Whether lifestyle improvement benefits in reducing cardiovascular diseases (CVD) events extend to hypertensive patients and whether these benefits differ between hypertensive and normotensive individuals is unclear. This study aimed to investigate the associations of an overall healthy lifestyle with the subsequent development of CVD among participants with hypertension and normotension.Using data from the Suzhou subcohort of the China Kadoorie Biobank study of 51,929 participants, this study defined five healthy lifestyle factors as nonsmoking or quitting for reasons other than illness; nonexcessive alcohol intake; relatively higher physical activity level; a relatively healthy diet; and having a standard waist circumference and body mass index. We estimated the associations of these lifestyle factors with CVD, ischemic heart disease (IHD) and ischemic stroke (IS).During a follow-up of 10.1 years, this study documented 6,151 CVD incidence events, 1,304 IHD incidence events, and 2,243 IS incidence events. Compared to those with 0–1 healthy lifestyle factors, HRs for those with 4–5 healthy factors were 0.71  for CVD, 0.56  for IHD, and 0.63  for IS among hypertensive participants. However, we did not observe this association among normotensive participants. Stratified analyses showed that the association between a healthy lifestyle and IHD risk was stronger among younger participants, and the association with IS risk was stronger among hypertensive individuals with lower household incomes.Adherence to a healthy lifestyle pattern is associated with a lower risk of cardiovascular diseases among hypertensive patients, but this benefit is not as pronounced among normotensive patients. Cardiovascular diseases (CVD) continue to be the leading cause of death and disability globally . MoreoveIt has been demonstrated that avoiding smoking , nonexceTherefore, this large prospective cohort study aimed to investigate the associations of healthy lifestyle with incidence of CVD, IHD, and IS among Chinese adults with and without hypertension.We used participants’ data from the China Kadoorie Biobank (CKB) study in Wuzhong District of Suzhou city, Jiangsu Province. Detailed descriptions of the CKB cohort have been previously published . We colln = 331), stroke (n = 466), heart disease (n = 574) and outliers of duration of hypertension (n = 8), current analysis included 51,921 participants.Overall, a total of 53,269 participants aged 30–79 years were eligible for inclusion. After excluding individuals who had self-reported previous medical histories of cancer (2).In the baseline questionnaire, a variety of lifestyle factors were assessed. Questions about cigarette smoking included smoking status , amount of daily cigarette smoking for current smokers, and the reason for quitting and years since quitting for former smokers. Alcohol consumption included drinking status ; drinkers who drank once or more per week were asked how much alcohol they consumed on a typical drinking day over the past year. The information about physical activity included the common type  and duration of activities in the past year. Based on the metabolic equivalent tasks (METs) for each activity, we calculated the daily level of physical activity by multiplying the MET value for each activity by hours spent on each activity and summing the MET-hours for all activities . DietaryBaseline questionnaire also collected sociodemographic information , personal and family medical history, time of sedentary behavior, consumption of preserved vegetable and use of antihypertensive drugs. Participants reporting at least one first-degree relative with stroke or heart attack were defined as having a family history of these diseases. Participants were asked how many hours per week they spent watching TV or reading to calculate the time of sedentary behavior per week. Trained staff members used a UA-779 digital monitor to measure blood pressure at least twice, using the mean of the 2 measurements for analyses. Self-reported diabetes or screen-detected diabetes were considered as diabetes mellitus . Screen-2) and WC (WC < 90 cm for men and < 85 cm for women). The healthy lifestyle score ranged from 0 to 5. To avoid extreme groups with limited cases, we subsequently categorized the lifestyle scores into four groups .Smoking status, alcohol intake, physical activity, diet, and body shape have been proven to be closely related to the risks of CVD. We included these five lifestyle factors to define a healthy lifestyle . The heaInformation on CVD incidence cases since baseline recruitment was ascertained from local disease and death registries, the health insurance system, and active follow-up . The heaThe primary outcomes were incidences of total cardiovascular diseases (CVD), ischemic heart disease (IHD) and ischemic stroke (IS). Total CVD included all circulatory diseases coded as “I” in ICD-10  and were coded as I00 to I99. IHD and IS were coded as I20 to I25 and I63, which were subdivisions of total CVD.Participants contributed person-years from enrollment into the study until the diagnosis of CVD, loss to follow-up, or December 31, 2017, whichever came first. A Cox proportional hazards model was used to estimate the hazard ratios (HRs) and 95% confidence intervals (CIs) for the associations of individual and combined lifestyle factors with risks of incidence of total CVD, IHD and IS among participants with or without hypertension. The Cox model was stratified by age at baseline in 5-year intervals.2 were excluded. Forth, for alcohol consumption, the healthy group was redefined as moderate drinking.All lifestyles were included when analyzing individual lifestyle factors. Model 1 was adjusted for sex. Model 2 was additionally adjusted for education level, occupation, marital status, family history of heart attack or stroke, time of sedentary behavior, and usage of antihypertensive drugs. Similarly, we made the same adjustments in the analysis of combined lifestyle factors. We treated the number of healthy lifestyle factors as a continuous variable to analyze the linear trend. Analyses were further stratified by age, sex, education level, household income, occupation, time of sedentary behavior, and usage of antihypertensive drugs for hypertension. The likelihood ratio test including the cross-product term was used to estimate multiplicative interactions. To demonstrate the robustness of our findings, we conducted several sensitivity analyses. First, participants who had diabetes at baseline were excluded. Second, participants whose outcome occurred in the first 2 years of follow-up were excluded. Third, participants whose BMI < 18.5 kg/mp < 0.05 was considered statistically significant.R software (version 4.1.0) was used to perform the statistical analyses. A two-sided During a median follow-up period of 10.1 years, 6,151 incidence of total CVD cases, 1,304 IHD cases, and 2,243 IS cases were documented. When categorizing the five lifestyle factors into healthy and unhealthy groups (reference group), nonsmoking, being physically active, healthy body weight and fat were each independently associated with a 16, 8, and 10% lower risk of the incidence of total CVD, 18, 20, and 18% lower risk of incident IHD, and 26, 3, and 13% lower risk of incident IS among participants with hypertension, respectively. Those associations were only observed between healthy dietary habits and incident CVD among normotensive participants .p for trend <0.01) .When considering healthy lifestyle factors jointly, compared to those with ≤1 healthy lifestyle scores, the adjusted HRs (95% CIs) of those with 4–5 scores were 0.71  for the incidence of total CVD, 0.56  for the incidence of IHD, and 0.63  for the incidence of IS among hypertensive patients  . When evp for interaction <0.01), and adults with annual household incomes less than 20,000 RMB/year had a stronger inverse association between healthy lifestyle scores and IS risk as well (p for interaction = 0.05).When stratified by age, sex, education level, household income, occupation, duration of sedentary behavior, and antihypertensive drug use, the analyses yielded consistent results . For par2  with the incidence of total CVD, IHD, and IS. Compared with 0 or 1 ideal lifestyle factors, hypertensive patients having a score of 4 or 5 showed a 29, 44, and 37% reduction in the risk of total CVD, IHD, and IS, which was higher than that of normotensive individuals.2 was 0.25  for total CVD incidence, 0.17  for coronary heart disease (CHD) incidence  and the Oxford Tropical Research Ethics Committee, University of Oxford (UK). The patients/participants provided their written informed consent to participate in this study.JS and HG designed the study. HG performed the data analyses and drafted the manuscript. JS revised the data analyses. JS, LC, XF, JZ, MW, and RT critically revised the manuscript for important intellectual content. YL, YH, JJ, YG, JL, PP, and ZC edited and proofread the manuscript. All authors read and approved the final manuscript.This work was supported by grants from the National Natural Science Foundation of China , grants from the National Key Research and Development Program of China (2016YFC0900500), grants from the Kadoorie Charitable Foundation in Hong Kong and grants from the Wellcome Trust  in the UK.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


