Diagnostic Accuracy of Neutrophil/Lymphocyte Ratio, Red Cell Distribution Width and Platelet Distribution Width in Ovarian Torsion

Predictive Role of Neutrophil to Lymphocyte Ratio in Adnexal Torsion: A Systematic Review and Meta-Analysis

Introduction. The goal of this systematic review and meta-analysis was to consolidate the available data on the role of the neutrophil to lymphocyte ratio (NLR) in predicting adnexal torsion (AT), to help guide clinical decision-making and outcomes. Methods. We used Web of Science, PubMed, and Scopus to conduct a systematic search for relevant publications published before June 26, 2022. We reported standardized mean difference (SMD) with a 95% confidence interval (CI). Because a significant level of heterogeneity was found, we used the random-effects model to calculate pooled effects. We used the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2) too for quality assessment. Results. Overall, 15 articles were included in the analysis. A random-effects model revealed that patients with AT had elevated levels of NLR compared to those with other adnexal masses ( $\text{SMD}=1.06$ , $95\%\text{CI}=0.67$ to 1.45, $p<0.001$ ). So, NLR had diagnostic value. In the subgroup analysis according to ethnicity, we found that Caucasian patients with AT had elevated levels of NLR compared to patients who were operated due to adnexal mass and reported as having a benign ovarian cyst, without torsion ( $\text{SMD}=1.12$ , $95\%\text{CI}=0.71$ to 1.54, $p<0.001$ ). However, in the case of East Asian patients, there was no difference between cases and controls ( $\text{SMD}=0.86$ , $95\%\text{CI}=-0.21$ to 1.94, $p=0.11$ ). The pooled sensitivity of NLR was 0.79 ( $95\%\text{CI}=0.72–0.85$ ), and the pooled specificity was 0.84 (95% CI, 0.74–0.91). Conclusion. In conclusion, there has been an interest in the use of NLR as a diagnostic marker for AT.

Diagnosis and Management of Pediatric Ovarian Torsion in the Emergency Department: Current Insights

Ovarian torsion is defined as twisting of the ovary around an axis consisting of its vascular pedicle, the infundibulopelvic ligament and the tubo-ovarian ligament, and can occur in females of any age. Torsion can be a result of ovarian mass causing asymmetry and subsequent torsion, or can be spontaneous. While ovarian torsion is a surgical emergency, early diagnosis and treatment can preserve ovarian viability even if necrosis is seen operatively. Presentation classically involves sudden onset severe abdominal pain and vomiting but diagnostic delay can follow subtler presentations. Diagnosis is most commonly based on sonographic findings, but advanced imaging such as CT or MRI may be required if sonography is not diagnostic. Treatment is surgical, with ovarian preservation preferred in almost all cases. In this review, I present the most recent evidence on epidemiology, diagnosis, and management of pediatric ovarian torsion, with a focus on point-of-care ultrasound for the emergency care provider.

A clinical prediction model for adnexal torsion in pediatric and adolescent population

PURPOSE

To describe the clinical characteristics of children and adolescents that underwent diagnostic laparoscopy for suspected adnexal torsion (AT), and to develop a prediction model for preoperative detection of AT among young women.

METHODS

A retrospective cohort study. We included all girls ≤18 years old with clinically suspected AT who underwent a diagnostic laparoscopy between 3/2011 and 6/2020. We compared patients with AT to those without AT and constructed a prediction model.

RESULTS

Overall, 120 children and adolescents with suspected AT were included in the study. Of those, AT was identified in 83 (69.2%). In a multivariate analysis, the following risk factors were independently associated with AT and included in the prediction model: absence of right lower quadrant tenderness upon examination [adjusted odds ratio (aOR) (95% Confidence interval (CI)) 3.23 (1.23-8.47), p = 0.017], platelets level >240 K [aOR (95% CI) 3.15 (1.19-8.36), p = 0.021], and neutrophils level >5.4 [aOR (95% CI) 2.71 (1.02-7.52), p = 0.046]. The rate of AT was 12.5% in cases without risk factors for AT, 56.7% with one, 68.8% with two, and 94.1% with three risk factors present, respectively.

CONCLUSIONS

We have identified preoperative indicators independently associated with surgically confirmed AT in a large cohort of young women. Level of evidence- III.

