Characteristics of patients with late recurrence endometrial cancer

AIM

We planned this study to assess endometrial cancer (EC) patients who had late metastasis.

MATERIALS AND METHODS

This retrospective study constituted a review of the records of patients who were diagnosed with EC and underwent hysterectomy at the Gynecologic Oncology Clinic between 1996 and 2018. Relapses occurring after the first three years following primary treatment of EC are considered late recurrences. Post-relapse survival (PRS) refers to the time to the last follow-up or the patient's death after relapse.

RESULTS

Late metastases were identified in 42 patients, 20 (47.6%) of whom had locoregional recurrence and 22 of whom (52.4%) had extrapelvic recurrence. Median disease-free survival (DFS) times were 61 (range: 43-78) and 65 (range: 48-81) months for the groups with locoregional and extrapelvic recurrences, respectively (P = 0.462). The 5-year PRS rate for the patients was 61.1%, with 63.8% having locoregional and 59.4% having extrapelvic late metastasis (P = 0.969).

CONCLUSION

Among the patients with late metastases, those with endometrioid type EC were found to have a better prognosis. It has been shown that locoregional or extrapelvic organ recurrence does not significantly affect survival in patients with late relapse. Although our results are not statistically significant for cases of locoregional late metastases, surgical resection increases survival rates.

The prognostic value of P53 index in predicting the recurrence of early low-risk endometrial cancer

AIM

We aimed to clarify the clinical value of P53 index in patients with early low-risk endometrial cancer (EC) and find an optimal cut-off value of P53 index for predicting the recurrence of these patients.

METHODS

The clinicopathological data of 157 patients with early low-risk EC (stage 1A with grade 1 or 2 endometrioid EC) were analyzed. The optimal cut-off value of the P53 index was calculated by the receiver operating characteristic curve analysis and Youden index. Cox regression model was used to evaluate the independent prognostic predictors of recurrence of EC. Then all patients were divided into two groups according to the optimal cut-off value of the P53 index. Differences of the clinicopathological parameters between the two groups were compared.

RESULTS

Multivariate analysis showed age PR (p = 0.020) and P53 (p = 0.001) were independent prognostic factors for the recurrence of EC. The value of P53 index was found to be the optimal cut-off point of 17.5% in estimating the recurrence of EC. The 5-year recurrence-free survival rates of patients in the low P53 index group (<17.5%) and the high P53 index group (≥17.5%) were 94.6% and 65.4% (p < 0.001).

CONCLUSION

It has been revealed that the P53 index is a prognostic factor for recurrence in early low-risk EC. The optimal cut-off value of P53 index may contribute to the postoperative individualized treatment options for early low-risk EC patients.

Prognostic value of lymph node features in patients diagnosed with stage IIIC endometrial adenocancer

AIM

Our study investigated the lymph node (LN) features most affecting survival in endometrial adenocancer (EAC) patients with LN involvement.

MATERIALS AND METHODS

This retrospective study was based on a review of the records of patients diagnosed with EAC, who underwent hysterectomy and systematic retroperitoneal lymphadenectomy at the gynecologic oncology clinics of three centers between January 2009 and January 2019.

RESULTS

A total of 120 stage IIIC endometrioid-type EAC patients were included in the study. The patients were divided into small (<10 mm) and large (≥10 mm) groups according to the size of the largest metastatic LN. Patients were divided into single and multiple metastasis groups according to the number of metastatic LNs. The patients were divided into pelvic and paraaortic groups according to the location of the metastatic LNs. The effects of prognostic factors on disease-free survival (DFS) and overall survival (OS) were evaluated by Cox regression analysis. Large-sized metastatic LNs were an independent prognostic factor for DFS (hazard ratio [HR] = 5.4, 95% confidence interval [CI]: 1.-26.2; P = 0.035) and OS (HR = 9.0, 95% CI: 1.1-68.0; P = 0.033). The number (P = 0.093 for DFS, P = 0.911 for OS) and location (P = 0.217 for DFS, P = 0.124 for OS) of metastatic LNs were not independent prognostic factors for DFS or OS.

CONCLUSIONS

Large-sized metastatic LNs were an independent prognostic factor for survival in patients with stage IIIC EAC. Larger prospective studies including similar patient populations are required to verify these findings.

The prognostic significance of the heterologous component in uterine carcinosarcomas

OBJECTIVE

Uterine carcinosarcomas are aggressive, rare biphasic tumors with malignant epithelial and malignant sarcomatous components. The prognostic significance of the presence of extrauterine sarcoma (heterologous component) is controversial. Therefore, the aim of this study was to investigate the effect of heterologous components in uterine carcinosarcomas on disease-free survival, overall survival, and other prognostic factors.

METHODS

Clinical and histopathological data from patients treated for uterine carcinosarcoma in a tertiary cancer center in Turkey between July 2000 and January 2020 were collected. Independent risk factors affecting overall survival and disease-free survival were analyzed by univariate and multivariate Cox regression analyses.

RESULTS

A total of 98 patients were identified. The median follow-up was 21.8 (1.2-233.1) months. In the multivariate analysis, the median overall survival and disease-free survival were 23.8 and 20.7 months in those with homologous mesenchymal components and 17.6 and 9.7 months in those with heterologous mesenchymal components, respectively. It was found that the presence of heterologous mesenchymal components significantly reduced both overall survival and disease-free survival (odds ratio [OR], 2.861; 95% confidence interval [CI] 1.196-6.841; p=0.018 and OR, 3.697; 95%CI 1.572-8.695; p=0.003, respectively). In addition, both lymphadenectomy and adjuvant radiotherapy were found to significantly increase overall survival and disease-free survival. Age was found to increase only disease-free survival.

CONCLUSION

The results obtained in this study showed that the presence of heterologous components in uterine carcinosarcoma is a prognostic factor that adversely affects both overall survival and disease-free survival. Lymphadenectomy and adjuvant radiotherapy have beneficial effects on both overall survival and disease-free survival.

Analysis of vanishing endometrial cancer by pathological types

PURPOSE

We asked why endometrial cancer sometimes vanishes.

METHODS

A total of 454 patients diagnosed with endometrioid-type endometrial cancer (EC) (via endometrial sampling) and treated in our clinic over the past 5 years were enrolled. The patients were divided into two groups: vanishing and residual, depending on whether a tumor was detected in the postoperative hysterectomy specimen. Patient age, numbers of pregnancies and deliveries, menopausal status, systemic disease status, hemogram parameters, International Federation of Gynecology and Obstetrics (FIGO) grade, and invasion status (evident on magnetic resonance imaging [MRI]) were compared between the groups.

