Muscle-strengthening activity (MSA) has beneficial effects on hypertension, glucose homeostasis, and other health conditions; however, its association with mortality is not as well understood.We analyzed data from the Cancer Prevention Study-II Nutrition Cohort (data collection 1982–2014), a prospective US cohort that consisted of 72,462 men and women who were free of major chronic diseases; 18,034 of the cohort died during 13 years of follow-up (2001–2014). We used Cox proportional hazards modeling, controlling for various potential confounding factors, to calculate hazard ratios (HRs) and 95% confidence intervals (CIs) for MSA  in relation to mortality risk, independent of and in combination with aerobic physical activity.P value, <.001). After multivariable adjustment and comparison with no MSA, engaging in less than 2 hours per week of MSA was associated with lowered all-cause mortality , but engaging in 2 or more hours per week was not associated with reduced risk . Associations were similar but not significant for cancer mortality. Engaging in >0 to <1 hr/wk of MSA was associated with a 19% lower risk  of cardiovascular disease mortality, but more time spent in MSA was not associated with reduced risk . Associations did not vary by amount of moderate-to-vigorous aerobic physical activity.The association between MSA and mortality appeared to be nonlinear (quadratic trend Engaging in ≥2 hours per week of MSA was associated with lower all-cause mortality, independent of aerobic activity. Reasons for the lack of association with higher amounts of MSA are unclear. Our findings support recommending muscle-strengthening activities for overall health. Physical activity guidelines recommend muscle-strengthening activity (MSA) at least twice a week in addition to 150 to 300 minutes per week of moderate-to-vigorous aerobic physical activity. These activities are associated with lowered risk of various cardiovascular disease risk factors and other health outcomes.Our study documented an association between moderate amounts of muscle-strengthening activities and mortality risk in a large prospective cohort of older US adults.These results provide additional evidence of the health benefits of MSA and reinforce the value of public health messaging promoting MSA as part of physical activity guidelines.Public health guidelines state that adults should engage in 150 to 300 minutes of moderate-intensity aerobic physical activity or 75 to 150 minutes of vigorous-intensity activity per week and muscle-strengthening activity (MSA) at least twice a week ,5.A recent pooled analysis of 11 cohort studies that included a total of 80,306 adults aged 30 or older with 5,763 deaths found that participation in any MSA was associated with a 23% reduction in risk of all-cause mortality  . In thatBetter understanding is needed of the relationship between MSA and risk of death from all causes, cardiovascular disease, or cancer, independent of and in combination with MVPA, to inform public health messaging related to physical activity. Furthermore, because the US population of older adults ≥65) is expected to dramatically increase in the next 10 to 20 years 5 is expe. We used2), MVPA, MSA, or smoking status; had a date of death that preceded the date of the survey return; or self-reported poor health , a prospective study of cancer incidence and mortality established by the American Cancer Society in 1992 . Cohort r health . After eCPS-IINC assesses MSA and MVPA with the question, “During the past year, what was the average time per week you spent at the following kinds of activities: walking, jogging/running, lap swimming, tennis or racquetball, bicycling or stationary biking, aerobics/calisthenics, dancing, [or] weight training/resistance exercises?” Responses regarding each activity were none, 1 to 19 minutes, 20 to 59 minutes, 1 hour, 1 to 1.5 hours, 2 to 3 hours, 4 to 6 hours, 7 to 10 hours, or ≥11 hours. MSA was categorized as none, >0 to <1 hours/week, 1 to <2 hours/week, and ≥2 hours/week of weight training or resistance exercise. Summary MVPA metabolic equivalents of task (MET) hours per week were calculated by multiplying the midpoint of each aerobic activity category by the general MET value of each activity .Biennial automated linkage of the entire cohort with the National Death Index is used to ascertain deaths in CPS-IINC. For this analysis, deaths were classified by using the Tenth Edition of the International Classification of Disease (ICD-10)  for deatP value was calculated from the Wald χ2 statistic. All tests for significance were 2-sided, and P < .05 was considered significant. We used R version 3.5.2 to conduct all analyses  controlled for for sex  and age (continuous single year), 2) additionally adjusted for other potential confounders including BMI, race, marital status, education, self-reported overall health, aspirin use, smoking status , alcohol intake, sitting time while watching television, mobility limitations, and comorbidities , and 3) all covariates in model 2 with additional adjustment for MVPA. We considered additional potential confounders, such as measures of diet quality. Those that did not result in any change in risk estimates were not included in the final multivariable models. All covariate data were ascertained at baseline at the same time as MSA. Linear and quadratic trends were tested by using the median value of each MSA category, and the quadratic trend analyses .We conducted several sensitivity analyses. First,we exmained associations restricted to lifelong nonsmokers to rule out the possibility of residual confounding by smoking. Second, we performed analyses restricted to participants who reported no major physical limitations to account for inactive participants who may have been unable to engage in activity and may also have been at higher risk of mortality, because this would lead to bias away from the null. Lastly, although we excluded participants with a history of major chronic conditions, inactive participants possibly had other underlying conditions. Thus, we excluded those who died within the first 2 years of follow-up to minimize possible reverse causation. We examined associations stratified by sex, age, BMI, history of high blood pressure, and MVPA. We used interaction terms between MSA and follow-up time to test the Cox proportional hazards assumption and observed no violations.During 13 years of follow-up, 17,750 participants (25% of the cohort) died. At baseline, most participants (79.8% of men and 84.6% of women) reported no MSA, and 5.6% of men and 7.9% of women reported no MVPA. Compared with participants who engaged in MSA, participants who did not engage in any MSA were slightly older, had a higher BMI, were less likely to engage in MVPA, and were more likely to have a higher comorbidity score, some physical limitations, and be nonsmokers and nondrinkers .P value, <.001). Associations were similar, albeit not significant, for cancer mortality. Engaging in >0 to <1 hr/wk of MSA was associated with 19% lower risk  of cardiovascular disease mortality, but greater time spent in MSA was not .Associations between MSA and mortality appeared to be nonlinear, and additionally adjusting for MVPA in multivariable models did not appreciably change any risk estimates . After aP =.79). We found no evidence of effect modification by sex, age, BMI, or history of hypertension. Sensitivity analyses restricted to lifelong nonsmokers or to participants with no physical limitations or after excluding the first 2 years of follow-up were also virtually unchanged from those in the main analyses.We observed a mortality benefit with moderate amounts of MSA (>0 to <2 hr/wk) across all levels of MVPA . In contrast, the only meta-analysis to date . Other limitations were the lack of information on types and intensities of MSA, lack of information on past or long-term engagement in MSA, the use of self-reported physical activity information, and the relatively low percentage of participants engaging in any MSA. Lastly, an additional limitation of our study was the lack of information on occupational physical activity. However, given the older age of the population, most participants were retired, and past employment was largely sedentary occupations or homemaking. Previous studies lacked broad consistency in how MSA was queried, which limits the ability to interpret results across studies. For example, previous studies varied in timeframe of exposure assessment (ranging from the previous 4 weeks to the past year), in the level of detail on intensity, and in categories of duration of exposure .Engaging in moderate amounts of MSA is associated with lower all-cause mortality, independent of MVPA. Overall, 23.2% of US adults report engaging in MSA at least twice a week, and this percentage drops to 16.4% for adults aged 65 to 74 and 10.2% for older adults ; thus, i


