{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,26]],"date-time":"2026-08-26T19:10:24Z","timestamp":1787771424713,"version":"build-2784847793"},"reference-count":51,"publisher":"MDPI AG","issue":"2","license":[{"start":{"date-parts":[[2017,6,2]],"date-time":"2017-06-02T00:00:00Z","timestamp":1496361600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Diagnostics"],"abstract":"<jats:p>Background: The aim of this study was to assess and compare the performance of different ultrasound-based International Ovarian Tumor Analysis (IOTA) strategies and subjective assessment for the diagnosis of early stage ovarian malignancy. Methods: This is a secondary analysis of a prospective multicenter cross-sectional diagnostic accuracy study that included 1653 patients recruited at 18 centers from 2009 to 2012. All patients underwent standardized transvaginal ultrasonography by experienced ultrasound investigators. We assessed test performance of the IOTA Simple Rules (SRs), Simple Rules Risk (SRR), the Assessment of Different NEoplasias in the adneXa (ADNEX) model and subjective assessment to discriminate between stage I-II ovarian cancer and benign disease. Reference standard was histology after surgery. Results: 230 (13.9%) patients proved to have stage I\u2013II primary invasive ovarian malignancy, and 1423 (86.1%) had benign disease. Sensitivity and specificity with respect to malignancy (95% confidence intervals) of the original SRs (classifying all inconclusive cases as malignant) were 94.3% (90.6% to 96.7%) and 73.4% (71.0% to 75.6%). Subjective assessment had a sensitivity and specificity of 90.0% (85.4% to 93.2%) and 86.7% (84.9% to 88.4%), respectively. The areas under the receiver operator characteristic curves of SRR and ADNEX were 0.917 (0.902 to 0.933) and 0.905 (0.920 to 0.934), respectively. At a 1% risk cut-off, sensitivity and specificity for SRR were 100% (98.4% to 100%) and 38.0% (35.5% to 40.6%), and for ADNEX were 100% (98.4% to 100%) and 19.4% (17.4% to 21.5%). At a 30% risk cut-off, sensitivity and specificity for SRR were 88.3% (83.5% to 91.8%) and 81.1% (79% to 83%), and for ADNEX were 84.5% (80.5% to 89.6%) and 84.5% (82.6% to 86.3%). Conclusion: This study shows that all three IOTA strategies have good ability to discriminate between stage I-II ovarian malignancy and benign disease.<\/jats:p>","DOI":"10.3390\/diagnostics7020032","type":"journal-article","created":{"date-parts":[[2017,6,2]],"date-time":"2017-06-02T10:20:44Z","timestamp":1496398844000},"page":"32","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":38,"title":["Validation of the Performance of International Ovarian Tumor Analysis (IOTA) Methods in the Diagnosis of Early Stage Ovarian Cancer in a Non-Screening Population"],"prefix":"10.3390","volume":"7","author":[{"given":"Wouter","family":"Froyman","sequence":"first","affiliation":[{"name":"Department of Development and Regeneration, KU Leuven, Leuven post code3000, Belgium"},{"name":"Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven 3000, Belgium"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Laure","family":"Wynants","sequence":"additional","affiliation":[{"name":"Department of Development and Regeneration, KU Leuven, Leuven post code3000, Belgium"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Chiara","family":"Landolfo","sequence":"additional","affiliation":[{"name":"Department of Development and Regeneration, KU Leuven, Leuven post code3000, Belgium"},{"name":"Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven 3000, Belgium"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tom","family":"Bourne","sequence":"additional","affiliation":[{"name":"Department of Development and Regeneration, KU Leuven, Leuven post code3000, Belgium"},{"name":"Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven 3000, Belgium"},{"name":"Queen Charlotte\u2019s and Chelsea Hospital, Imperial College, London W12 0HS, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Lil","family":"Valentin","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynecology, Sk\u00e5ne University Hospital Malm\u00f6, Lund University, Malm\u00f6 20502, Sweden"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Antonia","family":"Testa","sequence":"additional","affiliation":[{"name":"Department of Oncology, Catholic University of the Sacred Heart, Rome 