RESULTS

ECs vanished in 42 (9.25%) patients. The vanishing rates were 19.7% (37/187) in FIGO grade 1 patients, 2.1% (5/238) in grade 2 patients, and 0% (0/29) in grade 3 patients. The average age was lower in the vanishing than the residual group, but the premenopausal status and grade 1 tumor rates were higher (both p < 0.001). An absence of invasion (as revealed by MRI) was more common in the vanishing group (p < 0.001). No recurrence developed in the vanishing group, but recurrences were noted in 3.3% (14/412) of the residual group. There were no significant between-group differences in any of the numbers of pregnancies or births, systemic disease status, or hemogram parameters (all p > 0.05).

CONCLUSION

Vanishing EC is more likely in premenopausal women with endometrioid grade 1 EC (as revealed by endometrial biopsy) who lack myometrial invasion on MRI.

POS0146 PERIPHERAL NEUROPATHY IN PSORIASIS AND PSORIATIC ARTHRITIS: A SINGLE BLIND, CONTROLLED, ELECTROPHYSIOLOGICAL STUDY

Background:

It is well known that both psoriasis (PsO) and psoriatic arthritis (PsA) causes morbidity and disability in patients’ lives. Additional pathologies such as peripheral neuropathy (PN) may interfere with disease specific symptoms and may increase the burden of disease. Neuropathic complaints of patients with PsO and PsA are observed during patients’ follow-up (1,2). However, the presence of PN in PsO and PsA is not well defined in clinical studies and clinicians might be neglecting this issue.

Objectives:

Our aim was to investigate the presence of PN by electrophysiological methods and to examine its relationship with neuropathic pain and with treatments in patients with PsO and PsA.

Methods:

38 patients with PsA, 36 patients with PsO and 37 age&sex-matched healthy volunteers were enrolled into this prospective, single-blind study. Disease activity was assessed with Psoriasis Area Severity Index (PASI) for patients with PsO and with Disease Activity in Psoriatic Arthritis (DAPSA) score for patients with PsA. Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) score was used to evaluate neuropathic pain. All participants were electrophysiologically examined in Electromyography (EMG) Laboratory by an experienced neurologist blinded for study groups.

Results:

There were no significant differences on patients age, sex and body mass index among 3 study groups (p>0.05). However, disease duration was significantly longer in PsO group compared to PsA group (median 19.1[1-43] years in PsO vs median 7.5[2-29] years in PsA; p<0.01). PN was detected in 7 patients (19.44%) in the PsO group, 14 patients (34.21%) in the PsA group, and in 1 volunteer (2.7%) in the control group (PsO vs control: p<0.05; PsA vs control: p<0.001, PsO vs PsA: p>0.05) (Table 1). Among patients with PsA, 1 patient had ulnar neuropathy and 1 patient had both carpal tunnel syndrome (CTS) and sensory polyneuropathy. All other PNs detected electrophysiologically were CTS. Neuropathic pain was present in 11 patients (30.56%), 20 patients (52.63%) and in 2 volunteers (5.41%) in PsO, PsA and control groups consecutively (PsO vs control: p<0.05; PsA vs control: p<0.001, PsO vs PsA: p>0.05). PN did not show any significant correlation with disease activity or treatments including biological agents.

Table 1.

Results of peripheral neuropathy and neuropathic pain in control group and patients with PsO and PsA

Control Group (n=37)PsO Group (n=36)PsA Group (n=38)p^p+p&CTS1 (%2.70)7 (%19.44)13* (%34.21)0.028a<0.001a0.153aUlnar Neuropathy001 (%2.63)Polyneuropathy001* (%2.63)Total PN1 (%2.70)7 (%19.44)14 (%36.64)0.028a<0.001a0.097aLANSS Score5 (0:13)6.50 (0:16)13 (3:19)0.170b<0.001b0.004bAccording to LANSSlikely neuropathic pain2 (%5.41)11 (%30.56)20 (%52.63)0.005 a<0.001a0.054a

*: Both polyneuropathy and CTS were detected in one patient in the PsA group; Data are given as n (%) and median (minimum: maximum); a: Chi-Square Test, b: Kruskal Wallis Test; p^ value: control vs PsO, p+ value: control vs PsA, p& value: PsO vs PsA

Conclusion:

To our knowledge, this is the first study to investigate simultaneously the presence of neuropathic pain and PN by electrophysiological methods in patients with PsO and PsA. We observed PN and neuropathic pain high in patients with PsO&PsA and among them CTS appears as the most prominent neuropathy. Clinicians should keep this in mind during routine care of patients with PsO and PsA, which may improve patient-centred care. Large, prospective studies are needed to understand the characteristics of these neuropathies and its prognosis.

References:

[1]Rifbjerg-Madsen S, Christensen AW, Christensen R, Hetland ML, Bliddal H, Kristensen LE, Danneskiold-Samsøe B, Amris K (2017) Pain and pain mechanisms in patients with inflammatory arthritis: a Danish nationwide cross-sectional DANBIO registry survey. PLoS One 12(7):e0180014.

[2]Ljosaa TM, Mork C, Stubhaug A, et al. Skin pain and skin discomfort is associated with quality of life in patients with psoriasis. J Eur Acad Dermatol Venereol. 2012;26:29-35.

Disclosure of Interests:

None declared

Retrospective Analysis of Pure Ovarian Immature Teratoma in Patients Aged 15-39 Years: A Turkish Multicenter Study

Purpose: To evaluate the clinicopathological characteristics and surgical outcomes in patients with pure ovarian immature teratomas (POITs). Materials and Methods: In this multicenter study, a retrospective review was made of the databases of six Gynecology Oncology Departments in Turkey to identify patients with POITs who had undergone surgery between 1993 and 2019. Results: Evaluation was made of 48 patients with a median age at diagnosis of 22.5 years (range, 15-37 years). In 40 (83%) patients, stage I was determined and in eight patients, an advanced stage (IIIB, IIIC, and IVB) was determined. Tumors were found to be grade I in 17 (35.4%) cases, grade II in 12 (25%), and grade III in 19 (39.6%). Fertility-sparing surgery was applied to 42 (87.5%) patients and radical surgery to 6 (12.5%). The median follow-up was 60 months (range, 3-246 months). Recurrence was seen in seven patients, all with grade III tumors. In the final pathological examination of recurrent tumors, mature teratoma was reported in five patients, and immature teratoma in one patient. Salvage surgery was not performed in one patient as the tumor was unresectable and so a regimen of bleomycin, etoposide, and cisplatin (BEP) was administered. Conclusion: POITs are rare tumors seen at a young age, and benign or malignant relapse can be seen in these tumors. In this cohort, the malignant recurrence rate was 4.1%, and the benign recurrence rate was 10.4%. All the recurrences were in grade III tumors. Benign recurrences can be treated with surgery alone and the malignant group should be treated with surgery followed by chemotherapy.