Autoimmune bullous diseases, if left untreated, are life-threatening conditions affecting primarily skin and mucous membranes. These blistering disorders are characterized by epidermal or subepidermal detachment. Autoimmunity plays a key role in pathogenesis; therefore, immunosuppressive agents are the treatment of choice. The aim of this study is to document relative frequencies of different autoimmune bullous diseases, patient characteristics, treatment options, and side effects in patients presenting to our bullous skin disease center at İstanbul University, Cerrahpaşa, Cerrahpaşa Medical Faculty.Medical files were examined retrospectively for all patients with autoimmune bullous diseases who were followed up between 2003 and 2019 at the Bullous Skin Disease Center at İstanbul University, Cerrahpaşa.A total of 346 patient files were examined. Pemphigus vulgaris was the most frequent autoimmune bullous disease, followed by bullous pemphigoid and pemphigus foliaceus, according to our study. There is a general female predominancy for all autoimmune bullous diseases. The most commonly preferred treatment options were high-dose daily corticosteroids.This retrospective study summarizes the patient characteristics, comorbidities, treatment choices, and side effects during 16 years of clinical practice. Autoimmune bullous diseases (AIBDs) are rare but potentially devastating disorders of the skin and mucous membranes, characterized by the presence of tissue-bound and circulating antibodies directed against disease-specific target antigens. Based on the level of blister formation, these diseases can be divided into 2 groups: intraepidermal immunobullous diseases, also referred to as the pemphigus group, and subepidermal immunobullous disorders. The pemphigus group comprises pemphigus vulgaris (PV) and its variant pemphigus vegetans, superficial pemphigus (pemphigus foliaceus (PF) and pemphigus erythematosus (PE)), paraneoplastic pemphigus (PNP), and IgA pemphigus. The incidence of pemphigus ranges from 0.5 to 16.2/1,000,000 per year [1–5]. The subepidermal immunobullous disorders group includes pemphigoid diseases (bullous pemphigoid (BP), mucous membrane/cicatricial pemphigoid (MMP/CP), pemphigoid gestationis (PG), linear IgA disease (LAD), and lichen planus pemphigoides (LPP)), epidermolysis bullosa acquisita (EBA), dermatitis herpetiformis (DH), and bullous systemic lupus erythematosus (BSLE). The incidence of BP has been estimated between 2 and 42.8/1,000,000 per year . PV is frequently observed in Turkey, as in other countries of the Mediterranean region. However, there has not yet been any study of the relative frequencies and demographic features of different AIBDs in Turkey. Notably, the relative frequencies of subepidermal immunobullous disorders versus those of diseases in the pemphigus group are unknown. Our aim is to define the spectrum of AIBDs seen at the Center for Bullous Diseases in the Cerrahpaşa Medical Faculty, one of the major tertiary referral centers for AIBDs in Turkey, over a 16-year period.A retrospective analysis was performed at the Bullous Disorders Center in the Department of Dermatology and Venereology, University Hospital of Cerrahpaşa Medical Faculty in İstanbul, which is one of the major tertiary care follow-up and referral centers for patients with bullous diseases in Turkey. Although there is no systematic referral system or central registry for AIBDs in Turkey, this hospital is one of the most preferred tertiary referral centers, both in terms of public and private hospitals. All medical files of newly diagnosed patients with AIBDs were retrospectively recruited and analyzed for a period of 16 years between 2003 and 2019. Diagnoses were based on clinical findings, histopathology of affected skin or mucosa, direct immunofluorescence (DIF) microscopy of perilesional mucous membrane or skin biopsies, indirect immunofluorescence (IIF) microscopy on monkey esophagus, and enzyme-linked immunosorbent assay (ELISA) for anti-desmoglein 1 and 3 antibodies. Patient inclusion criteria for the retrospective analysis comprised a diagnosis of AIBD confirmed by histopathological and direct immunofluorescence (DIF) examinations of tissue samples, in addition to clinical findings. Thus, histopathological examination and direct and indirect immunofluorescence examination were performed for all the patients included in this study. Detailed reviews of the patients’ clinical histories, other autoimmune diseases, and comorbidities of patients and their relatives, in addition with data about age, sex, age at onset of the disease, and duration of the disease were recorded. Clinical status at the onset such as mucosal and/or cutaneous involvements was evaluated. Histopathological examination, direct and indirect immunofluorescence test results, ELISA testing of antidesmoglein (anti-Dsg) 1 and 3 antibodies for the pemphigus group, local and systemic treatment modalities, relapses and remissions, side effects, and reported deaths during the follow-up period were also recorded.Between 2003–2019, 346 new cases of AIBDs, 151 men and 195 women (an average of 23 new cases per year), were analyzed in this study. The average annual age-adjusted AIBD incidence rate for our center was 0.307 per million in the population for both sexes. The mean age was 54.4, and mean duration of the disease was 85.6 months. Only 5 of all of these patients had a family history. The most common diagnoses were PV, BP, and PF, respectively , all of which seem to have occurred more commonly in females. Other rare diagnoses included hereditary epidermolysis bullosa, pemphigoid gestationis, Hailey–Hailey disease, dermatitis herpetiformis, subcorneal pustular dermatosis, LPP, and Grover’s disease. Table 1 summarizes the epidemiological and clinical characteristics of all AIBDs. The mean follow-up period for PV patients was 79.9 months, whereas for PF it was 82.8 months and for BP the total was 75.4 months. The most commonly used treatment options were high-dose corticosteroids and immunosuppressives such as azathioprine, mycophenolate mofetil, or sodium. Plasmapheresis, methotrexate, cyclosporine, dapsone, and colchicine in the case of acquired epidermolysis bullosa were less preferred options. Intravenous immunoglobulin, rituximab and pulse steroid therapy were commonly used in recalcitrant cases. For AIBDs, a high-dose daily systemic steroid was the most preferred treatment, with azathioprine being the most common adjuvant, as summarized, together with other treatment options, in Table 2. It is important to note that the most common adverse events such as osteoporosis, aseptic bone necrosis and compression fractures, myopathy, and cataracts are related to high-dose and long-term use of systemic corticosteroids. Other rare side effects include depression, diabetes, hypertension, neuropathy, pancytopenia, glaucoma, hepatotoxicity, pneumonia, and steroid acnes. To the best of our knowledge, a total of 8 deaths were declared during the follow-up period of these patients; however, there may have also been some underreporting. Three of the patients died due to bronchopneumonia, 3 from cardiopulmonary arrest, and the exact cause of death for the remaining 2 patients remains unknown. Two hundred and forty-two patients were diagnosed as PV . Only one of them had a family history. The female to male ratio was 1.4  and the mean age was 51.4 years. The mean duration of the disease was 77.9 months. Table 3 summarizes the comorbidities of PV patients, together with other AIBDs. Approximately 12% of all PV patients (30 patients) presented with only cutaneous lesions, and 32% (77 patients) of them with only mucosal lesions, while remaining 135 patients (56%) had both cutaneous and mucosal involvements. In addition to systemic treatment modalities, all PV patients received local treatment, including topical antimicrobials and local corticosteroid ointments. All patients with mucosal involvement were also given intralesional triamcinolone acetonide (20 mg/mL) injections. All PV patients were started on high-dose systemic corticosteroids immediately after diagnosis. The mean initial systemic steroid dosage was 100 mg/day of methylprednisolone or the equivalent, which gradually tapered to maintenance levels in a few months to years, according to the clinical course and prognosis of each and every patient. Azathioprine was the most commonly used adjuvant, with a mean daily dosage of 150 mg. Mycophenolate mofetil (2000 mg/day) or mycophenolate sodium (1440 mg/day) were the second-line adjuvants and were preferred in patients who could not tolerate azathioprine or had a long-term history of azathioprine use. Pulse steroid therapy was given intravenously in divided doses for 3 consecutive days (1000 mg methylprednisolone per day). It was preferred in only 48 patients during this 16-year period in case of frequent relapses or to avoid side effects of long-term systemic steroids. Beside physical examination of all skin and mucosal membranes, follow-up examinations every 3 months included indirect immunofluorescence titer and antidesmoglein 1 and 3 antibody levels. Complete blood count, fasting blood glucose level, and liver and kidney function tests are also routinely done for detecting possible adverse events related to treatment. Annual bone mineral density measurements were also performed. Approximately 41% of all our patients had at least one relapse during their long-term follow-ups. The most common treatment-related adverse events are shown in Table 4. Throughout the follow-up period, 3 deaths were reported. IVIg was used at a monthly dose of 2 g/kg, which was divided equally over 5 consecutive days for 3 to 9 months for refractory PV, alone or in combination with rituximab. Anti-CD20 monoclonal antibody rituximab was administered as 1000-mg intravenous infusions, 2 weeks apart. In our clinic, 59 patients used IVIg and/or rituximab, 55 of which had PV and 4 had PF. Fourteen patients used rituximab alone, while 13 patients used IVIg alone, and the remaining 32 patients used both agents in combination. In the ‘only IVIg’ group, 10 out of 13 patients had clearance of disease with no recurrence after a mean treatment duration of 4.3 months. Two patients were able to recover with IVIg , but they had recurrences 3 years after the treatment period, while the other patient still had ongoing disease reoccurrence in spite of 6 treatment courses of IVIg administration. In the ‘only rituximab’ group, 13 out of 14 patients had no recurrence after 1 or 2 administrations . One patient was lost to follow-up. Out