correlated with the delay in treatment. Testicular torsion has thus been identified as one of the main causes of male infertility in Africa. However, clinical diagnosis and surgical treatment require few resources and remain accessible in an environment with low resources or in precarious conditions. Indeed, despite the contribution of ultrasound in certain situations, the clinical picture is at the center of the diagnosis and therapeutic decision making. At the slightest doubt, surgical exploration is necessary. The multi-tunic anatomy of the testicle facilitates its surgical fixation in the event of conservation, ideally by triangulation of single-strand non-absorbable thread. Simultaneous fixation of the contralateral testicle is currently the subject of debate in the literature. In Africa, the benefit/risk balance, taking into account in particular the difficulty of subsequent access to care, justifies, from our point of view, performing contralateral orchidopexy at the same time. Depending on the appearance of the testicle and, to a lesser extent, the duration of the evolution of the symptoms, orchidectomy may be necessary. This article describes the clinical picture of spermatic cord torsion and the orchidopexy technique.
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Affiliation(s)
- Thibaut LONG-DEPAQUIT
- Service d’urologie, Hôpital d’instruction des armées Sainte-Anne, 2 boulevard Sainte Anne, BP 600, 83000 Toulon, France
| | - Paul CHIRON
- Service d’urologie, Hôpital d’instruction des armées Bégin, 69 avenue de Paris, 94160 Saint-Mandé, France
| | - Stéphane BOURGOUIN
- Service de chirurgie viscérale, Hôpital d’instruction des armées Sainte-Anne, 2 boulevard Sainte Anne, BP 600, 83000 Toulon, France
| | - Julie HARDY
- Service d’urologie, Hôpital d’instruction des armées Sainte-Anne, 2 boulevard Sainte Anne, BP 600, 83000 Toulon, France
| | - François-Xavier DELEDALLE
- Service d’urologie, Hôpital d’instruction des armées Sainte-Anne, 2 boulevard Sainte Anne, BP 600, 83000 Toulon, France
| | - Julien LAROCHE
- Service d’urologie, Hôpital d’instruction des armées Sainte-Anne, 2 boulevard Sainte Anne, BP 600, 83000 Toulon, France
| | - Benoit MOLIMARD
- Service d’urologie, Hôpital d’instruction des armées Sainte-Anne, 2 boulevard Sainte Anne, BP 600, 83000 Toulon, France
| | - Pierre-Henri SAVOIE
- Service d’urologie, Hôpital d’instruction des armées Sainte-Anne, 2 boulevard Sainte Anne, BP 600, 83000 Toulon, France
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Murali TV, Jaya KV, Kumar R. Testicular torsion - symptomatology and outcomes of 101 scrotal explorations. Urol Ann 2022; 14:167-171. [PMID: 35711480 PMCID: PMC9197001 DOI: 10.4103/ua.ua_142_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2020] [Accepted: 12/21/2020] [Indexed: 11/18/2022] Open
Abstract
Objective: The objective was to study the symptomatology of testicular torsion of patients operated in our hospital and their operative results in relation to the duration of symptoms. Materials and Methods: Data of all patients operated for acute scrotum at all ages over a 14 months’ time were collected from hospital records. Symptomatology and operative results were studied. Results: Out of 101 consecutive scrotal explorations done in this time, 63.4% of all scrotal explorations were testicular torsion (n = 64). 22.8% were appendage torsion (n = 23) and 13.9% were epididymo-orchitis (n = 14). The peak age of testicular torsion was in the 11–15 years range and the left side is more common (65.6%). Symptoms of scrotal pain (92.2%), abdominal pain (18.8%), nausea/vomiting (18.8%), fever (9.4%), and urinary symptoms (3.1%) were seen in decreasing order of frequency. Among acute scrotum patients who had symptoms of nausea/vomiting or abdominal pain, testicular torsion was found to be significantly higher compared to those who did not have these symptoms (χ2 = 0.044, P < 0.05). In all cases presented within 6 h of symptom onset, testicles were saved and salvage rates reduced with delay in presentation. The testicular salvage rates were 28.1% (18 out of 64 torsions). Patients below 18 years had more chance of going for orchiectomy than others (75% vs 66.7%). Patients who presented after 24 h had a statistically significantly lower salvage rate of 7.7% compared to those who presented within 24 h duration, 52.2%(χ2 = 0.001, P < 0.05). Those with orchiopexy had a median duration of symptom of 6.5 h and the same for orchiectomy patients were 72 h. Our median symptom duration for testicular torsion was 36 h and it is higher than many other countries. Conclusions: Delay in presentation to the health-care facility is the major cause of poor salvage rates in the state and its improvement requires public health interventions and health education.