The study results provide a reference for healthcare professionals to identify the factors for family caregiver burden, as well as the characteristics of patients and family caregivers particularly vulnerable to caregiver burden, thus improving family-centred care.Oral cancer is currently the fourth leading cause of cancer-related death in Taiwan. The complications and side effects of oral cancer treatment cause a tremendous burden on patients’ family caregivers. This study explored the burden on primary family caregivers of patients with oral cancer and its related factors. One hundred and seven patients with oral cancer and their primary family caregivers were included through convenience sampling. The Caregiver Reaction Assessment (CRA) scale was employed as the primary research instrument. The primary factors of caregiver burden, in descending order, were disrupted schedules , a lack of family support , health problems , and financial problems . The CRA scores of the caregivers differed significantly in terms of education level (t = 2.57,  In Taiwan, oral cancer is associated with alcohol and betel nut consumption ,2. More Although oral cancer can be treated through a combination of surgery, chemotherapy, and radiotherapy, surgery is the main treatment of choice . HoweverFamilies play a major role in caregiving to patients with oral cancer in Taiwan; families are required to provide direct home care and economic, social, and emotional support . This chStudies indicate a correlation between caregiver burden and age, sex, education level, marital status, religious affiliation, employment status, financial status, relationship with patients, whether they live with patients, length of care for patients, and whether they are supported by other family members ,18,19,20The study of the burden of primary family caregivers to patients with oral cancer and its related factors will help medical professionals to more clearly understand the caregiver burden status and, accordingly, provide family-centred care. The present study explored the burden of primary family caregivers in providing home care to patients with oral cancer and its related factors.A cross-sectional descriptive study was conducted, with convenience sampling. A structured questionnaire was administered from May 2016 to May 2018 to 107 outpatients with oral cancer from the radiology department in a teaching hospital in Northern Taiwan and their primary family caregivers. The inclusion criteria for the patients were (1) age 20 years or older, (2) diagnosis of oral cancer, and (3) receipt of surgery, chemotherapy, or radiotherapy targeting oral cancer. The inclusion criteria for the patients’ primary family caregivers were as follows: (1) age 20 years or older, (2) primary family caregivers as recognised by the patients, and (3) living together with the patients. The exclusion criteria for primary caregiver were the primary caregiver had an employment relationship with the patient. This study was approved by the institutional review board of the hospital, and informed consent forms were signed by the patients and their primary family caregivers. The questionnaires were distributed by the research assistants and voluntarily filled in by the caregivers, after which the research assistants examined the responses on-site to check for any unanswered items. The family caregivers were requested by the assistants to fill in any items that were not answered. The patients’ medical characteristics were collected from their medical history by the research assistants.This study was approved by the institutional review board of a teaching hospital (VGHIRB no.: 2014-04-001AC) in Northern Taiwan. The research assistants verbally explained the research objective, data protection method, and research procedure to the participants before acquiring signed consent from the participants. The participants’ personal information was coded in the questionnaire to protect their privacy. Participants who were unwilling to continue being surveyed or unfit for further survey because of poor physical condition were free to withdraw from the study, and their data collection was discontinued by the researchers.The data collected in this study were the sociodemographic variables of the patients and their primary family caregivers, as well as the types of care and the patients’ medical characteristics. The sociodemographic variables included sex, age, marital status, education level, religious affiliation, employment status, and household income. The medical characteristics included the time of oral cancer diagnosis, the stage of cancer, current treatment status, and reported side effects from the treatment. The data on the primary family caregivers also included their relationship with the patients and the type and length of care.Caregiver Reaction Assessment (CRA), a tool used to assess caregiver burden, consists of 5 subscales encompassing 24 items, namely, disrupted schedules (5 items), financial problems (3 items), health problems (4 items), lack of family support (5 items), and self-esteem (7 items). While disrupted schedules, financial problems, health problems, and lack of family support constituted negative caregiver reactions, self-esteem constituted positive caregiver reactions. A 5-point Likert scale was employed , with a higher score indicating a higher caregiver burden . The Crot-test. The correlation between the CRA scores and the caregivers’ and patients’ age, length of patient care, and length of patient illness was analysed through Pearson product–moment correlation. Subsequently, multiple regression analysis was conducted on the caregiver burden predictive power of the sociodemographic variables and medical characteristics.SPSS 22.0 for Windows was employed for statistical data analysis. Descriptive statistical analysis was performed on the means, standard deviations, frequencies, and percentages for the sociodemographic variables of all the participants, the patients’ medical characteristics, the relationship between the primary family caregivers and the patients, the type and length of care, and caregiver burden (according to the CRA). The differences in caregiver burden based on various sociodemographic variables and medical characteristics were examined using analysis of variance and an independent sample When certain sociodemographic variables and medical characteristics were significantly correlated with caregiver burden, dummy coding was to be conducted for the variables and characteristics that are discrete or nominal before conducting multiple regression analysis. During the multiple regression analysis, the sociodemographic variables, medical characteristics, the relationships between the primary family caregivers of the patients, and the types and lengths of care that are significantly correlated with caregiver burden were treated as independent predictors of caregiver burden, which is the dependent variable.Of the 107 primary family caregivers, 98 were women (91.6%). The average age of these caregivers was 51 ± 10.8 years, and their ages ranged from 20 to 70 years. Regarding the relationships between the caregivers and patients, 78 of the caregivers were spouses to the patients (72.9%). Of these caregivers, 60 had senior high school or higher levels of education (56.1%); 94 were married (87.9%); 28 were employed and provided care to their patients after work (26.2%); 51 had household incomes of no higher than NT$500,000 (47.7%); 93 had religious affiliations (86.9%); and 28 were diagnosed with chronic diseases themselves 26.2%; .Of the primary family caregivers, 44 provided care to their patients together with other family members or hired caregivers (41.1%), whereas 28 had to care for their patients independently throughout the day (26.2%). The primary family caregivers had provided care to their patients for an average of 36.4 ± 40.3 months, with the length of care ranging from 1 to 171 months. Of the caregivers, 43 had provided full care for patients each week (40.2%); 40 had irregular rest time each week (37.4%); and 89 were inexperienced in providing care to patients 83.20%; .Of the 107 patients with oral cancer, 100 were men (93.5%), and the average age was 56.4 ± 9.7 years . Of the total patients, 59 graduated from educational institutes no higher than junior high schools (55.1%); 38 remained employed in full-time jobs even after developing oral cancer (35.5%), but 37 were unemployed (34.6%); 88 lived with their families or friends (82.2%); and 87 had a religious affiliation 87.3%; .The patients had experienced oral cancer for 1–171 months, with an average of 42.5 ± 44.4 months. Of all the patients, 39 were at the fourth stage of oral cancer (36.4%), and 32 were at the second stage (29.9%); 84 had completed their treatment (78.5%); and 39 experienced the side effects of their treatment 36.4%; .CRA was used to assess the caregiver burden. Specifically, the assessment subscales were disrupted schedules, financial problems, health problems, a lack of family support, and self-esteem. The results reveal the highest average scores in disrupted schedules (3.19 ± 0.84), followed by a lack of family support (2.82 ± 0.85), health problems (2.67 ± 0.68), and financial problems (2.59 ± 0.84) among primary family caregivers to patients with oral cancer. However, the caregivers’ feelings about providing care to their family members were not always negative. The caregivers obtained an average score of 3.58 ± 0.49 in self-esteem . ThereafHigher scores indicate a higher burden, with the exception of scores in self-esteem, where a higher score indicates a lower burden.r = 0.12, p > 0.05) and the length of care  were not significantly correlated with the total average burden. Only the education level  and the household income  of the caregivers were significantly correlated with the total average burden, but no other sociodemographic variables and no type of care were significantly correlated with the total burden  and the length of illness  were not significantly correlated with caregiver burden. Furthermore, the other sociodemographic variables and medical characteristics were not significantly correlated with the caregiver burden (The age of the patients (r burden .p = 