of 32 patients who were using combined therapy, 26 had no recurrences after a mean duration of 4.2 months. Three patients had only IVIg treatment for 6 months with limited response and, after the combination with rituximab, they healed completely. Two patients had reoccurring symptoms after 1 year of 3 IVIg and one rituximab course, but later on they responded well to the same treatment regimen. The remaining patient had refractory disease even after 6 courses of IVIg and one course of rituximab treatment. It is important to note that 1 patient had an episode of deep venous thrombosis during the 3rd session of IVIg infusions, which led to the discontinuation of the therapy.BP was the 2nd most frequent AIBD in our study, with 45 patients (13%). Among these patients, 35 had only cutaneous lesions, one of them had only mucosal lesions, while the remaining 9 patients had both. None of them had a family history. The female to male ratio was 1.25 , and the mean age of and mean duration of the disease were 75.6 years and 75.4 months, respectively. It is important to note that BP patients were significantly older than PV patients (mean age: 75.6 years vs. 51.4 years) with more comorbidity, as shown in Table 3. All patients received topical treatment as a first-line therapy. Lower systemic steroid doses (about 0.5 mg/kg/day) are preferred when compared to PV, with a mean initial dose of 55.4 mg/day of methylprednisolone; tapering to maintenance levels was done more rapidly. One patient was given due to long-term side effects of corticosteroids. Azathioprine (N: 10), dapsone (N: 6), pulse steroid therapy (N: 1), and methotrexate (N: 1) were adjuvants used for refractory cases. The main treatment-related side effects in this patient group are summarized in Table 4. Throughout the follow-up period, 6 recurrences and 5 deaths were reported. PF was the 3rd most frequent AIBD, with 23 patients. None of them had a family history. The female to male ratio was 1.09 , the mean age was 49.4, and the mean duration of the disease was 84 months. All of the patients had only cutaneous involvement, as expected. Two patients were treated with only topical corticosteroids, due to limited disease, and the remaining 21 patients were given high-dose systemic steroids, together with azathioprine. Two of them were switched to mycophenolate sodium and 3 to mycophenolate mofetil due to side effects. Three patients received IVIg, 1 patient received rituximab, another was given both, and 4 patients received pulse steroids, due to resistant disease, with successful results. Ten patients had recurrent attacks during the course of the disease. One patient was diagnosed with benign familial pemphigus and treated with topical agents. Four patients  with mucous membrane pemphigoid were also treated as PV. Thirteen patients were diagnosed as having linear IgA disease. Only one of them had mucosal involvement, while the remainder had cutaneous lesions. Only one patient had a family history of the disease. The mean age of the patients was 44.5 years. One patient had ulcerative colitis, which is the most common disorder associated with linear IgA bullous dermatosis. Seven patients were given a combination of dapsone (50–100 mg/day) and systemic steroids, 3 patients used azathioprine, 1 patient was treated with colchicine, and 1 patient with rituximab. Of 8 epidermolysis bullosa patients, 5 received systemic corticosteroids, 1 was given dapsone, 1 received colchicine, and 1 recalcitrant case was treated with IVIg. AIBDs are a group of rare and potentially lethal disorders characterized by the onset of vesiculobullous lesions on the skin or mucous membranes, alteration of cutaneous or mucous membrane components, and presence of pathogenic autoantibodies targeting structural proteins of the desmosomes and the dermal-epidermal junction. Most cases of AIBD occur sporadically, without evidence of geographic or familial clustering. Little is known about the epidemiology of AIBD in Turkey. Epidemiologic surveys encompassing the whole spectrum of AIBDs, not a single disease or a group of diseases, are also limited in other countries. This is the first study on the entire group of AIBDs in Turkey, based on strict diagnostic criteria, including clinical, histological, and immunohistological evaluation. The large number of patients and long observation period, coupled with the epidemiological and clinicopathological aspects, treatment modalities, and side-effect profiles, are the main assets of this study. On the other hand, the incidence of BP and DH could have been underestimated due to their atypical and mild clinical presentation in some individuals. There is an overall female predominance in AIBDs, and this female predominance also applied to individual diseases, except IgA pemphigus, LAD, and EBA, which involved only a few patients [8]. PV is characterized by autoantibodies working against intercellular adhesion molecules: Dsg3 or both Dsg 1 and 3, resulting in suprabasal acantholytic blisters. Our present observation confirms the data in previous studies and adds further support to the earlier notion that the clinical phenotype of pemphigus correlates with the anti-Dsg autoantibody profile. As expected, PV was the most common type of AIBD in our study, representing 70% of all cases. This finding is in line with reports from other Mediterranean, Middle Eastern, and East Asian countries such as Kuwait [6], Iran [8], China [9], Malaysia [10], and also from other studies from Turkey [11] but contrasts with reports from countries such as Switzerland, Germany, the UK, and Singapore, where SABDs, notably BP, predominated . Compared with epidemiologic surveys in different regions of the world, the incidence of PV in İstanbul is very similar to that of neighboring countries such as Macedonia [2], Romania [3], Bulgaria [14], and Kuwait [6]. While the incidence is higher than in Western European countries such as Switzerland and the United Kingdom , it is lower than the rate in Iran , Tunisia [17], Greece [19], as well as rates found in Jewish individuals in the US [20]. The incidence of PV has been estimated to be 0.76, 0.77, and 1.7 in terms of new cases per million people per year in Finland, Germany, and France, respectively . In contrast, in countries around the Mediterranean sea, the reported incidence is significantly higher, with 6, 6.7, and 8 new cases per million people per year in Eastern Sicily, Tunisia, and Northern Greece, respectively . In a study from Germany, the age-adjusted incidence of PV was 9-fold higher in patients with a migration background, compared with native Germans, emphasizing the geographical and thus genetic background of the disease [22]. Of all the pemphigus group patients, PV was the most common subgroup in our study, with a 90% incidence rate . Our findings on PV being the most frequent type are also compatible with the rates of most other countries such as India [23], South Korea [24], Bangladesh [25], Saudi Arabia [26], Kuwait [6], Iran [27] Israel [28], South Africa [29], Bulgaria [14], Serbia, Montenegro [30], Macedonia [2], Croatia [31], Greece [32], Italy [33], Germany [12], Spain [34], and France [17]. This was also true for the UK, Switzerland, and Singapore . On the other hand, there are some notable, exceptional regions such as Tunisia [17], Mali [35], South Africa [29], Brazil, and other Latin American countries  where fogo selvagem, an endemic form of PF predominated. In Finland [16], PE was the most common type of pemphigus and, in Morocco [38], equal frequencies of superficial and deep forms of pemphigus were observed. The mean age of 51.4 years old for PV patients in this report, as well as those in previous studies, is relatively low compared to mean ages reported in South Korea [24], Japan [39], and in most European countries where the disease is reported to present in the 6th and 7th decades of life. According to a study conducted in Serbia, when age-specific incidence rates are calculated, the incidence of PV among women (compared to men) remains higher until the age of 80 years or older, after which the incidence for men becomes slightly higher [40]. Our results of mean age are close to the reports from Iran [27], Saudi Arabia [26], South Africa [29], Singapore [41], and other studies conducted in Turkey [11]. However, the mean age of PV patients was lower than in our study group in Kuwait and India, with a presentation usually in the 4th decade of life . In the present study, the number of women with PV outnumbered that of men ; which concurs with data from most previous studies worldwide, except for countries with a male predominance such as Saudi Arabia [26], Kuwait [6], Bangladesh [25], and China [9]. In this study, common comorbidities were hypertension, diabetes, hyperlipidemia, and osteoporosis, observed in 7%, 4%, 2.5%, and 2,5% of the patients, respectively. Frequent comorbidities for this patient population are cardiovascular diseases, concomitant malignancies, diabetes, and neurological disease, according to various studies [1]. High-quality controlled prospective clinical trials for the treatment of autoimmune blistering diseases are rare; therefore, treatment decisions are mainly guided by published reviews in this field or from personal experiences. In our clinical practice, all of the patients with PV were started on high-dose systemic steroids (1–1.5 mg/kg/day of methylprednisolone), together with at least one immunomodulatory adjuvant, most commonly azathioprine or mycophenolate, in order to minimize the adverse effects of steroid therapy. Pulse steroid therapy, rituximab, and IVIg are treatments of choice in case of relapse. Our mean initial systemic steroid dose in this study was 100 mg/day