Does ovarian preservation have an effect on recurrence of early stage low-grade endometrial stromal sarcoma?

Surgical treatment of low-grade endometrial stromal sarcoma consists of hysterectomy. The role of oophorectomy is yet to be established. We aimed to examine the effect of preserving the ovaries on the pattern of recurrences in patients with stage I disease. Thirty-four patients with stage I low-grade endometrial stromal sarcoma were retrospectively analysed. Based on ovarian preservation the whole cohort was divided into two groups. Recurrence (liver, lung, groin and bone) was detected in 4 (11.8%) cases. No significant differences in overall survival or disease-free survival (DFS) were observed between the ovarian preservation and bilateral salpingo-oophorectomy (BSO) groups. Subset analysis revealed no significant difference in DFS between the ovarian preservation and BSO groups in the premenopausal arm. And also, the performance of pelvic (n = 2) or para-aortic lymphadenectomy (n = 6) or adjuvant hormonal therapy did not alter DFS significantly. The 5-year DFS rate for the group which received adjuvant radiotherapy was 62.5 and 94.4% for those which did not (p = .014). Preserving the ovaries had no adverse effect on the recurrence of stage I disease.IMPACT STATEMENTWhat is already known on this subject? Due to the rarity of the disease and the common postoperative diagnosis, only retrospective studies have been reported on low-grade endometrial stromal sarcoma. This disease is commonly diagnosed in premenopausal patients during the early stage. There is no consensus on preserving the ovaries, particularly in young patients, due to the tumour's hormonal characteristics and the risk of late recurrences.What do the results of this study add? Ovarian preservation had no effect on the recurrence of stage I low-grade endometrial stromal sarcoma. Lymphadenectomy and adjuvant hormonal treatment had no effect on DFS, and adjuvant radiotherapy decreased DFS in the current study.What are the implications of these findings for clinical practice and/or further research? Ovarian preservation should be considered, to prevent the negative effects of surgical menopause, particularly in young patients.

Life quality of endometrioid endometrial cancer survivors: a cross-sectional study

Endometrial cancer is the most common gynaecologic malignancy in developed countries with increasing incidence worldwide. A total of 201 patients were enrolled and a cross-sectional study was performed using the European Organisation for Research and Treatment of Cancer quality of life questionnaire (EORTC QLQ-C30) and Female Sexual Functioning Index (FSFI) after the approval by an institutional review board (University of Health Sciences, Tepecik Education and Research Hospital, Turkey, March 13, 2019, Approval no. 2019/4-27). Morbidly obese patients (body mass index (BMI) ≥40 kg/m²) had lower physical functioning scores compared to non-obese (BMI < 30 kg/m²; p = .008) and non-morbidly obese patients (BMI < 40 kg/m²; p = .011). The overall sexual dysfunction rate was high (94.5%). No significant sexual function differences were observed among the study groups.IMPACT STATEMENTWhat is already known on this subject? Previous efforts to assess the influence of obesity and BMI on endometrial cancer patient quality of life have indicated that obesity adversely affects physical function and the effects of obesity on sexual function remains vague. In addition, the influence of patient age, surgical approach, adjuvant therapy type and time after diagnosis on quality of life and sexual function have not been clearly defined.What do the results of this study add? Increased BMI is associated with impaired physical function in endometrial cancer patients. However, BMI does not appear to affect sexual function in this population.What are the implications of these findings for clinical practice and/or further research? After endometrial cancer treatment, lifestyle interventions aimed at weight loss should be implemented to improve the quality of life.

AB0793 CHANGES IN PSAID-12 SCORES BEFORE AND AFTER BIOLOGICAL TREATMENT IN PATIENTS WITH PSORIATIC ARTHRITIS

Background:

Psoriatic Arthritis Impact of Disease 12-item questionnaire (PsAID-12) is a patient-reported outcome measure (PROM) which allows a more precise assessment of the impact of PsA and helps treatment decisions geared to either disease activity or, for example, physpsychological distress (1,2).

Objectives:

Our objective is to evaluate change of PsAID-12 values after three-months biologic drug treatment and to find out its relationship with other quality of life indices and disease activity parameters in PsA patients

Methods:

Patients with a diagnosis of PsA according to CASPAR criteria were recruited to the study. The data of the patients before and after three-month treatment were evaluated retrospectively. The number of swollen (0-66) and tender joints (TJ) (0-68), ESR, CRP, Patient Global Assessment(PGA), physician’s global assessment (PhGA),DAPSA and BASDAI were used for the assessment of disease activity. Functional status was assessed with BASFI, quality of life with EuroQol, DLQI and HAQ. Enthesitis evaluation was performed with MASES. Dermatological assesment was done with BSA and PASI. In addition, PSARC and MDA criteria was used to assess patient’s response to treatment. A p-value less than 0.05 was statistically significant.

Results:

Fifteen patients who met the study criteria were evaluated. 3 patients were excluded because of irregular drug usage. 9 of the 12 patients were women, the average age was 46,41, and BMI was 32,68. Both acute phase reactants were decreased after treatment, and there was significant decrease at CRP levels but not at ESR. It was also observed that there were significant differences at PGA, PhGA, BASDAI, BASFI, MASES, DAPSA and PsAID-12 scores after treatment. There were no statistically significant differences at number of swollen and tender joints, HAQ,EuroQol, PASI, BSA and DLQI scores. 3 patients achieved MDA and 7 patients achieved PSARC criteria. There were statistically significant correlations between pre-treatment mean scores of PsAID-12 and BASDAI, BASFI, DAPSA, HAQ, EuroQol, PhGA. There were statistically significant correlations between after-treatment mean scores of PsAID-12 and BASDAI, DAPSA, PASI and BSA. The correlations between PSAID-12 change (ΔPsAID-12) with other outcome measure changes were as follows: ΔHAQ (r=0,27, p=0,39), ΔBASDAI (r=0.37, p=0,22), ΔPGA (r =0.28, p=0,36), ΔDLQI (r=0.71, p=0,17), ΔBASFI (r=0.41, p=0,18), ΔESR (r=0,20, p=0,55),and ΔCRP (r=-0.39, p=0,20), ΔDAPSA (r=0,77, p=0,009), Δnumber of TJ (r=0,81, p=0,004), ΔMASES (r=0,57, p=0,08), ΔEuroQol (r=-0,29, p=0,34), ΔPASI (r=0,30, p=0,62). It is also observed that PsAID-12 scores decreased more in PSARC responders rather than non-responders, but this difference was not statistically significant. No cases of major adverse event were reported.