00168, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Povilas","family":"Sladkevicius","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynecology, Sk\u00e5ne University Hospital Malm\u00f6, Lund University, Malm\u00f6 20502, Sweden"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dorella","family":"Franchi","sequence":"additional","affiliation":[{"name":"Preventive Gynecology Unit, Division of Gynecology, European Institute of Oncology, Milan 20141, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Daniela","family":"Fischerova","sequence":"additional","affiliation":[{"name":"Gynecological Oncology Center, Department of Obstetrics and Gynecology, Charles University, Prague 12108, Czech Republic"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Luca","family":"Savelli","sequence":"additional","affiliation":[{"name":"Department of Obstetrics and Gynecology, S. Orsola-Malpighi Hospital, University of Bologna, Bologna 40138, Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ben","family":"Van Calster","sequence":"additional","affiliation":[{"name":"Department of Development and Regeneration, KU Leuven, Leuven post code3000, Belgium"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Dirk","family":"Timmerman","sequence":"additional","affiliation":[{"name":"Department of Development and Regeneration, KU Leuven, Leuven post code3000, Belgium"},{"name":"Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven 3000, Belgium"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2017,6,2]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"210","DOI":"10.1097\/AOG.0b013e318298def5","article-title":"Frequency and disposition of ovarian abnormalities followed with serial transvaginal ultrasonography","volume":"122","author":"Pavlik","year":"2013","journal-title":"Obstet. Gynecol."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"965","DOI":"10.1016\/j.ygyno.2003.11.029","article-title":"Natural history of sonographically detected simple unilocular adnexal cysts in asymptomatic postmenopausal women","volume":"92","author":"Castillo","year":"2004","journal-title":"Gynecol. Oncol."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"345","DOI":"10.1046\/j.1469-0705.1999.13050345.x","article-title":"Transvaginal sonographic ovarian findings in a random sample of women 25\u201340 years old","volume":"13","author":"Borgfeldt","year":"1999","journal-title":"Ultrasound Obstet. Gynecol."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"S42","DOI":"10.1006\/gyno.1994.1340","article-title":"Management of the Adnexal Mass","volume":"55","author":"Curtin","year":"1994","journal-title":"Gynecol. Oncol."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"1374","DOI":"10.1016\/j.ejca.2012.12.027","article-title":"Cancer incidence and mortality patterns in Europe: Estimates for 40 countries in 2012","volume":"49","author":"Ferlay","year":"2013","journal-title":"Eur. J. Cancer"},{"key":"ref_6","unstructured":"(2016, November 20). Cancer Research UK. Available online: www.cancerresearchuk.org."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"719","DOI":"10.1038\/nrc3144","article-title":"Rethinking ovarian cancer: Recommendations for improving outcomes","volume":"11","author":"Vaughan","year":"2011","journal-title":"Nat. Rev. Cancer"},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"S161","DOI":"10.1016\/S0020-7292(06)60033-7","article-title":"Carcinoma of the Ovary","volume":"95","author":"Heintz","year":"2006","journal-title":"Int. J. Gynecol. Obstet."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"414","DOI":"10.1111\/j.1525-1438.2007.01035.x","article-title":"A randomized study of screening for ovarian cancer: A multicenter study in Japan","volume":"18","author":"Kobayashi","year":"2008","journal-title":"Int. J. Gynecol. Cancer"},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"2295","DOI":"10.1001\/jama.2011.766","article-title":"Effect of Screening on Ovarian Cancer Mortality","volume":"305","author":"Buys","year":"2011","journal-title":"JAMA"},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"945","DOI":"10.1016\/S0140-6736(15)01224-6","article-title":"Ovarian cancer screening and mortality in the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS): A randomised controlled trial","volume":"387","author":"Jacobs","year":"2016","journal-title":"Lancet"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"11","DOI":"10.1136\/ijgc-00009577-200602001-00002","article-title":"Improved