of methylprednisolone. However, especially in Western countries, treatment approaches are less aggressive, with lower doses of systemic steroids for shorter periods and occasionally with adjuvants [1]. This is probably due to the milder course of disease in these populations. In our patient group, 20% had at least 3 infusions of pulse steroid therapy, 11% used either rituximab or IVIg, and 13% used these 2 agents in combination. In total, almost half of our PV patients (44%) experienced relapses despite conventional steroids, in addition to adjuvant agents and required advanced treatment approaches for their recalcitrant disease. During the clinical course of PV, relapses are frequent and inevitable [42]. Almost half of the patient population (N: 100) had recurrent attacks. However, the rates of recurrence were significantly lower in the IVIg and rituximab groups , similar to the literature [43]. It is important to consider the acute and chronic side effects of high-dose steroid infusions such as hypertension, hyperglycemia, fluid and electrolyte imbalances, sleep disturbances, mood alteration, and psychosis. Avascular necrosis of the hip, cardiac arrhythmias, cardiac arrest, and sudden death are rare but notable.In the case of PF, autoantibodies against desmoglein 1 result in superficial subcorneal blisters without mucosal involvement. PF was the 3rd most common AIBD, occurring at a frequency of 6.6%. It has been reported less frequently than PV worldwide, except in endemic areas of the world such as Brazil, North Africa, Tunisia, and Algeria [44]. A study [17] comparing the rate of incidence of PV in France and Tunisia showed a higher incidence rate in the former (6.7 vs. 1.7 new cases per million people per year), especially for PF occurring in young women. This is possibly related to exposure to risk factors that are either more prevalent in or more often expressed among young women living in particular areas of Tunisia. Another prospective study [45] found a significant association of PV occurring in young women from traditional Tunisian backgrounds who came into contact with ruminants, cut and handled raw poultry, had Turkish baths, or used cosmetics. The mean age and sex ratio of PF were close to those of PV in our study. (49.4 vs. 54.4)This ailment is characterized by autoantibodies against hemidesmosomes at dermoepidermal junction, and it presents with subepithelial blisters and, sometimes, urticarial plaques. In the present study, BP ranked 2nd in frequency among AIBDs, although it was much less common than PV (13% vs. 70%). The ratio of BP to PV has been reported to be 1:5.4, which is similar to ratios found in Singapore (3:1) and in a previous study conducted in Turkey (1:5.1) . Unlike Turkey and other Eastern countries such as Kuwait, China, Iran, and Malaysia, this ratio is completely different in Europe . Subepidermal AIBDs represent about 60% to 70% of all AIBD cases in Germany and France, with an incidence rate of 13.4 and 10.4 cases per year and per million inhabitants, respectively . Similar results were also observed in Switzerland and the UK . Compared to epidemiologic surveys in different parts of the world, the incidence of BP in Turkey is higher than that of neighboring Romania and Kuwait [6]. By contrast to the various studies mentioned above, the incidence of BP in different countries shows an opposite pattern, with 3–20 times higher values in Western European and Asian countries such as Germany, Italy, Switzerland, Scotland, Finland, Poland, the USA, Singapore, France, and the United Kingdom, where the incidence of BP is the highest (42.8 pmp/year) . According to a very recent study, Serbia is the only country with similar average crude and age-adjusted incidence rates for both PV and BP [40]. The incidence rate of BP, especially in Western countries, progressively and significantly increases with age, particularly after the age of 70, with a peak after 90 years old [40]. The incidence rate appears to be higher in women until the age of 70 but, thereafter, the incidence is higher in men [1]. The mean age of presentation for BP in our study was 75.6 years old, which is significantly higher than PV, as expected. The lower incidence of BP and lower mean age of affected patients may reflect the paucity of the elderly population in less industrialized countries. Nevertheless, the possibility that different genetic or environmental factors may play some role in the disease profile cannot be ruled out. It must be noted that in most of these studies, only absolute numbers of patients were reported and not sex-specific incidence rates. In the present study, the highest incidence rates of pemphigoid for both sexes were registered in age groups 70–79 years old and particularly in individuals 80 years or older, which is in accordance with the literature. In our study, women were affected 1.25 times more often than men, which corresponds to results from other countries, except for Kuwait, which showed an even more pronounced female predominance (up to 6 times). Female predominance has been reported worldwide for BP, except in China and Germany . Male predominance was also reported in the elderly population after adjusting for sex in another recent study from Germany [12]. The most frequently observed comorbidities in BP patients in our study were hypertension and diabetes mellitus, followed by Alzheimer’s disease at 29%, 13%, and 7% respectively, similar to other studies [55]. According to a study conducted in the United States, cardiovascular diseases were the most frequently associated health problem, affecting more than half of patients. Neurological diseases, malignancies, atopic diseases, chronic kidney failure, and diabetes were also common, similar to our cohort [56]. There are many studies in the literature establishing an association between BP and a higher prevalence of neurological disorders, namely dementia and cerebral stroke, when compared with the general population. In France, 36% of BP patients were diagnosed with at least 1 neurological disorder, namely dementia, in 20% of BP patients [57]. However, lacking a control population, it was not possible for this study to confirm or reject the association of BP with neurological diseases, especially with the cases of Parkinson’s disease, dementia, and multiple sclerosis reported in previous studies . Chuang et al reported an association between BP and diabetes, showing 20% diabetic BP patients versus 2.5% diabetic controls (P = 0.004). This was supported by other studies. It has been proposed that an autoimmune response occurs after exposure to BP antigens by glycation of proteins of the dermoepidermal junction [60]. Considering the overall, advanced age of this population, the observed association between both cardiovascular and neurological diseases is not surprising. Notably, of the patients with BP, 71% were treated with systemic steroids only, and the mean initial corticosteroid dose required to control the disease symptoms was relatively lower than in the PV group (60 mg/day vs. 100 mg/day of methylprednisolone). The steroid dose was also tapered more quickly. In 17 cases (38%), systemic immunosuppressive drugs such as azathioprine, dapsone, and methotrexate were used as adjuvants. The main side effects observed during therapy were steroid-related, like osteoporosis and myopathy. MMP represented 0.86% of ABDs. This percentage may also reflect an underestimation of the incidence of this disease because many patients are diagnosed and seen by dentists and ophthalmologists.EBA, in the group of mechanobullous disorders, was diagnosed in 2.02% of patients by DIF on salt-split skin. It was predominantly seen in men, as it was in Germany, Singapore, and China . Thirteen patients (3.7%) were diagnosed as LAD. This finding may also reflect an underestimation, as we suppose that a significant proportion of such patients may have been diagnosed by pediatricians. Only 1 patient had a mucosal involvement, while the remainder had cutaneous lesions. Actually, this outcome is not compatible with studies found in the literature that say mucosal involvement occurs in up to 80% of patients [40]. One patient had accompanying ulcerative colitis, which is the most common disease associated with LAD. We were unable to accurately estimate the incidence and prevalence rates of bullous diseases in Turkey or in İstanbul according to the results of our study, although our clinic is the leading referral center for bullous diseases in the country. The lack of a central registry for bullous diseases and the limited number of other minor clinics or private practitioners covering the same patient population make this goal impractical at present. PV was the most frequent AIBD according to our study; cases of PV outnumbered those of BP by a ratio of almost 5:1. This contrasts with findings from Western European countries, where BP predominates. Female predominance was found in the patient profile for most subtypes of AIBD. The mean age at onset of PV and BP was lower in Turkey than in Europe and higher than in some Middle Eastern countries. Almost half of our PV patients were recalcitrant and required advanced treatment options, demonstrating the hard-to-control nature of the disease. Given the country’s large number of PV patients, future clinical trials regarding the efficacy and side effects of treatment options can be conducted in Turkey. Future studies may reveal additional information on patterns of incidence with respect to the entire spectrum of AIBDs in different areas of the world.The study protocol received institutional review board approval from ethical committee of Cerrahpaşa Medical Faculty and that all participants are provided informed consent.