Conclusion:

PsAID-12 evaluates effect of both physical and psychosocial aspects of PsA and shows close relationship with other PROMS but it may be inadequate in assessing biological treatment response in PsA.

References:

[1]Kalyoncu, Umut, et al. “Change in PsAID-12 scores in patients continuing or discontinuing anti-TNF treatments in psoriatic arthritis: results from the HUR-BIO biologic registry.”Clinical rheumatology38.4 (2019): 1187-1192.

[2]Gossec, Laure, et al. “A patient-derived and patient-reported outcome measure for assessing psoriatic arthritis: elaboration and preliminary validation of the Psoriatic Arthritis Impact of Disease (PsAID) questionnaire, a 13-country EULAR initiative.”Annals of the rheumatic diseases73.6 (2014): 1012-1019.

Disclosure of Interests:

None declared

Effect of tumor size on the accuracy of frozen section in the evaluation of mucinous borderline ovarian tumors

OBJECTIVE

This study aims to evaluate the accuracy of frozen section (FS) in mucinous borderline ovarian tumors (BOTs) and to examine the factors associated with misdiagnosis.

METHODS

In this retrospective study, cases diagnosed as mucinous BOTs by FS or final pathologic (FP) results were studied. The results of FS and FP were compared, and the factors associated with misdiagnosis were analyzed.

RESULTS

Seventy-nine cases were examined. The median tumor diameter was 16 (6-50) cm, and 89.9 % of cases had tumors ≥10 cm. The overall agreement ratio between FS and FP was 79.7 %. Over-diagnosis and under-diagnosis rates were 3.8 % and 16.5 %, respectively. The sensitivity and positive predictive values were both 88.7 %. None of the underdiagnosed patients (13 cases) had recurrence during the 100-month median follow-up (9-222). Misdiagnosis was more common in tumors <10 cm (p = 0.025). The under-diagnosis rate for tumors <10 cm was 30.8 %. Tumor size <10 cm was significantly associated with misdiagnosis in univariate and multivariate analyses (Odds ratio {OR} 4.92, 95 % Confidence Interval {CI} (1.08-22.45) p = 0.040; OR 5.17, 95 % CI (1.07-25.05) p = 0.041, respectively). Laterality and preoperative CA 125 levels were not associated with misdiagnosis.

CONCLUSION

Tumor size <10 cm is associated with misdiagnosis in mucinous BOTs. Laterality and CA 125 levels do not affect diagnostic accuracy. The evaluation of FS by gynecologic pathologists can help to increase the accuracy of FS.

Dilatation of the cervix at non-labour caesarean section: Does it improve the patients' perception of pain post-operatively?

Our aim was to determine the effect of cervical dilatation at non-labour caesarean section on post-operative pain and maternal morbidity. This prospective, randomised, single-blinded trial was conducted from March 2013 to February 2014. In all, 199 patients were enrolled in the study: 102 in non-dilated group and 97 in cervical dilatation group. Based on Visual Analogue Scale, there were no significant differences between the two groups on post-operative 8th, 24th and 48th hour pain scores. We observed thinner endometrial cavity thickness, shorter operation time and shorter hospitalisation duration in cervical dilatation group. However, change in haemoglobin concentrations and puerperal fever rates were found to be comparable between the groups. In conclusion, intra-operative cervical dilatation does not seem to benefit in terms of post-operative pain, change in haemoglobin concentrations or puerperal fever.

Placental site trophoblastic tumor: report of a tertiary center experience

OBJECTIVE

To analyze the clinical and pathological characteristics of placental site trophoblastic tumor (PSTT) cases and to discuss the diagnosis, treatment, and prognosis of PSTT.

MATERIALS AND METHODS

The clinical and pathological data of eight patients with PSTT at Istanbul Medical Faculty Hospital from 1988 to 2010 were analyzed retrospectively.

RESULTS

The mean age of the patients was 31 years. The antecedent pregnancy was full-term delivery in most of the patients (6/8, 75%). The mean interval from last pregnancy to diagnosis of PSTT was 35 months (range, six to 192). Serum human chorionic gonadotropin (hCG) levels at the time of diagnosis ranged from 0.1 to 2280 mIU/ml (mean, 614). All patients had Stage 1 disease and ultimately underwent hysterectomy. None of the patients received adjuvant chemotherapy. One patient died of an unknown reason, one month after the surgery. The rest of the patients were alive and without evidence of disease after an average of 3.5 years (range, one to 11) of follow-up.

CONCLUSION

Hysterectomy alone can provide long-term survival in early-stage disease.

Essure microinsert hysteroscopic tubal sterilization: eight-years follow-up results

OBJECTIVES

To evaluate the effectiveness and reliability of microinsert hysteroscopic sterilization method at short- and long-term.

MATERIALS AND METHODS

In the period between January 2004 and December 2005, 34 patients who submitted to the present gynecology outpatient clinic seeking for permanent contraception and accepted tubal sterilization with microinsert method were included in this prospective, interventional study.

RESULTS

Bilateral microinsert placement was successful in 28 (87.5%) of 32 patients that underwent the procedure. In all of the 30 patients (100%) in whom the placement procedure was attempted, bilateral tubal occlusion was documented by hysterosalpingogram (HSG) including the two patients in whom unilateral placement was carried out. First three procedures were performed under general anesthesia. Local or general anesthesia was not administered in any other cases (97.5%). The mean visual analogue scale score for pain felt during the procedure was 3.1. The mean procedure time was 11.5 ± 4.88 (5-22) minutes, the average time from beginning the procedure to discharge of the patients was 41.7 ± 18.5 (15-94) minutes. One intrauterine pregnancy was detected in one of the patients nine months after cessation of the alternative contraceptive period. This patient was excluded from the follow-up. At short-term all patients rated their microinsert-wearing tolerance as good or excellent. At eighth year, three patients were lost to follow-up. Mean follow-up time was 83.4 ± 15.0 (36-103) months. During 2,420 woman-months of follow-up, no other pregnancies were detected. Almost all of the patients were happy with the procedure and recommended it to a friend.