0.007) , and the variance inflation factors ranged between 1.09 and 2.26 , indicating that the variables exhibited no collinearity . In the = 0.007) .This study examined the burden on primary family caregivers to patients with oral cancer and its related factors. The results may help medical professionals to understand the current status regarding caregiver burden and identify the family and patient characteristics that incur caregiver burden, facilitating family-centred care. The results of this study reveal that the primary family caregivers exhibited high self-esteem; disrupted schedules represented the most prominent factor to their burden, followed by a lack of family support, health problems, and financial problems.Disrupted schedules were reported by the primary family caregivers as the greatest contributing factor to their burden, which is consistent with the findings of studies on the burden on primary family caregivers to patients with rectal, lung, oral, and terminal cancer ,17,18,20A lack of family support constituted the second most prominent factor to caregiver burden. This differs from the findings of most studies, which have indicated that a lack of family support is the least prominent contributor to caregiver burden ,17,18,20Health problems were the third highest contributor to caregiver burden, which is consistent with the findings in some of the existing studies ,12,13,17Many studies have indicated financial problems as the second greatest contributor to caregiver burden ,12,13,17In fact, household incomes significantly predict the overall burden of primary family caregivers. According to Cheng et al. , family The primary family caregivers scored high in self-esteem. Because self-esteem is a positive aspect of caregiver reactions, a higher score in self-esteem indicates a lower caregiver burden. This is consistent with the findings of most studies ,13,14,15After self-esteem was scored in reverse, the total average caregiver burden score was calculated. A higher score indicates a higher total caregiver burden. The results of this study reveal that the education levels and household incomes of the primary family caregivers significantly predicted their total burden. The caregivers with higher education levels exhibited lower burdens than those with lower education levels, whereas those with lower household incomes experienced higher burdens than those with higher household incomes. Studies have reported that financial and educational problems in a family critically affect the caregiver burden ,28,29. AA meta-analysis has shown that case management, psychoeducation, and multicomponent interventions can significantly reduce the burden on caregivers. In particular, case management and counselling appeared to be better than cognitive behavioural therapy . The mulThis study was a cross-sectional descriptive study and did not clarify the changes in the burden of primary family caregivers over changes in patients’ conditions or time. Moreover, because participants were enrolled from only one teaching hospital in Northern Taiwan, the results may not be representative of all primary family caregivers. Convenience sampling used in the current study may cause sampling bias. Families with high care burdens may be eliminated inherently. On the other hand, the sample size was small for several sociodemographic and medical variable groups. It is unlikely that statistical differences could be detected in caregiver burden by patients’ sociodemographic information and medical characteristics.The primary factors contributing to the burden of primary family caregivers, in descending order, were disrupted schedules, a lack of family support, health problems, and financial problems. The results of this study reveal that the caregivers exhibited high self-esteem, which is a positive aspect of caregiver reactions. Although home care presented a huge burden to the primary family caregivers, the caregivers were still willing to provide care and considered it pivotal. Moreover, low household income and low education levels significantly affected the caregiver burden.Medical professionals should prioritise the arrangement of primary family caregivers’ time for care in their education strategies. Referral of related care resources is also crucial in providing family caregivers adequate time to rest. Additionally, supportive communication between family members must be promoted. Self-care strategies should be taught to family caregivers. Furthermore, economically disadvantaged families, particularly those with low education levels, should be assisted in finding substantial support from social welfare institutions.This study recommends that future research builds on the results of this current study and focuses on the development of relevant interventions to reduce the burden of primary caregivers at home.


SLPEBP3, SLPEBP5, SLPEBP6, SLPEBP8, SLPEBP9, and SLPEBP10 might be related to tomato flowering and that SLPEBP2, SLPEBP3, SLPEBP7, and SLPEBP11 might be related to ovary development based on the tissue-specific expression analysis of SLPEBP gene family members at five different stages during flower bud formation to fruit set. This article’s goal is to offer suggestions and research directions for further study of tomato PEBP gene family members.The PEBP gene family is crucial for the growth and development of plants, the transition between vegetative and reproductive growth, the response to light, the production of florigen, and the reaction to several abiotic stressors. The PEBP gene family has been found in numerous species, but the SLPEBP gene family has not yet received a thorough bioinformatics investigation, and the members of this gene family are currently unknown. In this study, bioinformatics was used to identify 12 members of the SLPEBP gene family in tomato and localize them on the chromosomes. The physicochemical characteristics of the proteins encoded by members of the SLPEBP gene family were also examined, along with their intraspecific collinearity, gene structure, conserved motifs, and cis-acting elements. In parallel, a phylogenetic tree was built and the collinear relationships of the PEBP gene family among tomato, potato, pepper, and Arabidopsis were examined. The expression of 12 genes in different tissues and organs of tomato was analyzed using transcriptomic data. It was also hypothesized that  A highly conserved protein known as the phosphatidylethanolamine-binding protein (PEBP) gene family has been found in a variety of biological tissues. These proteins were initially isolated from the brains of cows and were given the name phosphatidylethanolamine-binding protein due to their strong affinity for phospholipids ,2. The sFT, TSF, and tomato SFT genes are FL-like genes. SFT has been demonstrated to produce a signal to guide flowering and play a regulatory role in plant meristem growth [TFL1, ATC, and BFT in Arabidopsis and the SP gene of tomato are TFL1-like genes, and SP can antagonize the effect of SFT [SFT/SP balance controls the flowering initiation time [MFT gene is an MFT-like gene that is involved in seed germination. According to previous studies, replication events in the plant PEBP gene family occur at the same time as plant evolution. Only MFT-like genes have been found in bryophytes [FT, TSF, TFL1, BFT, ATC, and MFT—have been discovered in Arabidopsis [Brassica oleracea, some of which affected the curd formation and flowering of cauliflower, and a study suggested that the high expression of the TFL1 gene and the low expression level of flowering-promoting genes  may be among the factors that affect curd formation in cauliflower [The PEBP gene family controls a wide range of biological processes. Some studies have found that PEBP genes can be involved in regulating flowering and growth-related signaling pathways ,6, and pm growth ,14. TFL1t of SFT . The SFTion time , constition time . The Arayophytes , and MFTyophytes . Due to yophytes ,18, but yophytes . PEBP fayophytes , maize [yophytes , rice [2yophytes , and soyyophytes ,23. Six bidopsis ,24,25. Tliflower . Regardiliflower .SP2G, SP3C, SP3D (SFT) SP3I, SP5G, SP6A, SP, and SP9D [SP gene, which can inhibit tomato flowering, is orthologous to the CEN gene and the Arabidopsis TFL1 gene [SP gene can regulate the determinate or indeterminate growth of tomato. After gene mutation, tomato changed from indeterminate to determinate growth, the plant type became compact and dense, and maturity was consistent [SP gene mutant is beneficial to the mechanical harvesting of tomato [SP3D is homologous to the FT gene of Arabidopsis thaliana, and its deletion can prolong the flowering period of tomato [SP5G regulates the photoperiod sensitivity of tomato [One of the most popular vegetable crops is the tomato. The tomato fruit has a unique flavor, can be eaten raw or cooked, and has great economic and nutritional value. According to inflorescence development at the top of the stem, tomatoes have two types of growth, determinate and indeterminate, being a typical sympodial branching crop . The detand SP9D ,30. ThesFL1 gene ,31,32. Tnsistent . The SP f tomato . SP3D isf tomato . SP5G ref tomato . AlthougSLPEBP1-12. Basic information about the SLPEBP gene family and the physicochemical properties of its encoded proteins is shown in Through HMMER 3.0 software analysis and screening with HMMER and SMART online software, 12 PEBP family members were analyzed and named SLPEBP8 at 423 bp and the longest is SLPEBP2 at 699 bp; the average length is 527 bp. SLPEBP family genes are distributed across seven tomato chromosomes. The physicochemical properties of the proteins were predicted by ExPASy online software. The smallest molecular weight was 16.06 for SLPEBP8, and the largest was 24.80 for SLPEBP2. The theoretical isoelectric