To evaluate the association between prolonged second stage of labor and the risk of adverse neonatal outcomes with a systematic review and meta-analysis. PubMed, Scopus and EMBASE were searched using the search strategy “Labor Stage, Second” AND . Observational studies that examine the relationship between prolonged second stage of labor and neonatal outcomes were selected. Prolonged second stage of labor was defined as 4 h or more in nulliparous women and 3 h or more in multiparous women. The main neonatal outcomes were 5 min Apgar score <7, admission to the Neonatal Intensive Care Unit, neonatal sepsis and neonatal death. Data collection and quality assessment were carried out independently by the three reviewers. Twelve studies were selected including 266,479 women. In nulliparous women, a second stage duration greater than 4 h increased the risk of 5 min Apgar score <7, admission to the Neonatal Intensive Care Unit and neonatal sepsis and intubation. In multiparous women, a second stage of labor greater than 3 h was related to 5 min Apgar score <7, admission to the Neonatal Intensive Care Unit, meconium staining and composite neonatal morbidity. Prolonged second stage of labor increased the risk of 5 min Apgar score <7 and admission to the Neonatal Intensive Care Unit in nulliparous and multiparous women, without increasing the risk of neonatal death. This review demonstrates that prolonged second stage of labor increases the risk of neonatal complications in nulliparous and multiparous women. The second stage of labor is the period of time between full cervical dilatation and birth of the baby, during which the woman has an involuntary urge to bear down, as a result of expulsive uterine contractions .The description of the onset of the second stage of labor in clinical practice is often not precisely known. If complete dilatation is found on vaginal examination, it remains uncertain how long this cervical status has been present .Multiple observational studies ,3,4 haveThus, diagnosis and management of prolonged second stage of labor and its complications are difficult and often pose a dilemma to the obstetrician regarding timing and type of intervention . AdditioNevertheless, there are professionals involved in childbirth care that try to reduce the duration of the second stage by obstetric interventionism in order to avoid neonatal complications. Paradoxically, these interventions, such as immediate pushing (initiated as soon as complete dilation is identified) , instrumIn the past, a prolonged second stage of labor had been defined as a period of time that lasted beyond 2 h with epidural analgesia or 1 h without epidural analgesia for multiparous women. For nulliparous women, a prolonged second stage is defined as a period of time that lasted beyond 3 h with epidural analgesia or 2 h without epidural analgesia . RecentlThus, our objective was to evaluate the evidence on the association between prolonged second stage of labor (defined as 4 h in nulliparous women and 3 h in multiparous women) and the risk of adverse neonatal outcomes.This systematic review with a meta-analysis was done according to PRISMA  ,14.The adopted search strategy was: “Labor Stage, Second” (Mesh) AND . Studies were identified in three main databases: PubMed , Scopus All members of the research team had prior training in the methodology of systematic reviews, literature reviews and critical reading. AAA and AHM are also experts in meta-analysis.Studies were included according to four criteria: (I) duration of second stage of labor greater than 4 h in nulliparous women; (II) duration of second stage of labor greater than 3 h in multiparous women; (III) studies reporting neonatal outcomes in relation to duration of second stage of labor; (IV) studies that stratified results by parity. Reference lists from the selected studies were also examined to locate further studies not identified using the search strategy. Two authors (NIT and AAA) independently performed the literature search and excluded any articles that did not meet the established inclusion criteria. A third author (MMA) was consulted to resolve any disagreements or uncertainty regarding inclusion.The primary outcomes were 5 min Apgar score < 7, admission to the Neonatal Intensive Care Unit, neonatal sepsis and neonatal death. All neonatal outcomes examined by the available studies were included in this review. The definitions of some of the variables included in our study are shown in Data collection and quality assessment were carried out independently by the three reviewers . We tried to contact the authors of several studies to provide us with data that did not appear in their manuscripts.We used the Joanna Briggs Institute Critical Appraisal tools for use in JBI Systematic Reviews to assess the risk of bias in each included study . Eleven 2 and the statistical Cochran’s Q tests. I2 values of < 25%, 25–50 and >50% normally correspond to small, medium and large heterogeneity, respectively [For the categorical results, the odds ratio (OR) was used along with its 95% confidence intervals (95% CI). To calculate the OR, either the Mantel–Haenszel fixed-effects or Der Simonian–Laird random-effects models were used, depending on whether there was heterogeneity between the studies. Heterogeneity was assessed using the Iectively ,25,26. Pectively ,27. StatAll calculations were done with the StatsDirect statistical software, version 2.7.9.  .A total of 1868 studies were selected from the literature search. After removing any duplicated articles, 267 were selected by title and abstract. After applying the inclusion/exclusion criteria, twelve articles were selected for the qualitative and quantitative analyses  .The description of the studies included in this systematic review are shown in The included studies had a low risk of bias, except for three studies that did not identify confounding factors ,28,31 anWith regard to the selection of subjects, all studies except one  specifieSeven of the studies included in the meta-analysis ,23,28,32As for data and information collection, five studies ,23,30,32n = 116,624) [p-value = 0.0041; I2 = 71.0)  ,30,31,32 = 71.0) .To assess the risk of admission to the Neonatal Intensive Care Unit, eight studies were employed  ,28,29,30p-value = 0.057; I2 = 48.8) . For this analysis, a random-effects model was used since medium heterogeneity was observed (Cochran’s Q  = 48.8) .n = 82,053) [p-value = 0.7962; I2 = 0.0)  ,20,21, w2 = 0.0) .n = 28,032) [Two studies  ,21 were No significant associations were reported between prolonged second stage in nulliparous women and 1 min Apgar score < 1, 5 min Apgar score ≤ 3, umbilical artery pH < 7, acidosis, meconium-stained amniotic fluid, meconium aspiration, birth depression, minor or major trauma, birth trauma, shoulder dystocia, brachial plexus injury, Erb’s palsy, resuscitation at birth, heart compressions, hypoxic ischemic encephalopathy, hypothermia treatment or composite neonatal morbidity. When the results of two studies were combined ,22, onlyn = 72,857) [p-value = 0.987; I2 = 0.0)  ,19,23. A2 = 0.0) .n = 76,692) [p-value = 0.417; I2 = 0.0)  ,19,29. T2 = 0.0) .None of the studies that analyzed multiparous women considered this variable when assessing neonatal morbidity in relation to the duration of the second stage of childbirth .None of the studies that analyzed multiparous women considered this variable when assessing neonatal morbidity in relation to the duration of the second stage of childbirth .No significant associations were reported between prolonged second stage in multiparous women and umbilical artery pH < 7.0, umbilical artery pH < 7.10, umbilical artery base excess ≥12, meconium aspiration, shoulder dystocia, prolonged neonatal stay, advanced neonatal resuscitation, birth depression, minor or major trauma or any perinatal morbidity. After combining two studies ,29, onlyWe did not observe publication bias for the study in any of the variables studied .We can observe a summary of results obtained following meta-analysis of all variables studied in nulliparous and multiparous women in Our meta-analysis results suggested that duration of second stage of labor of more than 4 h in nulliparous women increased the risk of low 5 min Apgar score < 7, admission to the Neonatal Intensive Care Unit, neonatal sepsis and neonatal intubation. In multiparous women, when the second stage of labor was longer than 3 h, the risk of 5 min Apgar score < 7, admission to Neonatal Intensive Care Unit, meconium staining and composite neonatal morbidity increased.However, a prolonged second stage of labor did not increase the risk of any of the other variables studied, such as umbilical artery pH < 7, birth depression, neonatal death meconium aspiration or shoulder dystocia.The literature has very limited data on neonatal outcomes of women with duration of second stage of labor of more than 4 h in nulliparas and of more than 3 h in multiparas. We were only able to locate 12 articles with these durations for this review.An example of this is a recent systematic review by Gimovksy et al., which evaluated the maternal and fetal morbidities associated with prolonged second stage of labor in nulliparous women with epidurals, in which the authors defined prolonged second stage as greater than three hours . Only twAnother systematic review studied the influence of prolonged second stage of labor on the risk of adverse maternal and neonatal outcomes from 1980 until 2005 . It did Only one randomized controlled trial  specificHowever, Zipori et al.  recentlyOne of the strengths of this study is that it is the first systematic review to define prolonged second stage of labor according the most recent recommendations (11), that is, 4 h for nulliparous women and 3 h for multiparous women. Most of the studies had large sample sizes with sufficient numbers of participants in each group to lend power to the findings, and the majority of them used methods to control for potential confounding factors.Among the limitations of our systematic review is that neonatal outcome measures were discordant in the included studies, meaning it was difficult to combine data to summarize important clinical findings, and that the definition of two variables  differed among included studies. None of the studies considered the pushing duration or pushing techniques employed (delayed pushing or immediate pushing). Finally, since they were observational studies, there is a risk of confounding bias even though many of the studies included techniques to control confounding. In nulliparous women, a prolonged second stage of labor is not related with an increased risk of neonatal death. However, it is related with an increased risk of 5 min Apgar score < 7, admission to the Neonatal Intensive Care Unit, neonatal sepsis or intubation. In multiparous women, a prolonged second stage of labor is related with an increased risk of 5 min Apgar score < 7, admission to the Neonatal Intensive Care Unit, meconium staining and composite neonatal morbidity.These potential risks associated with a prolonged second stage of labor in both nulliparous and multiparous women should serve as an incentive for professionals involved in childbirth care to increase supervision of mothers who exceed these durations.More studies are needed, especially clinical studies, to guarantee the safety of newborns when the second stage of labor exceeds 4 h in nulliparous women and 3 h in multiparous women.