A validated predictive model for adnexal torsion pre-operative diagnosis

PURPOSE

To develop a simple predictive model for pre-operative diagnosis of adnexal torsion (AT).

METHODS

A retrospective cohort study with a retrospective validation, including 669 separate episodes of women who underwent laparoscopy due to a suspected AT between January 2011 and June 2020. We compared the pre-operative characteristics between women with surgically confirmed AT and those without.

RESULTS

The derivation cohort included 615 episodes of suspected AT. AT was surgically confirmed in 445 episodes (72%). The retrospectively collected validation cohort included 54 episodes, with 31 (57.4%) surgically confirmed AT. In a multivariate regression analysis, vomiting, neutrophils to lymphocytes ratio > 3.5 and sonographic finding of enlarged ovary were independently associated with AT [OR 95% CI 2.78 (1.21-6.36), 3.15 (1.42-6.97) and 2.80 (1.33-5.88), respectively]. In the derivation cohort, the PPV for AT diagnosis was 69.7%, 84.5% and 93.1% if 1, 2 and 3 risk factors were present, respectively. Retrospective validation analysis underlined a PPV of 67.6%, 82.6 and 66.6% for 1, 2 and 3 risk factors, respectively.

CONCLUSION

We have developed and validated a simple predictive model for pre-operative diagnosis of AT, based on three parameters. Our model may assist clinicians while evaluating patients with suspected AT and improve pre-operative diagnosis.

Can various complete blood count parameters helpful in preoperative diagnosis of adnexal torsion?

OBJECTIVE

Adnexal torsion is an important gynecological emergency due to nonfrequent but possible adverse reproductive outcomes. There is no specific laboratory marker to support the preoperative diagnosis or that can be used clinically. The aim of this study was to investigate the diagnostic values of platelet, neutrophil, lymphocyte, and red cell markers as an early indicator of ovarian torsion.

METHODS

This retrospective study included 28 female patients who were treated surgically for adnexal torsion between August 2010 and July 2020, and 29 control group women. The demographic data and routine hematological values of patients were compared for adnexal torsion prediction.

RESULTS

There were no differences between the groups in terms of the platelet count, platelet distribution width, red cell distribution width, and mean platelet volume values, and there were no differences in the demographic data. Statistical differences were found among white blood cell, hemoglobin, hematocrit, neutrophil and lymphocyte counts, neutrophil/lymphocyte ratio, and platelet/lymphocyte ratio, and 81.5% sensitivity and 82.1% specificity were identified for neutrophil/lymphocyte ratio 2.45 (area under the curve AUC 0.892; 95%CI 0.808-0.975; p<0.001). Odds ratio for neutrophil/lymphocyte ratio was 2.62 (95%CI 0.861-7.940, p=0.029).

CONCLUSION

According to the regression analysis, neutrophil/lymphocyte ratio was found to be the most beneficial among all blood count parameters for the pre-diagnosis of AT.

Surgically confirmed adnexal torsion during pregnancy: Does the trimester make a difference?

AIM

To investigate the clinical and the sonographic characteristics of adnexal torsion (AT) during pregnancy and to underline differences in AT manifestation between pregnancy trimesters.

METHODS

This is a retrospective cohort study in a tertiary medical center. The study included all pregnant women with surgically confirmed AT between March 2011 and April 2020. The patients were divided into three groups according to pregnancy trimesters, and the clinical and sonographic characteristics were compared between the groups.

RESULTS

The study cohort included 140 cases of AT. Ninety-nine (70.7%) of the cases occurred during the 1st trimester, and 31 (22.1%) and 10 (7.1%) occurred during the 2nd and the 3rd trimesters, respectively. Conception by assisted-reproductive technologies (ART), nausea, and finding of enlarged ovary on ultrasound scan were all more common among patients in the 1st trimester group as compared to the 3rd trimester group (p = 0.001, 0.015, and 0.024, respectively). The mean time from admission to surgery was significantly shorter in the 1st trimester group as compared to late pregnancy (p = 0.001). The majority of cases were right-sided. There was a significant difference in the organs involved in every trimester of pregnancy-ovary only, ovary and fallopian tube, and fallopian tube only (p = 0.023).