point ranged from 5.26 (SLPEBP7) to 9.63 (SLPEBP2), and the instability index ranged from 28.46 (SLPEBP10) to 50.26 (SLPEBP9). The maximum aliphatic index value was 92.36 (SLPEBP8), and the minimum value was 72.71 (SLPEBP3). The results of hydrophilicity and hydrophobicity analysis indicated that all SLPEBP family proteins are hydrophilic proteins. The results of subcellular localization of the proteins analyzed using online software showed that all SLPEBP family proteins are cytoplasmic proteins.The shortest SLPEBP gene family coding sequence length is SLPEBP5 among the 12 SLPEBP family members is located away from the telomeric region. Among the 12 SLPEBP family members, only SLPEBP5 was in a region with low gene density. The analysis of collinearity between genes demonstrated the replication relationships between genes, and these relationships within species are shown in SLPEBP1 with SLPEBP9.The relationship between the location of the SLPEBP gene family on the chromosomes and the collinearity within the species is shown in SLPEBP2 and SLPEBP5 had no collinearity with genes from other species. Among the three species, SLPEBP is most closely related to STPEBP. Comparative analysis of the SLPEBP family with other species can provide a research reference for analyzing the genetic relationships and gene functions of species. Collinearity relationship of tomato SLPEBP gene with potato, pepper and Arabidopsis thaliana can be found in To determine the collinear relationships of the 12 SLPEBP family genes among other species, collinearity analysis was performed using Arabidopsis, potato, and pepper with PEBP family members from tomato. The results of the analysis are displayed in SLPEBP1, SLPEBP2, SLPEBP4, SLPEBP9, SLPEBP11). Fifteen genes belonged to the FT subfamily , and twelve genes belonged to the MFT subfamily .To investigate the phylogenetic relationships of SLPEBP genes with other homologous genes, a phylogenetic tree was constructed using the amino acid sequences of 10 identified ATPEBP proteins, 10 STPEBP proteins, 11 CAPEBP proteins, and 12 SLPEBP proteins . The phyA phylogenetic tree containing only SLPEBP family genes with subfamilies divided into three groups was constructed by MEGA-X, consistent with the previous evolutionary tree results, and based on this tree, we performed conserved motif and gene structure analysis of SLPEBP gene family members .SLPEBP3, SLPEBP6, SLPEBP8, SLPEBP10, and SLPEBP12 contained all 10 conserved motifs, and the 10 motifs were arranged in the same order. Only motifs 3 and 4 are shared by all 12 SLPEBP gene family members. The most complete conserved motif is found in the TFL1 subfamily, followed by the FT subfamily.In the gene structure analysis, six SLPEBP family genes contained four exons and two introns, accounting for 50% of the overall SLPEBP gene family members. Nine genes contained four exons, accounting for 75% of the family members. Seven genes contained two introns, accounting for 58.3% of the family members. Nine genes contained introns, accounting for 75% of the family members. The majority of SLPEBP gene family members contained four exons, and most of its members contained one or two introns. In the analysis of conserved motifs, 10 conserved motifs were found and named motifs 1–10. All genes except SLPEBP10 were evaluated as accurate by online software detection and evaluation. As shown in SLPEBP8) contain two α-helices.The structure of the protein encoded by a gene is related to the function of the gene. Homology modeling is a method to construct the three-dimensional structure of a target protein by using the amino acid sequence of the protein as a template for the three-dimensional structure of a protein that has been experimentally validated. Using the homology modeling method, we predicted the 3D structures of 12 SLPEBP proteins. The 3D structures obtained by the homology modeling method for all 11 genes except SLPEBP2 gene contained G-box. All family members except SLPEBP4 contained Box 4. Among the cis-acting elements in the promoter region of the SLPEBP family members, the number of light-responsive elements (141) was the highest. The number of development-related elements was the lowest (18); SLPEBP7 did not contain any development-related elements. Details of cis-acting elements in the promoter region of SLPEBP genes can be found in Cis-acting elements are important for gene transcription, and in this study, a 2000 bp sequence upstream of each gene was used to predict cis-acting elements in the 12 genes of the SLPEBP family . A totalSLPEBP3, SLPEBP12) were expressed in several tissues, while some genes  were not found to be expressed in any of the tissues examined. Average FPKM value of SLPEBP genes transcriptome in different tissues of tomato can be found in The results of the analysis are shown in SLPEBP1 to SLPEBP12, at five different periods of flowering, and the results are shown in SLPEBP1 and SLPEBP12 was extremely low and is therefore not shown in the figure. Among the 12 genes, SLPEBP3, SLPEBP5, SLPEBP6, SLPEBP8, SLPEBP9, and SLPEBP10 were expressed at high levels during the flowering period and might be involved in flower opening. The other genes may be related to ovary formation and may play a regulatory role in tomato yield.We determined the gene expression of all 12 genes, SLPEBP5 were distributed at the far end of the chromosome.The type of plant growth , the time of flowering, the number of flowers, and the development of flower organs are closely related to the yield of tomato. Currently, mechanized and automatic harvesting and processing are gradually replacing traditional manual work, further improving production efficiency and saving time and cost. To adapt to mechanized harvesting, it is necessary to study tomato plant types. Members of the PEBP gene family have obvious functions in plant growth type, flowering period, flower organ development, seed germination, root morphogenesis, and even abiotic stress resistance. Mutants of its genes in this family have been reported to cause changes in tomato flowering, flower morphology, plant growth type, root morphology, etc. However, no article has provided a comprehensive study and summary of the PEBP gene family in tomato to examine the common characteristics of its family members. We predicted 12 genes containing PEBP conserved domains through the tomato genome database, which is consistent with the results of Cao et al.  and MoreSLPEBP1 and SLPEBP9 genes had collinearity, indicating that SLPEBP gene family members had fewer copies, or that their copies were discarded more during evolution. At the same time, to further analyze the homologous relationships of SLPEBP gene family members in plants, we carried out interspecific collinearity analysis on tomato, potato, pepper, and Arabidopsis. The highest to lowest collinearity observed is potato (11), pepper (10), and Arabidopsis (4). This result is consistent with genetic distance [SLPEBP2 and SLPEBP5 have no collinear relationship with the other three species and may be unique to tomato. SLPEBP4, SLPEBP6, and SLPEBP9 and potato, pepper, and Arabidopsis all have a collinear relationship. These three genes may play an important role in the evolution of the PEBP gene family, or have irreplaceable functions. The phylogenetic tree of PEBP gene family members of tomato, Arabidopsis, pepper, and potato was constructed using MEGA-X. The evolutionary tree divides these members into three subgroups, namely TFL1, FT, and MFT (TFL1 (AT5G03840) and FT are antagonistic. TFL1 has been shown to move in the apical meristem (SAM), regulate the floral transition, and regulate the expression of hundreds of genes [ATC (AT2G27550) can inhibit floral transition, and its expression is induced under short-day conditions [SP3C (SLPEBP4) was found to be able to promote seed germination after being knocked out, and its overexpression can improve the tolerance of seedlings to water stress, and is related to root morphogenesis [SP (SLPEBP9) is homologous to CEN and TFL1 [SP gene changed tomato from indeterminate to determinate growth. The Solanum pennellii SP9D (SLPEBP11) infiltration system may be associated with semi-determinate growth [FT (AT1G65480) is a kind of floral integratorgene that plays a role in the floral transition process [BFT (AT5G62040) was found to play a role in the development of axillary inflorescence and regulate floral transition under high salt and drought conditions [TSF (AT4G20370) interacts with FT, but the direction of action is unknown at present [SP5G (SLPEBP7) was found to be related to the photoperiod sensitivity of tomato. It is a kind of flowering replicator, and its variation enables the cultivated tomato to be planted in a wider area without being affected by the photoperiod [SP5G 3′ untranslated region [SP3D/SFT (SLPEBP5) is an important gene controlling flower formation, responsible for encoding florigen and regulating the transformation of tomato from vegetative growth to reproductive growth [SFT function loss allele is heterozygous, it can increase the yield by more than 60% and has strong heterosis [SP6A (PGSC0003DMT400060057) controls the tuber vascular bundle transport signals and forms a complex with IT1 to regulate the formation of potato tubers. The absence of its PEBP domain leads to the failure of Solanum etuberosum to produce potatoes [MFT (AT1G18100) gene of Arabidopsis was found to promote flowering and regulate the germination of Arabidopsis seeds through the ABA and GA signaling pathways [Gene replication events often occur in plants. In this way, plants can evolve with higher efficiency . The memdistance . SLPEBP2 and MFT . In the of genes . ArabidoC AT2G275 can inhiogenesis . Puneli and TFL1 . The mute growth . In the  process . Arabidonditions ,53. Arab[FT AT1G680 is a kTC AT2G270 