short-term survival for advanced ovarian, tubal, and peritoneal cancer patients operated at teaching hospitals","volume":"16","author":"Paulsen","year":"2006","journal-title":"Int. J. Gynecol. Cancer"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"589","DOI":"10.1002\/cncr.21616","article-title":"Surgery by consultant gynecologic oncologists improves survival in patients with ovarian carcinoma","volume":"106","author":"Engelen","year":"2006","journal-title":"Cancer"},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"172","DOI":"10.1093\/jnci\/djj019","article-title":"Effect of surgeon specialty on processes of care and outcomes for ovarian cancer patients","volume":"98","author":"Earle","year":"2006","journal-title":"J. Natl. Cancer Inst."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"286","DOI":"10.1016\/j.ygyno.2012.04.012","article-title":"Centralisation of services for gynaecological cancer\u2014A Cochrane Systematic Review","volume":"126","author":"Woo","year":"2012","journal-title":"Gynecol. Oncol."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"357","DOI":"10.1046\/j.0960-7692.2001.00500.x","article-title":"Comparison of \u201cpattern recognition\u201d and logistic regression models for discrimination between benign and malignant pelvic masses: A prospective cross validation","volume":"18","author":"Valentin","year":"2001","journal-title":"Ultrasound Obstet. Gynecol."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"91","DOI":"10.1016\/j.bpobgyn.2003.09.009","article-title":"The use of mathematical models to evaluate pelvic masses; can they beat an expert operator?","volume":"18","author":"Timmerman","year":"2004","journal-title":"Best Pract. Res. Clin. Obstet. Gynaecol."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"17","DOI":"10.1016\/j.ejca.2016.01.007","article-title":"Subjective assessment versus ultrasound models to diagnose ovarian cancer: A systematic review and meta-analysis","volume":"58","author":"Meys","year":"2016","journal-title":"Eur. J. Cancer"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"500","DOI":"10.1046\/j.1469-0705.2000.00287.x","article-title":"Terms, definitions and measurements to describe the sonographic features of adnexal tumors: A consensus opinion from the International Ovarian Tumor Analysis (IOTA) group","volume":"16","author":"Timmerman","year":"2000","journal-title":"Ultrasound Obstet. Gynecol."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"681","DOI":"10.1002\/uog.5365","article-title":"Simple ultrasound-based rules for the diagnosis of ovarian cancer","volume":"31","author":"Timmerman","year":"2008","journal-title":"Ultrasound Obstet. Gynecol."},{"key":"ref_21","unstructured":"Royal College of Obstetricians and Gynaecologists (2011). Management of Suspected Ovarian Masses in Premenopausal Women, Royal College of Obstetricians and Gynaecologists. Green-top Guideline No. 62."},{"key":"ref_22","doi-asserted-by":"crossref","unstructured":"The American College of Obstetricians and Gynecologists (2016). Practice bulletin\u2014Evaluation and Management of Adnexal Masses. Obstet. Gynecol., 128, e210\u2013e226.","DOI":"10.1097\/AOG.0000000000001768"},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"449","DOI":"10.1093\/humupd\/dmt059","article-title":"Presurgical diagnosis of adnexal tumours using mathematical models and scoring systems: A systematic review and meta-analysis","volume":"20","author":"Kaijser","year":"2014","journal-title":"Hum. Reprod. Update"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"424","DOI":"10.1016\/j.ajog.2016.01.007","article-title":"Predicting the risk of malignancy in adnexal masses based on the Simple Rules from the International Ovarian Tumor Analysis group","volume":"214","author":"Timmerman","year":"2016","journal-title":"Am. J. Obstet. Gynecol."