Lanthanides (Ln), applied mostly in the form of nanoparticles (NPs), are critical to emerging high-tech and green energy industries due to their distinct physicochemical properties. The resulting anthropogenic input of Ln and Ln-based NPs into aquatic environment might create a problem of emerging contaminants. Thus, information on the biological effects of Ln and Ln-based NPs is urgently needed for relevant environmental risk assessment. In this mini-review, we made a bibliometric survey on existing scientific literature with the main aim of identifying the most important data gaps on Ln and Ln-based nanoparticles’ toxicity to aquatic biota. We report that the most studied Ln for ecotoxicity are Ce and Ln, whereas practically no information was found for Nd, Tb, Tm, and Yb. We also discuss the challenges of the research on Ln ecotoxicity, such as relevance of nominal versus bioavailable concentrations of Ln, and point out future research needs (long-term toxicity to aquatic biota and toxic effects of Ln to bottom-dwelling species). In the periodic table, the lanthanides (Ln) comprise 15 metals with atomic numbers from 57 (La) to 71 (Lu). Together with Sc and Y, they form the group of rare earth elements (REE), as defined by the International Union of Pure and Applied Chemistry (IUPAC). Ln (mostly in the form of oxides) is widely used in modern technologies, e.g., catalysis, electronics, cell phones, LED light bulbs, wind turbines, electric cars, fuel cells, and fuel additives, due to their unique magnetic, phosphorescent, and catalytic properties . Electri2 with the global estimated market volume at 2016 of 9100 t and the main application areas energy storage and polishing [2O3 NPs may replace the Gd-chelates currently used as contrast agents in magnetic resonance imaging due to their higher performance [2O3 NPs [2 NPs [2O3 NPs [Ln are often applied as manufactured nanoparticles  , usuallyformance . In addi[2O3 NPs  CeO2 NPss [2 NPs , Gd2O3 N[2O3 NPs , and Tb-[2O3 NPs  and Ln-d[2O3 NPs  also hav2 NPs have been estimated to reach the aquatic environment [A detailed review on technologies and environmental impact concerning Ln has recently been published by  and it iironment , where tironment . Howeverironment . Ln-cont2O3 NPs, dysprosium ion was the main contributor to the overall toxicity of the Dy2O3 NPs towards E. coli [2 NPs to algae Chlamydomonas reinhardtii [2 NPs) were taken up by C. reinhardtii [2 NP by Dahle and Arai [Gadolinium is perhaps one of the most widely studied lanthanide in the environment, due to the wide use of Gd chelates as contrast agents for MRI . A subst E. coli  and dissnhardtii . Additionhardtii . Thus, tnhardtii ,31 when nhardtii . During nhardtii ,33,34,35nhardtii ,37,38,39nhardtii  and on Cand Arai , and it and Arai ; overalland Arai ,43. A feand Arai ,44, but We intended to provide an overview on accumulated scientific information on lanthanides/Ln compounds’ environmental safety while considering the recent industrial developments and the safety information for chemicals and materials introduced to the market. This overview is mainly based on bibliometric survey on existing scientific literature with the main aim to identify the most important data gaps on Ln and Ln-based nanoparticles’ toxicity to aquatic biota that need to be addressed in the future studies. However, collection of the toxicity values available for Ln was not the target of this mini-review. We also discuss the main challenges of ecotoxicologica evaluation of Ln (interpretation of the toxicity results given the bioavailable fraction often remains unknown) as well as the applicability of laboratory test results for evaluating the risks of environmental Ln contamination. We chose Web of Science database  as a main source of information for our survey, while assuming that this database reflects both the scientific developments in technologies, as well as in hazard evaluation.D. magna acute test) and/or growth inhibition of aquatic plants . When the annual tonnage exceeds 10 t, a fish short-term toxicity test is also needed as well as activated sludge respiration inhibition test. From annual production exceeding 100 t, long-term toxicity tests on invertebrates, fish and bioaccumulation assays are mandatory and from annual tonnage of 1000 also long-term toxicity assays with benthic organisms must be performed. The above-described mandatory tests are a proxy of the aquatic ecosystem that is composed of organisms from different food-chain levels .According European Union (EU) Regulation REACH  the safety assessment must be performed for new and existing chemical compounds on the EU market . As a ruREACH has also issued additional toxicity testing guidelines for low solubility substances , for whThe search for information on ecotoxicity of different lanthanides  was performed in WoS on 4 June 2019, and the results of the search and the respective search terms (key-words) are presented in As seen in Daphnia sp. reproduction test was the most commonly used test for evaluating long term effects of Ln for zooplankton. Macrophytes also had a relatively high proportion (24%) of long-term toxicity data, possibly due to the fact that macrophytes have mainly been used for bioaccumulation  experiments (Long-term toxicity data were best represented among the studies with benthic organisms (40% of the studies) , which weriments . Long-teElodea nuttallii) with roots growing in the sediment. Most of the experiments and monitoring studies on Ln were conducted with bivalves and other sediment surface feeders (Corophium volutator).Although Ln and Ln-based NPs both tend to accumulate in the sediments , only 10 feeders . AlthougElement-wise, the studies mostly concerned La, Ce, Eu, Gd, and Sm, with no individual Ln ecotoxicological studies on nine Ln  .21% of the aquatic ecotoxicity publications on Ln  included information on the bioaccumulation of Ln . Most of2) [Altogether, there were seven studies that followed all of the major REACH recommendations, e.g., included long-term bioaccumulation studies with benthic organisms. These studies exposed bivalves ,54,55,562)  examinin2) ,66,67,682) ,66,67,682) , crustac2) ,60,61, s2) , insect 2) ,63, mite2) , and roo2)  were anaThe information on (i) potential hazard to living organisms  and (ii) environmental exposure levels  are the key data for environmental safety assessment of chemicals . For Ln,2) may pose a threat to aquatic biota, but the majority of the experiments reported effect concentrations exceeding 10 mg Ce/L. For example, ciliates were tolerant to CeO2 NPs at concentrations up to 200 mg/L, depending on the composition of the multispecies communities in a 64-day experiment [2 was observed for protozoan Tetrahymena thermophila (24 h EC50 > 100 mg/L) and bacteria Vibrio fischeri (30-min. EC50 > 500 mg/L) although the particles were producing reactive oxygen species (ROS) in abiotic conditions [2 NPs on chironomid development, growth, or emergence were reported upon exposure up to 100 mg/L, despite the fact that ingestion of the particles by organisms was recorded [2 NPs exposure to up to 100 mg/L did not induce mortality for sediment-dwelling amphipod Corophium volutator, while DNA damage and oxidative stress were induced at exposure concentration of 12.5 mg/L [2 NPs induced significant adverse biological effects in long-term studies with crustaceans and fish at 10–100 mg Ce/L [2 NPs increased the proportion of algae and decreased the proportion of bacteria in the biofilm [Daphnia magna (48 h immobilisation test) and algae Raphidocelis subcapitata (72 h growth inhibition assay) showed that the toxicity of the most toxic compounds was due to toxic heavy metals that were used as dopants that were shed into the test environment  [The available information shows that Ln based (nano)particles  ,78. Thus LaNiO4) ,80 nor sHydra attenuata (96 h EC50 0.1–1 mg/L), but in crustaceans Thamnocephalus platyurus assay, the same NPs induced no toxicity (24 h LC50 > 100 mg/L) [2, particle-induced toxicity might be more relevant [As a rule, Ln based (nano)particles have proven to be remarkably less toxic than the corresponding soluble Ln salts ,77. Howe00 mg/L) . Howeverrelevant ,82. The relevant ,83,84,85relevant ,87,88, irelevant ,90, and relevant ,92,93,94relevant ,77.50) to crustaceans D. magna that was calculated based on the measured total concentration in test medium ranged from 0.2 to 24 mg Ln/L [50 calculated on the measured dissolved Ln concentrations ranged from 0.04 to 1.2 mg Ln/L [50 for oligochaets exposed to Ln salts was 9.6–12 g Ln/L, which is a very high concentration but still similar to the results of toxic metals, such as Cd and Ni in the same test conditions [3+ and Eu complexes modified the microstructure and colour of pearls produced by pearl oysters indicating the possibility of Eu being metabolised similarly to Ca [Daphnia to natural REE-enriched mine tailing leachates resulted