can inhd region . Tomato e growth . When theterosis . By adjueterosis . Potato potatoes . In the s potato , pepper pathways . ThroughSLPEBP3, SLPEBP6, SLPEBP8, SLPEBP10, and SLPEBP12 contain all 10 conserved motifs, and the 10 motifs are arranged in the same order. At present, there are no detailed reports on the functions of these five genes. Among the genes containing all 10 conserved motifs, SLPEBP1 and SLPEP2 have not been found to have specific functions. SLPEBP3, SLPEBP6, and SLPEBP10 belong to the MFT subfamily. The FT and TFL1 subfamilies are believed to have evolved from the genes of this subfamily, which may be the reason why the conserved motifs of these three genes are incomplete. The prediction of the conserved motifs of the SLPEBP gene family provides a theoretical basis for gene classification and gene function prediction. The gene structure of the SLPEBP gene family is basically composed of four exons, with 75% of family members containing four exons, while there is loss of introns in the gene family, with the family members containing at most two introns. SLPEBP8 has five exons, and SLPEBP10 contains only two exons. SLPEBP12 contains eight exons, and the gene structure is in good agreement with the conserved motif analysis, so it is likely that two genes were spliced together. The three-dimensional structure of proteins determines how they interact with other molecules, and determines their role in cells. The abundant three-dimensional structure of proteins allows them to perform a considerable number of functions in cells, and the three-dimensional structure of proteins can be inferred from their amino acid sequences [SLPEBP1, SLPEBP2, and SLPEBP4 have very similar three-dimensional structure prediction results, and they belong to the same subfamily. The predicted results are in line with the characteristics of a gene family protein, and all have similar conserved domains. In the process of protein transcription, the gene promoter and its cis-acting element play an important regulatory role. The core promoter of the gene encoding the protein usually contains a “TATA-box”. The cis-acting element and core promoter can become the binding sites of transcription and regulate the specific binding sites of the protein [SP9D, SP, SP5G, and SP3D, have been shown to be expressed in many tissues and organs of tomato [SP, SFT, and SP5G. By analysis of RNA-seq data, we found that some members of the SLPEBP gene family have tissue-specific expression . Tomato flower buds, incompletely opened flowers, completely opened flowers, and organs with 3 and 5 days of fruit set were collected to examine gene expression.Total RNA was extracted from tomato materials using TaKaRa RNA extraction kit . cDNA synthesis and gDNA removal were performed using reagents produced by Vazyme . The obtained cDNA was stored at −80 °C.http://plants.ensembl.org/index.html, accessed on 4 September 2021) for the identification of tomato PEBP family members and subsequent analysis. The conserved domain of PEBP (PF01161) was downloaded from Pfam  [http://hmmer.org/, accessed on 4 September 2021) was used to retrieve tomato protein data and obtain possible tomato PEBP family members. Then, HMMER  and SMART  online software were used to screen and confirm whether these genes contained conserved PEBP domains, and genes without complete domains were eliminated [https://web.expasy.org/protparam/, accessed on 4 September 2021) was used to predict the physicochemical properties of the SLPEBP, e.g., MW (kDa), theoretical pI, instability index, etc., and Psort  was used to predict the subcellular localization of the SLPEBP proteins [The genome sequence information of tomato, potato, pepper, and Arabidopsis was downloaded from the Ensemble database (er 2021) . HMMER3.iminated ,66. Pseuiminated . ExPASy proteins ,69.https://solgenomics.net/, accessed on 8 September 2021). A chromosome distribution map of the SLPEBP genes was drawn using TBtools [The chromosome position data, including chromosome length and gene starting and ending positions, were obtained from Solanaceae Genomics Network (SGN)  and the protein evolution model JTT (Jones–Taylor–Thornton), as well as 1000 bootstrap replicates, and other default values.http://gsds.gao-lab.org/, accessed on 15 September 2021) was used to construct the gene structure map [https://meme-suite.org/meme/tools/meme, accessed on 15 September 2021). The predicted number of motifs was 10, and the other was the default value.Gene Structure Display Server 2.0 (GSDS)  was used to predict the three-dimensional structure of the protein by homology modeling [https://saves.mbi.ucla.edu/, accessed on 7 October 2021) [http://www.ks.uiuc.edu/Research/vmd, accessed on 7 October 2021) [SWISS-MODEL  . The temer 2021) .http://bioinformatics.psb.ugent.be/webtools/plantcare/html/, accessed on 6 October 2021) was used to predict the potential cis-acting elements on the promoter sequence [The sequence of 2000 bp upstream of the transcription initiation site was extracted as the promoter sequence of the SLPEBP gene, and PlantCARE  accession number D004 were used [To investigate the differences in expression of the SLPEBP gene in different tissues of tomato, FPKM (fragment per million exons mapping) data for tomato variety Heinz 1706 with TFGD  and synthesized by BGI Genomics Co., Ltd. Detailed primer sequence information can be found in Actin gene was used as the internal reference gene as the control for data standardization. The final calculation 2−ΔΔ Ct was used to analyze the relative expression of genes. GraphPad Prism 9 was used to analyze the variance, and one-way ANOVA (and nonparametric or mixed) was used to analyze the significance.Specific primers were designed using NCBI  are hypothesized to be associated with tomato flowering and four  may be associated with ovary development. The above analysis can provide research directions and ideas for future research on SLPEBP gene family members.In this study, 12 SLPEBP gene family genes were identified and analyzed. There is a collinear relationship between


Pseudonocardia, Irregularibacter, and Castllaniella, were the key bacteria affecting ARG changes in soil after fertilization. In addition, nutrient factors and heavy metals also affect the distribution of ARGs in soil and are positively correlated. This paper reveals the possible reasons for the increase in the number of total soil ARGs and their relative abundance under different fertilization treatments, which has positive implications for controlling the transmission of ARGs through the soil-human pathway.Although the enrichment of resistance genes in soil has been explored in recent years, there are still some key questions to be addressed regarding the variation of ARG composition in soil with different fertilization treatments, such as the core ARGs in soil after different fertilization treatments, the correlation between ARGs and bacterial taxa, etc. For soils after different fertilization treatments, the distribution and combination of ARG in three typical fertilization methods  and non-fertilized soils were investigated in this study using high-throughput fluorescence quantitative PCR (HT-qPCR) technique. The application of organic fertilizers significantly increased the abundance and quantity of ARGs and their subtypes in the soil compared to the non-fertilized soil, where sul1 was the ARGs specific to organic fertilizers alone and in higher abundance. The conventional fertilizer application also showed significant enrichment of ARGs, which indicated that manure addition often had a more decisive effect on ARGs in soil than chemical fertilizers, and three bacteria,  AntibiotetT, tetW, tetZ) were commonly present in swine manure and soil, while tetY, tetS, tetC, tetQ, tetH were also introduced into the soil by manure application (Antibiotic resistance genes (ARGs) are genetic elements carried by microorganisms that cause them to develop resistance to target antibiotics . They arlication . Tang stlication . Heuer flication . Ross anlication . Wu detelication . All of In this study, we set up an inorganic fertilizer group, an organic fertilizer group and an additional conventional fertilizer group (organic fertilizer mixed with inorganic fertilizer) to compare with the control group. High-throughput fluorescence quantitative PCR (HT-qPCR) was used to analyze ARGs in different treatment groups to assess the similarities and differences of total and core ARGs in different treatment groups, and also to determine the bacterial communities and physicochemical properties affecting the composition of ARGs in soil. This result will help to reduce the enrichment of ARGs during fertilization and has positive implications for explaining the mechanism.2.2.1.2 (61 m × 8 m) was selected for a long-term locational trial of eggplant-sweet pepper rotation. The greenhouse was started in spring 2009 with four different fertilizer treatments as: no fertilizer (CK), chemical fertilizer alone (IF), organic fertilizer alone (OF), and conventional fertilizer (MF) .In this study, samples were collected from a vegetable base in Daxing District, Beijing , and a greenhouse with an area of 488 m2 of urea, 0.05 kg/m2 of diammonium phosphate and 0.03 kg/m2 of potassium sulfate, the organic fertilizer alone group (OF) with 2.38 kg/m2 , and the conventional fertilizer group (MF) with a compound fertilizer  0.06 kg/m2 and commercial organic fertilizer 1.20 kg/m2 in the conventional fertilizer group (MF). The application rates of N, P, K fertilizer were converted from plant uptake amount considering the fertilizer utilization ratio  of each plot, four different treatments, and three samples were collected from each treatment, for a total of 12 soil samples.2.3.2.3.1.DNA extraction of soil samples was performed using the kit Fast DNA SPIN Kit for Soil (USA). The instructions were followed. After DNA extraction, the concentration of DNA extracted is measured and a portion of it is used for 16SrRNA sequencing and the rest for PCR quantification and other applications, and stored at −20°C for a long time until use.2.3.2.ARGs were quantified using the Wafergen Smart Chip Real-Time Quantitative PCR System (Wafergen Inc. USA). 