CONCLUSION

Essure microinsert is a safe, effective, minimally invasive sterilization method which can be performed in outpatient settings without any anesthesia requirement. It appears to be a good alternative to laparoscopic tubal sterilization. The procedure time and the time to discharge are brief. Patient tolerance during the procedure and at long-term is very good.

Borderline epithelial ovarian tumors: a single center experience

AIM

To evaluate the clinical outcomes of the patients treated for borderline ovarian tumor (BOT).

MATERIALS AND METHODS

In this retrospective study, records of the patients between November 2001 and December 2012 who underwent surgery and whose final pathological diagnosis were BOT were retrieved.

RESULTS

During the study period, 78 patients were diagnosed as BOT. The patho- logical diagnoses of the tumors were serous in 26 (33.3%) and mucinous in 52 patients (66.6 %), respectively. Accuracy of frozen section diagnosis was observed in 63 of 89 patients (70.7%). Sixty-eight women (87.1%) underwent complete staging procedure. According to final pathological diagnoses, Stage IA, IB, and IC were found in 52 (67%), five (6.5%), and seven (9%) patients, respectively. FIGO Stages IIC and IIIC were found in one case in each (1.25%). Remaining 12 patients were classified as unstaged (15%). The median follow-up time was 63 months. The authors observed only one recurrence (1.3%) and that patient died of disease.

CONCLUSION

The survival rate in patients with BOTs confined to the ovary is excellent. Surgical staging procedure can be omitted in the patients with grossly apparent Stage I mucinous tumors.

Clinical analysis of emergency peripartum hysterectomies in a tertiary center

OBJECTIVE

To investigate the incidence, indications, complications, and risk factors associated with increased mortality and morbidity of emergency peripartum hysterectomy (EPH).

MATERIALS AND METHODS

The authors retrospectively analyzed 48 cases of EPH performed within six-year interval at Ondokuz Mayis University Hospital. EPH was defined as the operation performed for life-threatening hemorrhage which could not be controlled with conservative treatment modalities within 24 hours of a delivery.

RESULTS

The incidence of EPH was 5.03 per 1,000 deliveries. The most common indication for EPH was abnormal placental adherence (n = 22, 45.8%), followed by uter- ine atony (n = 19, 39.6%). All the patients with placenta accreta had a history of repeat cesarian section (CS) and placenta previa.Total hysterectomy was performed in almost all of the patients (n = 47, 97.9%). All women required blood transfusions. Maternal morbidity was significant, with bladder injury (31.3%) and disseminated intravascular coagulation (18.7%) among the most common complications. There were one maternal (2.1%) and five neonatal deaths (10.4%).

CONCLUSION

Since most of the EPH cases are associated with prior cesarean delivery, decision of the first CS should be made for true obstetrical indications.If conservative treatments fail to control massive obstetrical bleeding, blood products and an experienced obstetrician should be ready to perform EPH to decrease the maternal mor- bidity and mortality.

Analyses of atypical glandular cells re-defined by the 2006 Bethesda System: histologic outcomes and clinical implication of follow-up management

BACKGROUND

To evaluate the histopathology and the long-term follow-up outcome of women who had atypical glandular cells on Pap smears.

MATERIALS AND METHODS

All women with atypical glandular cells (AGC) who underwent colposcopic and histopathologic evaluation between January 2005 and October 2010 were reviewed. Patient data were examined up to October 2012, allowing for at least two years of follow-up for all patients.

RESULTS

Forty-four women with AGC Pap test underwent histologic follow-up during the study period. Overall, upon reclassification of smears, 35 (79.5%) cases were diagnosed with AGC "not otherwise specified" (NOS) and nine (20.5%) with AGC "favour neoplasia". Seven out of nine patients (77.7%) with AGC "favour neoplasia" had significant pathology. On the other hand, only 11 out of 35 cases (31.4%) with AGC "NOS" had significant pathology. Significant correlation was found between AGC "favour neoplasia" smears and a significant pathology (p: 0.01). Of the 44 patients, 18 (40.9%) had significant pathology. Eight patients (18.2%) had low grade cervical intraepithelial neoplasia (CIN 1), four (9%) had high-grade cervical intraepithelial neoplasia (CIN 2/3), one (2.2%) had microinvasive squamous cell carcinoma of uterine cervix, one (2.2%) had cervical adenocarcinoma in situ, one (2.2%) had cervical adenocarcinoma, one (2.2%) had endometrial adenocarcinoma, and two (4.5%) had endometrial hyperplasia.

CONCLUSION

Reporting AGC in the population is clinically significant due to the high prevalence of underlying preinvasive and invasive diseases (40.9%). The subtypes of the AGC category are significant predictor of such lesions.

Pyomyoma after dilatation and curettage for missed abortion

Infection of a leiomyoma is a very rare clinical entity called pyomyoma. Pathology may be encountered during the reproductive period, pregnancy, and even postmenopausal period. In this report, we present a case of pyomyoma which developed after dilatation and curettage managed by broad spectrum antibiotics and myomectomy to preserve the fertility in a 31-year-old patient.

Determination of serum CRP, VEGF, Leptin, CK-MB, CA-15-3 and IL-6 levels for malignancy prediction in adnexal masses

OBJECTIVE

Investigation of serum markers which could be used in the malignancy prediction of adnexal masses.

MATERIAL AND METHODS

Vascular endothelial growth factor (VEGF), interleukin 6 (IL-6), leptin, C-reactive protein (CRP), creatine-kinase-MB (CK-MB) and cancer antigen 15-3 (CA 15-3) levels were determined prospectively in serum samples that were obtained from patients who underwent surgery for an adnexal mass and who were referred to Istanbul University, Faculty of Medicine, Department of Obstetrics and Gynecology, between 2009 and 2011, and then were compared with the serum samples of completely healthy outpatient patients as a control group. Based onto the ovarian cancer status, cases were divided into four groups: 13 patients were included in the early-stage malignant group, 12 patients were included in the advanced-stage malignant group, 25 in the benign group and 19 in the healthy control group. Patients with only epithelial ovarian cancer were included into the cancer group. Ethics Commitee approval was obtained for this study. The budget was supported by the Istanbul University Scientific Research Projects Unit.