in a larger number of offspring that was smaller in size when compared to the control, indicating that Ln might induce adverse effects in natural conditions [2 NPs [Most data on the Ln salts’ toxicity to aquatic organisms results from the acute tests , whereas mg Ln/L ,44,95 an mg Ln/L ,97. Movenditions . Long-tely to Ca . Additioly to Ca . Long-tenditions . The gils [2 NPs .Spirodela polyrrhiza with Ln mainly deposited in the cell wall [Lemna minor—was promoted by the presence of Ce salts at concentrations up to 139 mg Ce/L and only decreased at higher concentrations of Ce [3 [3, respectively [3 exposure levels [Studies with macrophytes also yielded highly variable results. Chlorophyll reduction and oxidative damage has already been observed at 1.4–2.8 mg Pr/L in duckweed ell wall ,104. On ns of Ce . The lonof Ce [3  and CeClectively . Higher e levels .Factors that may be the cause for high intraspecific variation of Ln toxicity values will be discussed below .3 when compared to application as Gd-based contrast agent common in hospital waste waters [It is difficult to draw conclusions regarding the Ln bioaccumulation results, since the test design  in different studies varied considerably . For exae waters . Studiese waters . Anthrope waters , thus coe waters . Howevere waters .Elodea nuttallii increased up to 127-fold when compared to the control plants during the first growing season after application of La-modified bentonite. The concentrations remained up to 112-fold elevated as compared to the control for at least two years after Ln-modified clay application proving the high accumulation potential for plants. The concentrations in E. nuttallii reached up to 871 mg/g La in its tissues within a month from application of La modified bentonite into the test environment, but accumulation in filter-feeding chironomid larvae was insignificant [According to most publications, Ln may be classified as elements with low bioaccumulation potential in aquatic organisms. The highest reported bioconcentration and bioaccumulation factor values for bivalves were between 23 and 357 ,54,55,56nificant .6 being the highest for La and Ce, whereas all 13 studied REEs could be classified as bioaccumulative [A relatively high Ln content in biota has also been reported. Ln (together with Sc and Y) concentration in soft tissue of bivalves reached 1.6 mg/kg in studies by Rodriguez-Hernandez et al. . Marine mulative .2 NPs in the constructing freshwater ecosystem [The biomagnification potential of Ln could still be considered to be limited, according to available literature. Indeed, even biodilution of Ln has been observed in natural ecosystems ,63. For cosystem .Assessment of the Ln release into the environment and the resulting accumulation in the aquatic ecosystems should consider different emission sources and pathways, as well as the fate of anthropogenic Ln in various environmental matrices. This is a very difficult task, given the variety of Ln industrial applications and lack of the experimental data on Ln behaviour in aquatic ecosystems ,41. NotaThe main problems that complicate the use of the laboratory ecotoxicity test results for the realistic chemicals’ safety assessment are similar to Ln compounds and other types of metal-based nanoparticles, namely (i) the interpretation of the obtained toxicity values and (ii) ecological relevance of the data that were obtained in the laboratory tests.Correct reporting of real exposure concentrations is the most important problem in the interpretation of the toxicity test results. The reported effect concentrations for Ln compounds may be calculated either on the basis of nominal or measured concentrations in the test media , making the comparison of the results from different studies complicated or impossible see . The sam2 NPs already stabilised with polymers by the manufacturer [2 NPs were more toxic to zooplankton than settled particles [2 in fish [2 to fish [2 interactions and, thus, the toxicity [It is known that speciation and, as a result, the bioavailability of Ln compounds (added in soluble or poorly soluble form) in the test environment, mostly depends on the chemical composition of the test medium. Indeed, variation of the Ln toxicity values, depending on the test medium, has been demonstrated in several studies ,96. For facturer . Suspendarticles . The sta in fish , but dec to fish . The pretoxicity .Ln-based NPs  and, espLow ecological relevance of standardized ecotoxicity testing methods is increasingly discussed ,145. TheIt has been previously shown that, for the hazard evaluation of Ln, acute toxicity data are not reliable due to very high nominal concentrations and the very short exposure duration used in acute toxicity assays , but mos2 NPs, largely by the gastrointestinal tract [2 via NPs uptake [Another limitation of the laboratory testing is the small number of tests species usually used in chemical safety evaluation. Moreover, in the case of Ln compounds, benthic organisms should be more represented. For example, fish take up CeOal tract , thus mas uptake . HoweverSkeletonema costatum and showed that the growth inhibitory effects of all these elements were similar, i.e., not dependent on Ln: the 96 h EC50 values were approximately 29 micromol/L. Five Ln nitrates  showed very similar toxicity to unicellular alga Rapidocelis subcapitata [Tetrahymena thermophila [Daphnia magna [V. fischeri, the toxicity values of these five Ln varied remarkably, ranging from 3 mg/L for Gd to 21 mg/L for La [It could be assumed that the toxicity of individual Ln to biota is similar due to similar chemical properties , and frocapitata , protozormophila , and cruia magna . HoweverL for La .In general, the accumulation of Ln is in accordance with their concentrations in nature , althougThe most ecotoxicologically studied Ln are Ce and Ln. Practically no information was found for Nd, Tb, Tm, and Yb. More attention in scientific research could be drawn to Ln with lower atomic mass, as they are more abundant and tend to bioaccumulate more than heavy Ln.There is a considerable lack of long-term ecotoxicity data from environmentally relevant exposure conditions (Ln concentrations and test media), although these data are the most relevant for an evaluation of the potential hazard of anthropogenic Ln to aquatic ecosystems.As Ln tend accumulate in the sediments, more attention should be paid to the adverse effects of Ln to bottom-dwelling species, especially to sediment-digesting ones that are underrepresented in the current literature.Although the current environmental concentrations of Ln are still too low to cause adverse effects, remarkable bioaccumulation of Ln in some aquatic plant species is a warning sign. Therefore, additional information on the Ln bioaccumulation potential at all food chain levels is needed.There is an urgent need for additional knowledge on the behaviour of Ln in the aquatic environment.Analysis of published information regarding the potential hazard of Ln compounds to aquatic ecosystems showed that the current accumulated knowledge on Ln toxicity and behaviour in the complex systems is too scarce to support the reliable environmental safety assessment. The main data gaps and recommendations for further investigations are as follows:


Aim of this study was to describe the outcome of patients with gingival squamous cell carcinoma (GSCC), and to recognize aspects affecting clinical course and to consider survival rate. The case records of patients, over a 10-year period, were retrospectively examined. Differences in distribution of the potential risk factors by prognosis were investigated through non-parametrical tests (Wilcoxon Rank-Sum and Fisher’s Exact). Survival curves for age, therapy and stage were built by the Kaplan-Meier method and compared with Log-Rank test. 79 patients were analysed. Significant increase in mortality for patients older than 77 and for those with advanced stages was found. Cumulative survival rate 5 years after the diagnosis was 43%, while at 10 years was of 11%. With a statistical relationship between age and tumour stage with survival rates, and 70% of GSCC cases identified as stage IV, early GSCC diagnosis remains challenging. Key words:Gingival cancer, clinical appearance, treatment, retrospective study. Oral squamous cell carcinoma (OSCC) is the most common head and neck cancer, accounting for more than 90% of total cases; between them, gingival squamous cell carcinoma (GSCC) is a rare disease, most commonly affecting elderly population ,2. It reWhen separating the oral cavity into subgroups, statistical power could be lost in the final evaluation, justifying why authors often group the subsites together into ‘‘oral cancer’’; this pooling usually gives fewer data about the unrelated trends and possible prognosis on the subsite levels .Despite the significant advances obtained in the diagnostic and therapeutic opportunities, OSCC