384 primer pairs were set , includi.2.4.p < 0.05 indicates significant differences at 95% confidence interval. Network plots were drawn using Gephi software.EXCEL 2013 was used to organize the data, Origin Pro 8.5 was used to draw bar graphs, the pheatmap package in R language was used to draw heat maps, the vegan package was used for redundancy analysis (RDA), and the TukeyHSD method was used for statistical analysis and PcoA principal coordinate analysis. Mantel test and typical correlation analysis (RDA) were used to explain the relationships between heavy metals , nutrient factors , pH and ARGs. 3.3.1.3.1.1.β-Lactamase, Chloramphenicol, MLSB, Multidrug, Clycopeptide, Sulfonamide, Tetracycline, Fluoroquinolone, and Others. The highest number of ARGs was 76 in organic fertilized soils, followed by 52 in conventionally fertilized soils, 37 in chemical fertilized soils alone, and the lowest number of ARGs was 36 in non-fertilized soils -Ib(aacA4)-01, aadA5-01, aph), 5 fertilizers alone, with the same number accounted for by different types, and 24 organic fertilizers alone, with the largest number being macrolides (erm(36), ermB, ermF lnuA-01, lnuB-01, lnuB-02), followed by tetracyclines (tet(32), tetM-01, tetM-02, tetPB-03, tetX) with aminoglycosides -Id-02, str), and 7 conventional fertilizers. The most multidrug-resistant classes . The total number of ARGs in the soil with organic fertilizer alone was approximately twice as high as that in the soil without fertilizer and the specific ARGs subtypes were much higher than those in the other three treatment groups, indicating that organic fertilizer alone increased the diversity of soil ARGs. In addition, for soils with mono-applied organic fertilizers, Aminoglycoside and MLSB ARGs were the most abundant, followed by Multidrug, which were largely consistent with the most numerous subtypes of endemic ARGs in mono-applied organic fertilizers. And it has been reported in the literature that long-term application of chicken manure significantly enriched the ARG associated with β-lactams and tetracyclines in the soil, which is consistent with the results obtained from the application of organic fertilizer alone in this study, where there was a significant increase in the number of β-lactam and tetracycline-based resistance genes in the OF group , IF, OF, MF all significantly changed the composition of ARGs in the soil compared to the control. This result further supports the difference in the composition of ARGs in soils with different fertilization treatments.To investigate the differences in the characteristics of ARGs in vegetable soils under different fertilization practices, PCoA was performed on the abundance data of ARGs . PCoA1 amepA, qacEdeltal-01, acrA-04, etc. in the soil for multiple resistance classes of resistance genes. There were 24 ARGs specific to the soil with organic fertilizer alone, indicating that the application of organic fertilizer could increase the variety of ARGs in the soil; sul1 (sulfonamides) was the ARGs specific to the soil with organic fertilizer alone, and the relative abundance was high.vanRA-01 (glycopeptides) was significantly increased in the soil with single fertilizer treatment compared to the soil without fertilizer, and the difference between the shared ARGs in the soil without fertilizer and the soil with single fertilizer was not significant. oprJ (multiresistant) was detected only in the soil with single fertilizer and the soil with single organic fertilizer, and its relative abundance was high. mexF (multiresistant) subtype had higher abundance in the soil with three different fertilizer applications except for the soil without fertilizer. The high abundance of mexF (multidrug-resistant) subtypes in all three fertilized soils, except the non-fertilized soils, indicated that fertilizer application increased the variety of ARGs in the soil. Conventional fertilization had higher relative abundance of fox5 (β-lactams) and sul2 (sulfonamides) compared to the other three fertilization treatment conditions. The figure also shows that aac(6)-Ib(aka aacA4)-03 (an aminoglycoside resistance gene) had higher abundance in all treatments, indicating that they have some stability in the soil and should be a key concern.The abundance of sul2, a sulfonamide resistance gene, was detected in soils treated with either chemical fertilizer alone, organic fertilizer alone, conventional fertilizer application, and no fertilizer application, and the gene copy number was as high as about 1.44 × 10−3 per gram of soil, while sul1 (sulfonamide), a specific ARGs, was detected in soils treated with organic fertilizer alone, and the gene copy number per gram of soil up to 4.72 × 10−3, indicating that the application of organic fertilizer changed the type of ARGs in the soil. One study found that sul2, a sulfonamide resistance gene, was also detected in 100% of black soil farm soils with organic fertilizer application, which is consistent with the findings of this paper  2.16 × 108 copies·g −1 (dry soil), which was 2.89 ± 0.54 × 106 copies·g −1 (dry soil) was about two orders of magnitude higher ; organic matter, total nitrogen, effective phosphorus, and fast-acting potassium were also significantly and positively correlated with ARGs (p < 0.01).To assess the correlation between soil ARGs and physicochemical factors, Mantel tests were conducted to determine the abundance of ARGs in vegetable soils with heavy metals, organic matter (OM), total nitrogen (TN), effective phosphorus (AP), and fast-acting potassium (AK) contents as well as pH in four different fertilization treatments. The results showed  that heaRDA was used to further assess the contribution of individual variables to the changes in ARGs, and the results are shown in qepA and qnrS. Heavy metals can persist in the environment for a long period of time and increase the abundance of ARGs under sustained selective pressure, and previous studies have also demonstrated that replacing chemical fertilizers with organic fertilizers induces the accumulation of Cd, Pb, Cu, and Zn in the soil, suggesting that fertilizer treatments can influence the abundance of resistance genes associated with them by affecting the accumulation of heavy metals in the soil , including multiresistant classes, macrolides, β-lactams, aminoglycosamides, tetracyclines, and the most subtypes of aminoglycoside ARGs, with 4. Irregularibacter has seven linkages with ARGs (p < 0.001), including tetracyclines, macrolides, multiresistant classes, aminoglycosides and β-lactams, the most numerous of which are the multiresistant classes with three subtypes of ARGs and the other classes with one subtype of ARGs each. Castllaniella has 24 linkages to ARGs (p < 0.001), which include sulfonamides, chloramphenicol, glycopeptides, and others in addition to macrolides, aminoglycosides, tetracyclines, β-lactams, multiresistance, and tetracyclines, and have 1, 1, 2, and 1 subtype of ARGs, respectively. The above results indicate that all three bacteria  were significantly correlated with ARGs, which is consistent with the previously reported findings that some ARGs were significantly correlated with multiple bacterial taxa (Pseudonocardia, Irregularibacter, and Castellaniella could potentially serve as host bacteria facilitating the transfer of ARGs. Pseudonocardia, commonly found in soil, plants, and various environmental settings, may promote the horizontal gene transfer of a multitude of ARGs (Castellaniella, known to prevail under antibiotic stress, could be a potential reservoir of antibiotic-resistant bacteria, thereby facilitating the horizontal transfer of ARGs within the environment.The symbiotic relationship between ARGs and bacterial families was investigated using Pearson’s based network analysis and the results are shown in ial taxa . Correla of ARGs . Castell4.In summary, changes in fertilization practices affect the composition of ARGs in soil, increasing their subtypes as well as abundance. According to our results, although organic fertilizers were also added to the conventional fertilizer application, the increase in the number of ARGs and their abundance was much less than that of the organic fertilizer application alone, while compared to the chemical fertilizer application alone, there was a significant increase in ARGs in the conventionally fertilized soil due to the addition of organic fertilizers. We suggest that the application of organic fertilizers leads to higher number and abundance of ARGs in the soil, and the main reason may be that the ARGs carried in organic fertilizers spread to the soil, while the alteration of ARGs from chemical fertilizer application comes only from the colonization of native microorganisms, and conventional fertilizers are in between. Soil factors TN, OM, AP, AK and heavy metals Cu, Zn, Cd and As contributed more to the variation of ARGs in soil than other factors. These findings provide a more comprehensive insight into the changes of ARGs in soil ecology under long-term application of different types of fertilizers.The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author.ZW: Conceptualization, Formal analysis, Investigation, Visualization, Writing – review & editing, Writing – original draft. NZ: Resources, Validation, Writing – review & editing. CL: Formal analysis, Writing – review & editing. LS: Investigation, Writing – review & editing.