RESULTS

RESULTS RELATED WITH SENSITIVITY, SPECIFICITY, POSITIVE PREDICTIVE VALUE (PPV), NEGATIVE PREDICTIVE VALUE (NPV) AND ODDS RATIO (OR), RESPECTIVELY, AND THE FOLLOWING VALUES WERE CALCULATED: 48%, 95%, 92%, 59% and +OR 9.6 -OR 0.5 for CA; 15-3; 52%, 75%, 72%, 55%, +OR 2.08 -OR 0.64 for leptin; 72%, 70%, 75%, 66% 2.4-0.5 for IL-6; 24%, 80%, 60%, 45%, 1.2-0.92 for VEGF; 68%, 30%, 55%, 43%, 0.97-1.06 for CRP; and 8%, 70%, 25%, 38%, 026-1.31 for CK-MB.

CONCLUSION

CA 15-3, IL-6, Leptin, VEGF and CRP were effective in the prediction of benign and malignant masses; however they may be more suitable in selected cases as they have a limited use because of their inadequate potential regarding sensitivity and specificity.

Sentinel lymph node biopsy in endometrial cancer: description of the technique and preliminary results

OBJECTIVE

To measure the feasibility of sentinel lymph node technique in endometrial cancer.

MATERIAL AND METHODS

The study was designed as a prospective non-randomized case-control trial. Between 2010-2011, in Istanbul University, Istanbul Medical Faculty, Gynecologic Oncology department, 26 patients who were preoperatively evaluated as endometrial cancer enrolled in the study. Patients' detailed informed consent and ethics committee approval were obtained. Sentinel lymph node (SLN) detection rate was determined as the primary outcome. Sensitivity, specificity, positive and negative predictive values and particularly false negative results were determined as secondary outcomes. As a technique of SLN, injection of methylene blue to the subserosal myometrium of the uterine fundus via 5 cc syringe following peritoneal aspiration cytology procedure was obtained. Surgery was made after injection for an average of 5 minutes due to the physiological spread of the blue dye. Then, the standard protocol of hysterectomy was performed and the retroperitoneum was opened to perform lymphadenectomy. The presence of lymph node regions, and presence of a sentinel node was recorded on the trial record form. Positive staining nodes were sent separately for pathological examination. In the course of the study due to insufficient rate of staining, the technique has been changed to cervical and multiple uterine injections.

RESULTS

As the primary outcome, an SLN positivity rate of 23% in 6 patients with a total of 8 lymph nodes were found. The remarkable finding was that in the first technique, the rate was 1/16 (6%), while the second technique, 5/10 (50%), respectively. The difference is statistically significant (p=0.001). In endometrial cancer stage I and II, secondary outcomes for sensitivity, specificity, positive predictive value, negative predictive value were 23%, 0%, 100%, 43%, respectively. Because there were no metastatic lymph nodes found, false negative rate was 0%.

CONCLUSION

SLN approach is not valuable enough to eliminate the need for lymphadenectomy. On the other hand, it facilitates scanning micrometastases and ultrastaging, while its clinical value has not yet been established. However, according to the recent pilot studies, it provides a means for assessing micrometastases for the medium-risk group for local recurrence.

Sleep quality in fibromyalgia and rheumatoid arthritis: associations with pain, fatigue, depression, and disease activity

OBJECTIVES

The aim of this study was to compare the sleep quality in patients with rheumatoid arthritis (RA) and fibromyalgia syndrome (FMS); and to evaluate the relationship between sleep quality and pain, fatigue, depression, and disease activity in patients with RA and FMS.

METHODS

Forty RA, 40 FMS and 40 healthy controls were enrolled in the study. Disease activity and disease duration were reported in patients. Pain by visual analogue scale (VAS), fatigue by Multidimensional Assesment of Fatigue (MAF), depression by Beck Depression Index (BDI), and sleep quality by Pittsburgh Sleep Quality Index (PSQI) were gathered in all participants.

RESULTS

All participants were aged between 20 and 65 years, with a mean age of 42.97±10.75 years. There was no significant difference with respect to demographic characteristics among the three study groups. Patients reported more depression than controls, but BDI scores were similar in FMS and RA patients. VAS pain scores and MAF scores were significantly different in the three groups (p<0.001). FMS and RA patients had poor sleep quality (p<0.001). FMS patients had daytime dysfunction due to sleep disorder and had worse habitual sleep efficiency than RA patients (p<0.05). In patients, positive correlations were found between PSQI and clinic assessment variables except disease duration.

CONCLUSIONS

FMS and RA may have poor sleep quality when compared to subjects without rheumatologic disorders. The quality of sleep can be impaired by pain, fatigue, depression, and disease activity in such patients.

Frequency of juvenile fibromyalgia syndrome in children with familial Mediterranean fever: effects on depression and quality of life

OBJECTIVES

To determine the prevalence of juvenile fibromyalgia syndrome (JFMS) in children with familial Mediterranean fever (FMF) and to evaluate quality of life (QoL) and depression.

METHODS

Ninety-one FMF patients (M/F: 44/47) who fulfilled the Livneh criteria and 60 healthy children (M/F: 27/33) were enrolled in the study. Yunus and Masi's criteria were used for diagnosis of JFMS. Depression was assessed with Children's Depression Inventory (CDI) and QoL was evaluated with child and parent reports of Paediatric Quality of Life Inventory 4.0 (PedsQL™).

RESULTS

While 20 (21.9%) of 91 FMF patients fulfilled JFMS criteria, 2 (3.3%) of the control group met the diagnostic criteria of JFMS (p=0.002). PedsQL™ scores (child self-report and parent-report) of the FMF patients were significantly lower and the depression scores were significantly higher than the healthy controls (p<0.001 for all). When the FMF patients were assigned to two groups as FMF with or without JFMS, patients with JFMS were found to have a higher depression score (p=0.007) and child and parent reports of PedsQL™ 4.0 were lower in the children with JFMS than in the patients without JFMS (p=0.001, p=0.003, respectively).