continues to portend a modest prognosis with an estimated 5-year overall survival rate of 56% in Western Europe . TNM staRecent data about gingival cancer reported a very bad prognosis ,8, but IFrom a standardised computerised database, medical charts of patients, with histologically confirmed diagnosis of GSCC, at the Oral Medicine Section , over a 10-year period from June 1, 2008 to June 1, 2018, were retrospectively examined. Subjects were resident in Piedmont region, North-west Italy.Inclusion criteria were the following: patients with histopathologic diagnosis of GSCC, formulated since June 1st 2008, emerging in gingiva, and biopsied either in gingiva, or in edentulous ridge, or in the retromolar area/tuber maxillae, providing complete information on sex/age of the patient involved, TNM staging, and subsequent follow-up, including exitus, whenever occurred.Exclusion criteria were the following: incomplete data on age/sex or follow-up of patients with GSCC; lack of histopathologic record of GSCC; lack of TNM staging; histopathologic diagnosis of GSCC before June 1st 2008; diagnosis of malignancies other than GSCC, such as verrucous carcinoma, salivary gland or mesenchymal malignancy.Demographic information, smoking (current or former smoker vs. non-smoker), alcohol consumption (current of former drinker vs. non-drinker), history of oral potentially malignant disorders (OPMD), tumour site, tumour grade according to the WHO classification , T classification and neck nodes involvement at the time of diagnosis UICC, 1997), staging based on the American Joint Committee on Cancer staging system (7th edition)  were used in order to analyse differences in distribution of the variables listed above by the prognosis. Kaplan-Meier method and Log-Rank test were used in order to estimate and compare survivals in different classes of age, therapy and stage, separately. All statistical analyses were performed using R software (version 3.5.3). Statistical significance was defined at Finally, 85 cases of GSCC were collected. With 6 clinical charts providing insufficient clinical and/or histopathologic data, 79 cases of GSCC were analysed, in 36 men (mean age: 67.5 ± 10.6) years and 43 women (mean age: 73.49 ± 11.1) , with GSOf these, 21 had previous OPMD, of which 8  Oral Lichen Planus, 7 (7 F) with proliferative verrucous leukoplakia, and 6  with oral leukoplakia.Almost 70% of total cases were identified with an advanced stage (54 patients with stage IV). Histologically, 21 cases were identified as well differentiated, 48 as moderately differentiated and 10 as poorly differentiated. The mandible was more commonly affected (69.6%).Almost 65% of the reported patients did not report the classical risk factors for oral cancer  . In situOf the 79 GSCC, 55 (69.6%) were located in mandible, whereas 24 31.3%) in maxilla; 34 (43.3%) were detected in the right side, 45 (56.7%) in the left side; 49 (62.02%) were detected in premolar-molar regions, and 30 (37.98%) in the incisors area. Five patients developed multiple malignancies: in detail, 2 patients experienced metachronous cancers, 1 in lower lip and 1 in side of tongue, respectively. On the other hand, 2 patients were diagnosed with synchronous cancers, 1 in fornix and 1 in buccal mucosa. Finally, 1 patient developed both a synchronous tongue cancer, and two metachronous malignancies in buccal mucosa and hard palate. Primary tumors’ size ranged from a minimum of 9 mm in one patient, to a maximum diameter of 4.2 cm in one case, with an average size of 1.7 cm. Regarding clinical appearance, 7 (8.9%) lesions were described as patches, 32 (40.5%) as either verrucous lesion or as submucosal node, with or without erosions, whereas 40 (50.6%) had ulcer or erosion as main clinical appearance  patients underwent surgery alone, of whom 11 required elective neck dissection; 19 (24%) were treated with a combination of surgery, radiotherapy and chemotherapy; 12 (15.2%) underwent surgery and adjuvant radiotherapy, of whom 7 required elective neck dissection; 3 (3.8%) patients underwent surgery and chemotherapy. On the other hand, in 14 (17.7%) cases, considered not eligible for surgery, were administered either chemotherapy (5 cases), or radiotherapy (3 cases), or chemo/radiotherapy (6 cases) combined. Finally, in 8 (10.1%) cases no treatment could be provided, due to extremely poor state of health already at diagnosis. .The median months of follow-up was of 21.00 [8.50-61.50]. During this period, 47 (59.5%) patients died; of these 36 (45.5%) were GSCC-related deaths, while for the others it was not possible to detect the exact cause. The overall cumulative survival rate 5 years after the diagnosis was 43%, while at 10 years it was 11%.p=.02, p<.0001, and p=.018 respectively)  revealed a statistical significance between patients treated by surgery and those not treated or treated without surgery.Oral cancer is a difficult disease to control, and small improvements have been seen in the survival rate over the last decades. Moreover, to the best of our knowledge, data about GSCC are very scarce, especially from Italy.GSCC is an insidious disease, not always having the appearance of a malignancy, ranging from an exophytic to a verrucous to an ulcerated lesion, as previously reported by these Authors . Such chIn this study, some factors possibly having influence on survival were analysed. Most general features of the present series were coherent with previous reports. Squamous cell carcinoma of the head and neck is commonly associated with the use of alcohol and tobacco; however, patients diagnosed with GSCC are typically not exposed to classical risk factors, as confirmed in the present series, especially for female patient . MoreoveAccording to the data collected in the present study, it should be necessary to pay particular attention to female patients without specific risk factors, especially when having flat lesions in the lower jaw. However, no prognostic differences emerged between males and females in the present series.The literature reports that the GSCC most frequently involves the jaw in the female population aged over 50 years; the present study sample confirms this data with a frequency very close to 70%, but with a decidedly higher onset age . However, the correlation of prognosis with age seems to be quite controversial. In a case-series of 450 gingival squamous cell carcinoma, a significant influence of age distribution on prognosis was detected, with a 5-years survival rate of 61.7% among patients of less than 50 years versus 34.1% for patients above 50 years of age . FurtherGingival SCC presents a high possibility of periosteal and bone invasion due to anatomical contiguity; this raises the risk of metastatic dissemination .The course of GSCC could be determined by specific factors, above all the staging of the disease. In the present series, the set of IVa and IVb stages included almost 70% of the total patients: this could explain the strongly aggressive nature of the neoplasm probably given by the close proximity to the underlying tissue layers and therefore the easier propensity towards invasion, in turn correlated to higher and earlier mortality. A series of 334 cases of oral carcinoma, published by this group in 2008 (To date, the treatment of GSCC remains mainly surgical, adding adjuvant radiotherapy for advanced stage disease or in patients at elevated risk of locoregional failure ; the preBearing in mind the limitations of a retrospective study conducted within a single-center on a relatively small sample of patients from North-West Italy, carrying a limited external validity, the present study, to the best of our knowledge, this is the biggest series of GSCC ever reported from Italy. We revealed age, stage and modality of treatment as autonomous factors in predicting survival in patients with GSCC. Carcinoma of the gingiva is an exception with regard to intraoral tumours, not apparently associated with risk factors and in close contact with the underlying tissues. It presents a high aggressiveness and the surgical therapy, frequently associated with chemotherapy and radiotherapy, is often not decisive. The similarity to periodontal lesions or benign formations leads to a diagnostic delay with a sudden worsening of the prognosis. The most worrying element is that a high mortality rate would not seem to be associated with lesions of unusual localization and therefore of more difficult investigation, but rather located in the gingival tissues which should be very recognizable in the daily clinical practice of dentists and hygienists.With these premises, dental practitioners should play a fundamental role in intercepting simple colour changes, especially in the gingival level, and motivating the patient to undergo a more thorough investigation if a regression of the aforementioned lesions cannot be attested, especially among women in the absence of traditional risk factors.