Adenoid cystic carcinoma (AdCC) is a rare heterogenous disease, often difficult to diagnose and prognosticate and, therefore, also challenging to treat optimally. To gain more knowledge with regard to clinical parameters, we conducted a retrospective study on a large cohort of AdCC of the head and neck. The strongest favourable prognostic factors were disclosed to be early disease stage (stage I and II) vs. late disease (stage III and IV) and major salivary gland subsite as compared to other subsites, with the best prognosis in the parotid gland, irrespective of the stage of the disease. Contrary to some studies, we did not find a significant correlation between survival regarding the perineural invasion and radical surgery. However, similar to others, we confirmed that other common prognostic factors, such as smoking, age, and gender, did not correlate to survival and should not be used for prognostication of AdCC of the head and neck.Adenoid cystic carcinoma (AdCC), a rare heterogenous disease, presents diagnostic, prognostic, and therapeutic challenges. To obtain more knowledge, we conducted a retrospective study on a cohort of 155 patients diagnosed in 2000–2022 with AdCC of the head and neck in Stockholm and investigated several clinical parameters in correlation to treatment and prognosis in the 142/155 patients treated with curative intent. The strongest favourable prognostic factors were early disease stage (stage I and II) as compared to late disease (stage III and IV) and major salivary gland subsite as compared to other subsites, with the best prognosis in the parotid gland, irrespective of the stage of the disease. Notably, in contrast to some studies, a significant correlation to survival was not found for perineural invasion or radical surgery. However, similar to others, we confirmed that other common prognostic factors, e.g., smoking, age, and gender, did not correlate to survival and should not be used for prognostication of AdCC of the head and neck. To conclude, in AdCC early disease stage, major salivary gland subsite and multimodal treatment were the strongest favourable prognostic factors, while this was not the case for age, gender and smoking nor perineural invasion and radical surgery. Adenoid cystic carcinoma (AdCC) is a rare malignancy originating from secretory glands with yet unknown aetiology and accounts for approximately 1% of malignant head and neck tumours ,3. It isAdCC can occur at all ages but is most common later in life (Fifth to Sixth decade) ,2. It frProspective clinical trials are uncommon, but many retrospective studies have shown that disease-free survival (DFS) is better when multimodal therapy is given . One repImportantly, however, AdCC is a rare and heterogenic disease, and many of the studied cohorts have been small, and moreover, since clinical studies are rare, it has been difficult to draw general conclusions. For this reason, here, we attempted to collect a large cohort of AdCC patients over more than a 20-year period to investigate clinical characteristics and long-time survival in AdCC patients originating from the head and neck region.Patients and tumour samples. Through the Swedish Cancer Registry, between 2000 and 2022, in total, 155 patients were identified as diagnosed with AdCC within the head and neck region  in the County of Stockholm/Gotland. Following the identification of these 155 patients in the Swedish Cancer Registry, we could successfully collect and examine the individual charts of all 155 patients at Karolinska University Hospital.Patients’ charts (collected prospectively during regular contact with the patients during the follow-up period) were assessed. Their tumours were reclassified according to the 8th Edition UICC TNM classification of Malignant Tumours, and age, gender, smoking, performance status , perineural growth pattern, type of treatment, recurrence, time to recurrence and location of recurrence, as well as survival were recorded. Treatment was classified as surgery, radiotherapy (RT) , chemoradiotherapy (CRT), or palliative therapy , but not at curative doses). Smoking data were obtained whenever noted in the charts and were classified as “never” smokers or “ever” smokers (including recent and previous smokers).All 155 patients were described and characterized according to the criteria above, but 13 were excluded from further survival analyses due to that they did not receive curative treatment or because they were not disease free 6 months after treatment.Furthermore, for the survival analysis, the 142 patients treated with curative intent were grouped into three subgroups. Most patients (118 cases) were included in the group defined as receiving multimodal treatment and receiving both surgery and RT with or without concomitant chemotherapy (CRT). The remaining patients were divided into two minor groups, one group with 14 cases obtaining only oncological treatment with RT or CRT and one group (10 cases) having surgery alone. DFS was followed through the charts of the patients, while OS was also followed through our access to the Swedish Death Registry from the Karolinska University Hospital.It is of note that there was no standard follow-up recommendation for AdCC patients and, therefore, in our cohort, all patients did not have the same follow-up period. Nevertheless, the standard follow-up for head and neck cancer (HNC) patients in our institution is clinical controls every 3rd month for the first 2 years and every 6th month until 5 years after treatment. Most patients treated without surgery undergo a computer tomography scan 3 months post-treatment to ensure that there is no residual tumour; the latter is, however, a practice of the more recent years. Most AdCC patients in this cohort continued with clinical controls 2 times yearly after 5 years due to the fact that late recurrences are common. Moreover, the date of death is automatically provided for all citizens that have deceased in Sweden through the digital medical journal system, providing reliable OS data.The study was conducted according to ethical permissions 99-237, 2005/431-31/4, 2009/1278-31/4, 2012/83-31/2, 2017/1035-31/2, 2019-05211 and 2022-05287-02 from the Ethics Committee at Karolinska Institutet, Stockholm, Sweden, the Stockholm Regional Ethical Review Board, and the Swedish Ethical Review Authority.t-test was used. A test result below 5% was considered statistically significant. R version 3.4.1 was used for data management and analysis.The Kaplan-Meier method was used to estimate overall survival (OS) and disease-free survival (DFS). OS was defined as the time from diagnosis until the date of death of any cause or end of follow-up, whichever comes first. DFS was defined as the time from diagnosis until local or distant recurrence confirmed by radiology or clinical check-up. The chi-square test was used to evaluate differences in categorical data; for continuous variables, an independent two-tailed In our cohort of 155 AdCC cases, there was a general predominance of female patients  and 59 males (M); F:M ratio 1.6:1) irrespective of tumour site, with the highest female ratio in AdCC of the parotid gland (F:M ratio 2.5:1) and the lowest female ratio in AdCC of the oral cavity (F:M ratio 1.25:1). For details see In addition, there was a clear predominance of AdCC localized in the major salivary glands (parotid and submandibular gland), the nasal cavity, the paranasal sinus, and the oral cavity  . More spA minority of the patients  presented with spread disease upon diagnosis; furthermore, in one case, the metastasis status was unknown because the patient did not want to undergo further diagnostics due to a high age at diagnosis (90 years old). This patient did not die of AdCC and became 94 years old.Stage IV disease  dominated , followed by stage II , stage I , and stage III  . Male paPerineural tumour growth was predominantly found in 100/155 (64.5%) cases, while 52/155 (33.5%) cases presented without a perineural growth pattern and in three cases, the status was not assessable. Perineural growth was over-represented in cases arising from the major salivary glands 62/84 (73.8%), whereas only 38/69 (55.1%) arising from other sites presented with a perineural growth pattern.In total, 142/155 (91.6%) patients were eligible for treatment with curative intent and were disease-free six months after finishing treatment and included in the further survival analyses. Of the excluded 13 patients, seven had advanced local and/or spread disease at diagnosis, and four were not eligible for intensive treatment due to high biological age and poor performance status. In addition, one patient did not accept treatment, and one showed signs of residual disease after surgical resection and full dose postoperative external beam radiotherapy (not disease-free after a definitive curative treatment regimen).Out of 142 patients treated with curative intent, 140 presented with locoregional diseases, while 2 had both locoregional and distant diseases.The latter two patients both had one single metastasis. One patient had metastasis in the liver (primary AdCC in the parotid gland), while the other one had metastasis in the lung (primary AdCC in the nasopharynx). However, both metastases were stable under the curative treatment of the locoregional disease and could later be radically extirpated , but unfortunately, both these patients presented with distant recurrence in the lung within three years after finished treatment. A summary of all the patients treated with curative intent is presented in The 142 patients treated with curative intent were for the sake of simplicity divided into three subgroups, and the characteristics of these patients are presented in Of the 118/142 (83.1%) cases treated with