CONCLUSIONS

Most AT cases during pregnancy occurred during the 1st trimester. Conception by ART and enlarged ovary on ultrasound scan were also more common in AT cases during early pregnancy. Time from admission to surgery was longer as pregnancy progressed and organs involved differed between trimesters. Understanding the difference in manifestation of AT in every trimester might improve the preoperative evaluation of AT in pregnancy.

Diagnostic value of the neutrophil-to-lymphocyte and platelet-to-lymphocyte ratios in adnexal torsion cases

AIM

To evaluate if the neutrophil-to-lymphocyte ratio (NLR) and the platelet-to-lymphocyte ratio (PLR) could be used to diagnose adnexal torsion.

METHODS

A retrospective study reviewed medical records of women who underwent surgery due to an adnexal mass between January 2012 and December 2017 at a tertiary referral center in Turkey. According to the surgical findings, the women were divided into a torsion group and a control group. NLR and PLR were compared between women who had adnexal torsion and those who did not.

RESULTS

A total of 201 women were included in the study: 67 in the torsion group and 134 in the control group. Mean WBC count (9584.0 ± 3080.8 vs. 6678.2 ± 1886.1 h/mm³ ), mean NLR (5.9 ± 4.3 vs. 2.1 ± 0.8), and mean PLR (210.5 ± 132.7 vs. 147.9 ± 48.7) were higher in the torsion group than in the control group (p < 0.001). According to the ROC curve analyses, the optimal cut-off value for NLR and PLR were 2.51 (sensitivity, 72%; specificity, 78%) and 154.4 (sensitivity, 61%; specificity, 64%) in the diagnosis of adnexal torsion, respectively.

CONCLUSION

NLR and PLR have been found useful hematological markers for the diagnosis of adnexal torsion. NLR and PLR could be helpful in cases, which is difficult to make a definitive diagnosis with patients' symptom and the ultrasonographic examination.

Prevention of preterm delivery by cervical cerclage; a comparison of prophylactic and emergency procedures

Objective:

Prophylactic or emergency type cervical cerclage procedures are being used for treatment of cervical insufficiency. The aim was to review and compare the outcomes of these cerclage types and identify factors affecting outcomes.

Material and Methods:

Retrospective review of seventy-five patients in whom transvaginal cervical cerclage procedures were performed over a seven-year period in a tertiary referral center.

Results:

Twenty seven of 75 (36%) patients were in the emergency cerclage group and 48 (64%) of them were in the prophylactic group. Mean body mass index (BMI), hospitalization time and gestational week at cerclage were significantly higher, whereas latency period was significantly shorter for the emergency group. Mean gestational ages at delivery were 35.6±4.5 and 33.6±5.9 weeks in the prophylactic and emergency groups, respectively (p=0.117). Delivery rates under 34^th gestational week were 20.8% and 37.0% in the prophylactic and emergency groups, respectively (p=0.175). Birthweight, and delivery ≥34^th gestational week was higher in the prophylactic group, whereas complication rate was higher in the emergency group, but these differences were not significant. High BMI was associated with more deliveries before 34-week in the prophylactic group. Pre-cerclage cervical length was shorter in patients who delivered before 34 gestational weeks at delivery.

Conclusion:

Prophylactic and emergency cerclage procedures have comparable results regarding gestational week at delivery. High BMI and low pre-cerclage cervical length may have adverse effects on success of cerclage procedures.

A Case Report of Pediatric Ovarian Torsion: The Importance of Diagnostic Laparoscopy

Introduction

Pediatric ovarian torsion is a relatively rare occurrence with chances of significant morbidity and possible mortality if not treated emergently.

Case Report

In this report, we review a case of pediatric ovarian torsion in a nine-year-old that was difficult to diagnose on initial presentation to the hospital due to various factors, which inevitably led to delayed resolution.

Conclusion

We discuss the diagnosis of pediatric ovarian torsion including risk factors, symptoms, imaging modalities, and surgical diagnostics. To improve diagnosis and shorten time to treatment, this case supports the use of laparoscopy for diagnosis of ovarian torsion if indicated by clinical suspicion and supplemental imaging studies.