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"g5920","DOI":"10.1136\/bmj.g5920","article-title":"International Ovarian Tumour Analysis, G. Evaluating the risk of ovarian cancer before surgery using the ADNEX model to differentiate between benign, borderline, early and advanced stage invasive, and secondary metastatic tumours: Prospective multicentre diagnostic study","volume":"349","author":"Valentin","year":"2014","journal-title":"BMJ"},{"key":"ref_26","doi-asserted-by":"crossref","unstructured":"Meys, E.M., Jeelof, L.S., Achten, N.M., Slangen, B.F., Lambrechts, S., Kruitwagen, R.F., and van Gorp, T. (2016). Estimating the risk of malignancy in adnexal masses: An external validation of the ADNEX model and comparison with other frequently used ultrasound methods. Ultrasound Obstet. Gynecol.","DOI":"10.1002\/uog.17225"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"542","DOI":"10.1038\/bjc.2016.227","article-title":"Evaluating the risk of ovarian cancer before surgery using the ADNEX model: A multicentre external validation study","volume":"115","author":"Sayasneh","year":"2016","journal-title":"Br. J. Cancer"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"490","DOI":"10.1016\/j.ygyno.2016.06.020","article-title":"External validation of the IOTA ADNEX model performed by two independent gynecologic centers","volume":"142","author":"Szubert","year":"2016","journal-title":"Gynecol. Oncol."},{"key":"ref_29","doi-asserted-by":"crossref","unstructured":"Araujo, K.G., Jales, R.M., Pereira, P.N., Yoshida, A., de Angelo Andrade, L., Sarian, L.O., and Derchain, S. (2016). Performance of the IOTA ADNEX model in the preoperative discrimination of adnexal masses in a gynecologic oncology center. Ultrasound Obstet. Gynecol.","DOI":"10.1002\/uog.15963"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"557","DOI":"10.1016\/j.gyobfe.2016.07.007","article-title":"Before surgery predictability of malignant ovarian tumors based on ADNEX model and its use in clinical practice","volume":"44","author":"Joyeux","year":"2016","journal-title":"Gynecol. Obstet. Fertil."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"680","DOI":"10.1038\/bjc.2014.333","article-title":"Strategies to diagnose ovarian cancer: New evidence from phase 3 of the multicentre international IOTA study","volume":"111","author":"Testa","year":"2014","journal-title":"Br. J. Cancer"},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"837","DOI":"10.2307\/2531595","article-title":"Comparing the areas under two or more correlated receiver operating characteristic curves: A nonparametric approach","volume":"44","author":"DeLong","year":"1988","journal-title":"Biometrics"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"209","DOI":"10.1080\/01621459.1927.10502953","article-title":"Probable inference, the law of succession, and statistical inference","volume":"22","author":"Wilson","year":"1927","journal-title":"J. Am. Stat. Assoc."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"g7594","DOI":"10.1136\/bmj.g7594","article-title":"Transparent reporting of a multivariable prediction model for individual prognosis or diagnosis (TRIPOD): The TRIPOD statement","volume":"350","author":"Collins","year":"2015","journal-title":"BMJ"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"360","DOI":"10.1002\/uog.11201","article-title":"Ultrasound criteria and CA 125 as predictive variables of ovarian cancer in women with adnexal tumors","volume":"40","author":"Hartman","year":"2012","journal-title":"Ultrasound Obstet. Gynecol."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"467","DOI":"10.1002\/uog.12485","article-title":"IOTA simple rules for discriminating between benign and malignant adnexal masses: Prospective external validation","volume":"42","author":"Alcazar","year":"2013","journal-title":"Ultrasound Obstet. Gynecol."},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"2448","DOI":"10.1038\/bjc.2013.224","article-title":"Multicentre external validation of IOTA prediction models and RMI by operators with varied training","volume":"108","author":"Sayasneh","year":"2013","journal-title":"Br. J. Cancer"},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"503","DOI":"10.1002\/uog.13437","article-title":"Use of IOTA simple rules for diagnosis of ovarian cancer: Meta-analysis","volume":"44","author":"Nunes","year":"2014","journal-title":"Ultrasound Obstet. Gynecol."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"3835","DOI":"10.7314\/APJCP.2015.16.9.3835","article-title":"IOTA Simple Rules in Differentiating between Benign and Malignant Adnexal Masses by Non-expert Examiners","volume":"16","author":"Tinnangwattana","year":"2015","journal-title":"Asian Pac. J. Cancer Prev."