CONCLUSIONS

We have determined that JFMS frequency was higher in children with FMF and patients with FMF and JFMS had a poor QoL and were more susceptible to depression. FMF patients with widespread and persistent pain should be evaluated for JFMS in order to avoid unnecessary investigations and inappropriate treatment.

The comparison of ultrasound treatment and local steroid injection plus splinting in the carpal tunnel syndrome: a randomized controlled trial

OBJECTIVES

This study aimed to compare the efficacy of ultrasound treatment to local corticosteroid injection plus splinting in carpal tunnel syndrome (CTS). There is still limited knowledge on the efficacy of conservative treatment options for CTS.

METHODS

Fourty-nine hands of 34 patients with CTS were enrolled in this study. Patients were randomly assigned to the ultrasound treatment (group A) or local corticosteroid injection plus splinting (group B). The primary outcome measures included clinical parameters such as symptoms severity score, visual analogue scale (VAS) pain, functional status score, grip strength and two-point discrimination. The secondary outcome measures were the electrophysiological tests. The examinations were performed at baseline, and then at 4th and 8th weeks.

RESULTS

At the end of the study, a statistically significant improvement was obtained in all clinical parameters in the group B: VAS pain, severity of symptoms, functional status, grip strength (p < 0.001 for each) and two-point discrimination (p < 0.016). Also the group A showed significant improvements in all clinical parameters (p < 0.001 for each), except for the grip strength. Additionally, significant improvements in the median nerve sensory conduction velocity and distal motor latency were also found in both groups at the end of the 8 week follow-up period. There was no significant difference between the groups in the primary and secondary outcome measures, except for the grip strength.

CONCLUSIONS

Both ultrasound treatment and corticosteroid injection plus splinting were effective on the clinical symptoms and the electrophysiological findings of CTS. Thus, the ultrasound therapy may be an alternative treatment for CTS, particularly in patient who do not accept injection or splinting (Tab. 3, Fig. 2, Ref. 36).

A new value of proximal femur geometry to evaluate hip fracture risk: true moment arm

This study was undertaken to determine the influence of proximal femur geometry on hip fracture risk independent of bone mineral density. We examined 34 hip fracture subjects (17 men, 17 women) and 36 control subjects (18 men, 18 women). The control subjects were matched with the hip fracture patients by femoral neck bone mineral density (+ or - 0.100 g/cm(2)). Hip axis length (HAL), femoral axis length (FAL), femoral neck-shaft angle (Theta angle), lateral and medial femoral cortical thickness were measured on standart pelvic radiographs. In the literature, there are conflicting views of the relationship between femur geometry and hip fracture risk which may be explained by different definitions of some parameters. We investigated the effect of a new parameter called true moment arm (TMA) on hip fracture risk. Longer TMA may be correlated to higher transmission of impact energy to the femoral neck. Thus it may be useful to define fracture prone individuals. The results of this study showed that HAL, FAL and TMA were significantly longer in the hip fracture subjects compared to the control group (p<0.001). Hip fracture patients had thinner lateral and medial femoral cortical thickness (p<0.001). Theta angle was wider in the hip fracture group than in the control group (p<0.001). In conclusion, our study showed that evaluation of TMA in addition to HAL, FAL, Theta angle, MCT and LCT can be used to determine of the fracture risk independently of BMD.

Angiotensin II Inhibition Attenuates Postexercise Proteinuria in Rats

An important explanatory theory for the mechanism of postexercise proteinuria is that angiotensin II could be inhibited by angiotensin converting enzyme inhibitors. Because of the kininase effect of the angiotensin converting enzyme, it is unclear whether the kallikrein-kinin system contributes to the effect of angiotensin converting enzyme inhibitors on postexercise proteinuria. The aim of this study was to evaluate any possible involvement of the kallikrein-kinin system in the therapeutic effect of angiotensin converting enzyme inhibitors on postexercise proteinuria. We evaluated urinary protein levels in exhausted rats receiving an angiotensin converting enzyme inhibitor (enalapril) or an angiotensin II type I receptor antagonist (losartan). Enalapril (30 mg/kg/day, two days) or losartan (20 mg/kg/day, two days) were given to animals using an intragastric catheter. Urinary protein levels increased (41 %) in rats which were exhausted via treadmill running (p < 0.05). In animals that received drug treatment (enalapril or losartan), but did not exercise to exhaustion, urinary protein levels were not different from the control group. Urinary protein levels were found to be significantly lower (p < 0.05) in animals which performed acute exhaustive exercise after enalapril or losartan administration, compared to rats which were exhausted without drug administration. Inhibition of postexercise proteinuria by either enalapril or losartan suggested that angiotensin II plays an important role in postexercise proteinuria, however, it appears the kallikrein-kinin system is not involved in angiotensin converting enzyme inhibitors effect.

Impact of obstructive sleep apnoea on left ventricular mass and global function

Obstructive sleep apnoea syndrome (OSAS) might be a cause of heart failure. The present study aimed to assess left ventricular mass and myocardial performance index (MPI) in OSAS patients. A total of 67 subjects without any cardiac or pulmonary disease, referred for evaluation of OSAS, had overnight polysomnography and echocardiography. According to apnoea-hypopnoea index (AHI), subjects were classified into three groups: mild OSAS (AHI: 5-14; n = 16), moderate OSAS (AHI: 15-29; n = 18), and severe OSAS (AHI: > or = 30; n = 33). Thickness of interventricular septum (IVS) and posterior wall (LVPW) were measured by M-mode, along with left ventricular mass (LVM) and LVM index (LVMI). Left ventricular MPI was calculated as (isovolumic contraction time+isovolumic relaxation time)/aortic ejection time by Döppler echocardiography. There were no differences in age or body mass index among the groups, but blood pressures were higher in severe OSAS compared with moderate and mild OSAS. In severe OSAS, thickness of IVS (11.2+/-1.1 mm), LVPW (11.4+/-0.9 mm), LVM (298.8+/-83.1 g) and LVMI (144.7+/-39.8 g x m(-2)) were higher than in moderate OSAS (10.9+/-1.3 mm; 10.8+/-0.9 mm; 287.3+/-74.6 g; 126.5+/-41.2 g x m(-2), respectively) and mild OSAS (9.9+/-0.9 mm; 9.8+/-0.8 mm; 225.6+/-84.3 g; 100.5+/-42.3 g x m(-2), respectively). In severe OSAS, MPI (0.64+/-0.14) was significantly higher than in mild OSAS (0.50+/-0.09), but not significantly higher than moderate OSAS (0.60+/-0.10). In conclusion, severe and moderate obstructive sleep apnoea syndrome patients had higher left ventricular mass and left ventricular mass index, and also left ventricular global dysfunction.