Predictive value of the red blood cell distribution width-to-platelet ratio for hepatic fibrosis

AIMS

The red blood cell distribution width-to-platelet ratio (RPR) has been reported to be an indicator of hepatic fibrosis in patients with chronic hepatitis B (HBV), nonalcoholic fatty liver disease (NAFLD) or chronic hepatitis C (HCV). However, no research has explored the RPR in all patients with hepatic fibrosis. There is a recognized need to establish whether the RPR could assess hepatic fibrosis and reflect the severity of fibrosis, regardless of the patient's etiology.

METHODS

Quantitative data from 1282 patients who underwent liver biopsy between January 2010 and December 2014 at the Second Affiliated Hospital of Zhejiang University School of Medicine were included. The etiologies included HBV or HCV infection, NAFLD, schistosomiasis, granulomatous liver disease, and vascular abnormalities. Five noninvasive models were calculated for all patients based on laboratory parameters. The degrees of fibrosis severity were evaluated based on the Metavir scoring scale.

RESULTS

The RPR demonstrated the best accuracy of predicting hepatic fibrosis among the selected five models (0.75, p < .001) regardless of etiology. In addition, the RPR values increased with advanced hepatic fibrosis progression. Furthermore, combining the RPR with the white blood cell (WBC) count improved the accuracy of grading hepatic fibrosis as reflected by the likelihood ratio (LR + 9.03, LR - 0.49).

CONCLUSION

The RPR is a useful indicator for hepatic fibrosis, regardless of etiology, and can reflect the severity of fibrosis. This study supports further clinical development of the RPR both in a stepwise manner or in combination with inflammatory parameters to improve the accuracy of scoring hepatic fibrosis.

Platelet distribution width as a prognostic factor in patients with COPD - pilot study

Background

Platelets may actively participate in inflammation in COPD. Platelet distribution width (PDW), a measure of platelets’ volume heterogeneity, may increase in platelets’ activation. We hypothesized that PDW may be a marker of hypercoagulation, which plays a significant role in conditions associated with worse survival of patients with COPD, eg, acute myocardial infarction and other forms of ischemic heart disease.

Methods

Retrospective analysis of 79 patients. Variables were compared after grouping patients according to the upper normal limit of PDW, using Welch’s t-tests or Mann–Whitney U, and chi-square tests. Survival in the two groups was compared using the Kaplan–Meier method and Cox proportional hazards regression.

Results

Ten patients presented values of PDW above 16 fL, which was the upper limit of normality for our laboratory. Compared to patients with normal PDW, they had lower forced expiratory flow between 25% and 75% of vital capacity (FEF 25–75) – 35% of reference value vs 57% (P=0.003) and peak expiratory flow – 39% vs 54% (P<0.001). The median survival of patients with elevated PDW was 743 days compared to those with normal PDW (1,305 days) (P=0.025). The adjusted HR was 4.59 (95% CI: 1.1, 19.19; P=0.04).

Conclusion

Our analysis indicates that elevated PDW is associated with reduced survival of patients with COPD. If our data are to be confirmed, PDW may be used as an inexpensive and repeatable prognostic tool in COPD.

Antitumor effect of the combination of manumycin A and Immodin is associated with antiplatelet activity and increased granulocyte tumor infiltration in a 4T1 breast tumor model

Manumycin A is a natural antibiotic isolated from Streptomyces parvulus with broad range of biological activities including antineoplastic activity in several in vitro and in vivo cancer models. Immodin [dialyzable leukocyte extract (DLE)] is a dialysate released from disintegrated blood leukocytes of healthy donors which exerts immunonormalizing effects on cell-mediated immune responses. The aim of the present study was to explore the antitumor potential of the combination of manumycin A and Immodin in an experimental breast cancer model. Experiments were carried using a 4T1 tumor-bearing BALB/c mouse model. Survival analysis, tumor growth, hematological and biochemical profiles, leukocyte differential, phagocytic activity of leukocytes and histology of the primary tumor were examined. The combination treatment suppressed the tumor growth and prolonged the survival of tumor-bearing mice, decreased the number of monocytes, plateletes and plateletcrit in peripheral blood of the tumor-bearing mice and increased the infiltration of neutrophils and eosinophils in the primary tumor. Moreover, individual therapies enhanced the phagocytic activity of monocytes and neutrophils. These findings demonstrate the antitumor effect of the combination of manumycin A and Immodin in 4T1 tumor-bearing mice associated with strong antiplatelet activity and innate immunity activation.