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"10","DOI":"10.1016\/j.ejogrb.2015.05.024","article-title":"Diagnostic performance of IOTA simple rules for adnexal masses classification: A comparison between two centers with different ovarian cancer prevalence","volume":"191","author":"Rodriguez","year":"2015","journal-title":"Eur. J. Obstet. Gynecol. Reprod. Biol."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"516","DOI":"10.1055\/s-0034-1398773","article-title":"The Prospective External Validation of International Ovarian Tumor Analysis (IOTA) Simple Rules in the Hands of Level I and II Examiners","volume":"37","author":"Knafel","year":"2015","journal-title":"Ultraschall Med."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"1511","DOI":"10.1016\/S0002-9440(10)63708-X","article-title":"Ovarian Tumorigenesis\u2014A Proposed Model Based on Morphological and Molecular Genetic Analysis","volume":"164","author":"Shih","year":"2004","journal-title":"Am. J. Pathol."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"438","DOI":"10.1002\/uog.2707","article-title":"Which extrauterine pelvic masses are difficult to correctly classify as benign or malignant on the basis of ultrasound findings and is there a way of making a correct diagnosis?","volume":"27","author":"Valentin","year":"2006","journal-title":"Ultrasound Obstet. Gynecol."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"456","DOI":"10.1002\/uog.9030","article-title":"Adnexal masses difficult to classify as benign or malignant using subjective assessment of gray-scale and Doppler ultrasound findings: Logistic regression models do not help","volume":"38","author":"Valentin","year":"2011","journal-title":"Ultrasound Obstet. Gynecol."},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"308","DOI":"10.1016\/S1470-2045(09)70072-5","article-title":"Screening for ovarian carcinoma: Not quite there yet","volume":"10","author":"Vergote","year":"2009","journal-title":"Lancet Oncol."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"1515","DOI":"10.1634\/theoncologist.2012-0139","article-title":"Diagnosis, treatment, and follow-up of borderline ovarian tumors","volume":"17","author":"Fischerova","year":"2012","journal-title":"Oncologist"},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"176","DOI":"10.1016\/S0140-6736(00)03590-X","article-title":"Prognostic importance of degree of differentiation and cyst rupture in stage I invasive epithelial ovarian carcinoma","volume":"357","author":"Vergote","year":"2001","journal-title":"Lancet"},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"vi24","DOI":"10.1093\/annonc\/mdt333","article-title":"Newly diagnosed and relapsed epithelial ovarian carcinoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up","volume":"24","author":"Ledermann","year":"2013","journal-title":"Ann. Oncol."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"918","DOI":"10.1016\/j.humpath.2011.03.003","article-title":"Molecular pathogenesis and extraovarian origin of epithelial ovarian cancer\u2014Shifting the paradigm","volume":"42","author":"Kurman","year":"2011","journal-title":"Hum. Pathol."},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"814","DOI":"10.1001\/jamaoncol.2015.1883","article-title":"Presymptomatic Identification of Cancers in Pregnant Women During Noninvasive Prenatal Testing","volume":"1","author":"Amant","year":"2015","journal-title":"JAMA Oncol."},{"key":"ref_51","doi-asserted-by":"crossref","unstructured":"Vanderstichele, A., Busschaert, P., Smeets, D., Landolfo, C., van Nieuwenhuysen, E., Leunen, K., Neven, P., Amant, F., Mahner, S., and Braicu, E.I. (2016). Chromosomal Instability in Cell-Free DNA as a Highly Specific Biomarker for Detection of Ovarian Cancer in Women with Adnexal Masses. Clin. Cancer Res.","DOI":"10.1158\/1078-0432.CCR-16-1078"}],"container-title":["Diagnostics"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2075-4418\/7\/2\/32\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,11]],"date-time":"2025-10-11T18:37:45Z","timestamp":1760207865000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2075-4418\/7\/2\/32"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2017,6,2]]},"references-count":51,"journal-issue":{"issue":"2","published-online":{"date-parts":[[2017,6]]}},"alternative-id":["diagnostics7020032"],"URL":"https:\/\/doi.org\/10.3390\/diagnostics7020032","relation":{},"ISSN":["2075-4418"],"issn-type":[{"value":"2075-4418","type":"electronic"}],"subject":[],"published":{"date-parts":[[2017,6,2]]}}}