QT interval dispersion in obstructive sleep apnoea syndrome patients without hypertension

QT interval dispersion (QT(d)) reflects inhomogeneity of repolarisation. Delayed cardiac repolarisation leading to the prolongation of the QT interval is a well-characterised precursor of arrhythmias. Obstructive sleep apnoea syndrome (OSAS) can cause cardiovascular complications, such as arrhythmias, myocardial infarction, and systemic and pulmonary hypertension. The aim of this study was to assess QT(d) in OSAS patients without hypertension. A total of 49 subjects without hypertension, diabetes mellitus, any cardiac or pulmonary diseases, or any hormonal, hepatic, renal or electrolyte disorders were referred for evaluation of OSAS. An overnight polysomnography and a standard 12-lead ECG were performed in each subject. According to the apnoea-hypopnoea index (AHI), subjects were divided into control subjects (AHI <5, n = 20) and moderate-severe OSAS patients (AHI > or =15, n = 29). QT(d) (defined as the difference between the maximum and minimum QT interval) and QT-corrected interval dispersion (QT(cd)) were calculated using Bazzet's formula. In conclusion, the QT(cd) was significantly higher in OSAS patients (56.1+/-9.3 ms) than in controls (36.3+/-4.5 ms). A strong positive correlation was shown between QT(cd) and AHI. In addition, a significantly positive correlation was shown between QT(cd) and the desaturation index (DI). The AHI and DI were significantly related to QT(cd) as an independent variable using stepwise regression analysis. The QT-corrected interval dispersion is increased in obstructive sleep apnoea syndrome patients without hypertension, and it may reflect obstructive sleep apnoea syndrome severity.

Pulmonary abscess due to leflunomide use in rheumatoid arthritis: a case report

A 43-year-old woman had rheumatoid arthritis (RA) for 5 years and complained of fever, arthralgia/myalgia, and night sweating for a month. She had been receiving only leflunomide (20 mg/day) for 5 months. On admission, there was no evidence of active arthritis or vasculitic lesion. Laboratory evaluation showed an erythrocyte sedimentation rate of 145 mm/h and C-reactive protein of 160 mg/dl. All cultures were negative. Chest radiograph and computed tomography (CT) revealed a pulmonary abscess. Staphylococcus aureus multiplied in the culture of a purulent sample obtained from the abscess under ultrasonography. The leflunomide was stopped, and sultamicillin (IV 4x2 g/day) was started for a further 6 weeks. Four weeks later, the patient had completely recovered and CT showed significant improvement of the pulmonary abscess. Ten milligrams/day of prednisolone and 7.5 mg/week of methotrexate were started for RA treatment. The patient has been under control for 5 months without any further abscess or RA activation.

Pulmonary involvement in rheumatoid arthritis

The primary objective of this investigation was to assess the relationships between clinical characteristics, lung involvement, and frequency of pulmonary involvement in rheumatoid arthritis (RA). Using high-resolution computed tomography (HRCT) and pulmonary function tests (PFT), we prospectively evaluated 52 patients with RA (eight males and 44 females, mean age 53.6 years). The HRCT was abnormal in 35 patients (67.3%), the most frequent abnormalities being reticulonodular patterns, which were found in 22 patients (62.9%), ground-glass attenuation (20%), and bronchiectasis (17%). In this group of patients, PFT results were normal in 13 patients (37%). Titers of rheumatoid factor and erythrocyte sedimentation rate were significantly higher in abnormal HRCT presence. Higher Larsen's score, advanced age, and severe disease were significant risk factors for lung involvement (p<0.001, p<0.01, and p<0.01, respectively) and are suggested by our data to be statistically significant predictors of lung involvement in RA.

The effect of one year's swimming exercise on oxidant stress and antioxidant capacity in aged rats

The effect of exercise on oxidant stress and on alterations in antioxidant defense in elderly has been investigated extensively. However, the impact of regularly performed long-term physical activity starting from adulthood and prolonged up to the old age is not yet clear. We have investigated the changes in the activities of antioxidant enzymes - superoxide dismutase (SOD), catalase (CAT) and glutathione peroxidase (GPx) - and lipid peroxidation in various tissues of rats which had performed (old-trained) or had not performed (old-control) regular swimming exercise for one year. These animals were compared with young-sedentary rats. Increased lipid peroxidation was observed with ageing in all tissues (heart, liver, kidney, striated muscle) and swimming had no additional effect on this elevation of lipid peroxidation. Heart and striated muscle SOD activites, and striated muscle CAT activity increased as a consequence of ageing, whereas kidney and liver CAT activities, as well as GPx activities in kidney, liver, lung and heart were significantly decreased compared to young controls. Lung and heart SOD, liver CAT activities as well as GPx activities in liver, lung and heart were increased significantly in rats which performed exercise during ageing, compared to the old-control group. These findings suggest that lifelong exercise can improve the antioxidant defense in many tissues without constituting any additional oxidant stress.

The effect of one year swimming exercise on oxidant stress and antioxidant capacity in aged rats

The effect of exercise on oxidant stress and on alterations in antioxidant defense in elderly has been investigated extensively. However, the impact of regularly performed long-term physical activity starting from adulthood and prolonged up to the old age is not yet clear. We have investigated the changes in the activities of antioxidant enzymes - superoxide dismutase (SOD), catalase (CAT) and glutathione peroxidase (GPx) - and lipid peroxidation in various tissues of rats which had performed (old-trained) or had not performed (old-control) regular swimming exercise for one year. These animals were compared with young-sedentary rats. Increased lipid peroxidation was observed with ageing in all tissues (heart, liver, kidney, striated muscle) and swimming had no additional effect on this elevation of lipid peroxidation. Heart and striated muscle SOD activites, and striated muscle CAT activity increased as a consequence of ageing, whereas kidney and liver CAT activities, as well as GPx activities in kidney, liver, lung and heart were significantly decreased compared to young controls. Lung and heart SOD, liver CAT activities as well as GPx activities in liver, lung and heart were increased significantly in rats which performed exercise during ageing, compared to the old-control group. These findings suggest that lifelong exercise can improve the antioxidant defense in many tissues without constituting any additional oxidant stress.