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Aquila I, Abenavoli L, Sacco MA, Ricci P. The limits of diagnosis of testicular torsion in the child: Medicolegal implications in clinical practice. Clin Case Rep 2021; 9:e05180. [PMID: 34938556 PMCID: PMC8659548 DOI: 10.1002/ccr3.5180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 11/07/2021] [Accepted: 11/22/2021] [Indexed: 11/05/2022] Open
Abstract
Testicular torsion is a pediatric urological emergency. We report a case of testicular torsion that occurred in a 10-year-old child. The case shows that it is a disease with risk of medicolegal litigation. We demonstrate the role of proper triage, and we analyze the limits and critical points for diagnosing it.
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Affiliation(s)
- Isabella Aquila
- Institute of Legal MedicineDepartment of Medical and Surgical SciencesUniversity “Magna Graecia” of CatanzaroCatanzaroItaly
| | - Ludovico Abenavoli
- Department of Health SciencesUniversity “Magna Graecia” of CatanzaroCatanzaroItaly
| | - Matteo Antonio Sacco
- Institute of Legal MedicineDepartment of Medical and Surgical SciencesUniversity “Magna Graecia” of CatanzaroCatanzaroItaly
| | - Pietrantonio Ricci
- Institute of Legal MedicineDepartment of Medical and Surgical SciencesUniversity “Magna Graecia” of CatanzaroCatanzaroItaly
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Abstract
Abdominal pain is the most common chief complaint in the Emergency Department. Abdominal pain is caused by a variety of gastrointestinal and nongastrointestinal disorders. Some frequently missed conditions include biliary pathology, appendicitis, diverticulitis, and urogenital pathology. The Emergency Medicine clinician must consider all aspects of the patient's presentation including history, physical examination, laboratory testing, and imaging. If no diagnosis is identified, close reassessment of pain, vital signs, and physical examination are necessary to ensure safe discharge. Strict verbal and written return precautions should be provided to the patient.
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Affiliation(s)
- Maglin Halsey-Nichols
- University of North Carolina at Chapel Hill, Houpt Building (Physician Office Building) Suite 1116, 170 Manning Drive- CB-7594, Chapel Hill, NC 27599-7594, USA.
| | - Nicole McCoin
- Department of Emergency Medicine, Ochsner Medical Center, 1514 Jefferson Highway, New Orleans, LA 70121, USA
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Is there an increased incidence of orchiectomy in pediatric patients with acute testicular torsion during COVID-19 pandemic?-A retrospective multicenter study. J Pediatr Urol 2021; 17:479.e1-479.e6. [PMID: 33994321 PMCID: PMC8087574 DOI: 10.1016/j.jpurol.2021.04.017] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 04/09/2021] [Accepted: 04/25/2021] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Testicular torsion is a real emergency condition which requires prompt diagnosis and surgical management to prevent testicular loss. During the coronavirus (COVID-19) pandemic, an increased avoidance of the emergency departments for non-COVID-19 illnesses has been reported in the medical literature. OBJECTIVE The aim of this study was to investigate whether the COVID-19 pandemic caused increased number of orchiectomies in pediatric patients presenting with acute testicular torsion compared to pre-COVID-19 period. STUDY DESIGN A total number of 119 pediatric patients who underwent surgery for acute testicular torsion from January 2019 to December 2020 were enrolled in retrospective multi-center study from six institutions in Croatia. The patients were divided in two groups. The first group (pre-COVID-19) consisted of the patients who underwent surgery before COVID-19 pandemic (n = 68), while the second group (COVID-19) consisted of the patients who underwent surgery during the COVID-19 pandemic (n = 51). Main outcomes of the study were orchiectomy rates and time from onset of the symptoms to emergency department presentation. RESULTS During the COVID-19 pandemic period 43.1% (22/51) of the patients underwent orchiectomy while orchiectomy was performed in 16.2% (11/68) of the patients from the pre-COVID group (p = 0.001). Median time from onset of the symptoms to emergency department presentation during COVID-19 pandemic and pre-COVID-19 periods was 14h (IQR 5, 48) and 6h (IQR 3, 22) (p = 0.007), respectively. A higher proportion of patients waited over 24 h to present to emergency department during the COVID-19 pandemic compared to the pre-COVID-19 period (47% vs 8.8%, p = 0.007). CONCLUSION During COVID-19 pandemic a significantly higher rates of orchiectomies and increase in delayed presentations for testicular torsion was found. More patient education during pandemic in regards to management of emergency conditions such as testicular torsion is required.
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