multimodal treatment, 89/142 (62.7%) underwent surgery followed by RT, while 29/142 (20.4%) had surgery and postoperative RT (PORT) with concomitant ChT (CRT). Of the 14/142 (9.9%) patients that did not undergo surgery, six received only RT, while eight obtained (CRT). The remaining 10/142 (7%) patients were treated with surgery as a single treatment modality. Below further details per treatment category and patient characteristics are presented.This group consisted of 118 patients and was heterogenic, with no subsite or disease stage being overrepresented, suggesting that the multimodal treatment modality was not chosen due to the more advanced disease stage or a certain localization. More specifically, of the 118 patients, 27/118, 22.9%  cases were stage I, 38/118, 32.2%  stage II, 18/118, 15.2%  stage III, and 35/118, 29.7%  stage IV.Any recurrence was observed in 39/118 (33.1%) patients. These recurrences were most frequently deriving from primary AdCCs in the nasal and paranasal sinuses 11/18 (61.1%), followed by those in the oral cavity 8/17 (47.1%), the submandibular gland 12/35 (34.3%), 4/14 (28.6%) in other sites, and finally, they were least commonly found 4/34 (11.8%) in AdCC primaries of the parotid gland.Locoregional recurrence (LRR), occurring in 15 cases , was most common in the nasal cavity and paranasal sinuses with 8/15 (53.3%) cases, where all but one had initially presented with stage IV disease at diagnosis. Interestingly 11/15 (73.3%) cases with LRR developed even distant metastases. However, only six of these patients died within five years of the diagnosis of LRR.Distant metastases were developed by 36/118 (30.5%) patients, of which 25/36 (69.4%) were diagnosed only with distant metastases and 11/36 (30.6%) with both LRR and distant diseases (see above). Distant metastasis without LRR was most common among primary AdCC located in the oral cavity 5/17 (29.4%), followed by those located in the submandibular gland 10/35 (28.6%), while the distant disease was less common in primary AdCC at other sites.The most frequent site of distant metastases was the lungs , followed by the liver , which was also the most common site of secondary metastases after the lungs. Other sites of the distant disease include: the bones, the kidneys and the adrenal glands, the brain, the skin, the lymph nodes, and the thyroid gland.In this group, the majority 12/14 (85.7%) presented with advanced disease (ten cases with stage IV and two with stage III disease), and 12/14 (85.7%) presented with any late recurrence, of which five cases had LRR, four had both LRR and distant metastasis, whereas two developed distant disease alone.In this group, all 10 cases had the early-stage disease (stage I and II), and the surgery was radical in 8 cases, while in the 2 cases where the surgery was not radical, both patients were recommended PORT, but this was not conducted initially.One patient undergoing non-radical surgery later presented with locoregional recurrence and was treated with RT, while the other never encountered a recurrence.Of the eight cases having a radical extirpation of the tumour, one patient still presented with a locoregional recurrence .Several survival analyses were performed on the 142 patients treated with curative intent, and some of the most notable parameters are presented below.Initial survival analysis for DFS and OS was performed including all 142 patients treated with curative intent, irrespective of treatment modality. For this cohort, the 5-year DFS was 64.9%, the 10-year DFS was 49.6%, and the 15-year DFS was 37.7%, while the 5-year OS was 83.5%, the 10-year OS was 59.4%, and the 15-year OS was 42.5% .p < 0.0001). More specifically, the five-year DFS was 70.7% in patients treated with multimodal treatment compared to 37% in patients receiving single modality treatment  was used.We could not confirm any of these factors to be prognostic for DFS in our cohort of 142 patients receiving treatment with curative intent, and the data are presented for DFS in Perineural tumour growth was observed in 95 (66.9%) of all cases undergoing curative treatment and was, in general, more frequent in the major salivary glands and most frequent in tumours from the submandibular gland , followed by the parotid gland 28/41 (68.3%), the oral cavity 16/25 (64%), the nasal cavity and paranasal sinuses 13/21 (61.9%). Perineural invasion was, however, much less common  in AdCC arising from other sites. Markedly, perineural growth did not always correlate with a higher disease stage since 55.9% of the cases had perineural invasion in stage I, 74.4% in stage II, 80% in stage III and 62.2% in stage IV. Furthermore, it is of note that there were no significant differences in DFS nor OS when separating the analysis for perineural invasion, dichotomizing positive and negative status, according to the pathological report  presented tumours in stage I, 43 (30.3%) in stage II, 20 (14.1%) in stage III, and 45 (31.7%) in stage IV. Patients presented with the lower disease stage, treated with curative intent, had a significantly better DFS and OS, with DFS presented in After performing the survival analysis for each individual stage, it became clear that stages could be clustered into two groups, with early-stage group clustering stages I and II and advanced-stage group clustering stages III and IV. Stages I and II clustered together had significantly better DFS and OS , the submandibular gland , the nasal cavity, the paranasal sinuses , and the oral cavity , were included in the analyses.Primaries from the nasal cavity and paranasal sinuses (Subsite C) had the least favourable DFS with a 5-year DFS of 42%, followed by the oral cavity at 61.2% (Subsite D), the submandibular grand 68.3% (Subsite B), and the parotid gland 81.1% (Subsite A), and for details of 10- and 15-year DFS, see p = 0.0062) but less obvious  to DFS and OS of all other sites ; more explicitly, five-year DFS and OS were 73.5% and 88.7%, respectively in AdCC of the major salivary glands as compared to 53.7% and 76.8%, respectively of AdCC in other sites. Moreover, 10-year DFS and OS for salivary glands were 61.3% and 63.6%, respectively, compared to 33.8% and 54.2%, respectively, for other sites. For further details and 15-year DFS and OS, see AdCC in major salivary glands had better DFS and OS compared to other sites , perineural invasion, and dichotomizing surgery and RT/CRT vs. surgery or RT/CRT alone, as well as subsites . For DFS, see The multivariable analysis confirmed that typical clinical prognostic factors, such as gender, age, smoking status, and perineural growth pattern, were not applicable in AdCC. However, the multivariable analysis supported that the stage of the disease, as well as the subside of the AdCC, could be used as a prognostic factor. In addition, the multivariable analysis supported that combinational treatment of surgery and RT w/o ChT was superior to single treatment modality and resulted in improved survival; for details of DFS, see In this retrospective study with a follow-up for >20 years, a large cohort of head and neck AdCC patients was examined with regard to clinical characteristics and long-time survival in correlation to gender, age, smoking, perineural invasion, tumour stage, subsite, and treatment modality. We could disclose that both DFS and OS were superior following multimodal treatment modality vs. single treatment modalities. Moreover, patients with tumour stages I and II had a better prognosis than those with stage III and IV disease and those with major salivary gland AdCC had a better outcome than those with AdCC at other subsites, irrespective of disease stage. In contrast, gender, age, smoking status, and perineural growth pattern in the tumour, factors otherwise used for prognostication in many solid cancers ,15, did Based on the findings above, we first compared our cohort to those of others and found no major differences in the characteristics of patients included in the study as compared to those included in other reports ,6,16,17.Moreover, only around 5% of the patients presented with metastatic disease at diagnosis, suggesting, in line with the present literature, that AdCC is mainly a locoregional disease ,17,19. FWe then investigated DFS and OS taking into account the whole cohort and independent of treatment modality; similar to others, we also showed that neither gender, age, or smoking influenced DFS, although some studies have shown that older age is associated with higher disease stage and consequently poorer DFS ,16,17,18Notably, however, we found that AdCC in the major salivary gland subsite and lower disease stage were prognostic factors, and these data are presented in more detail below upon also discussing treatment modality.Combinational treatment  has been suggested to be important for achieving good control of AdCC in general ,12,22, aA large American cohort study compared surgery alone to surgery and PORT and found similar to us that the latter is superior and significantly improves survival . They, hInduction chemotherapy (ICT) is, to our knowledge, not commonly used in the treatment of AdCC of the head and neck region and was not often reported in the studies we have cited above . In lineInterestingly, we could not show that radical surgery  could be used as a possible prognostic marker, as suggested in other studies ,24,25. IThe fact that patients with tumour stages I and II had longer survival than those with tumour stages III and IV was not unexpected since this is usually the case for most solid tumours, including AdCC ,26,27. TWe also showed that subsites could be used as a prognostic factor since major salivary gland AdCC had a significantly better prognosis than AdCC in other subsites, and notably, especially AdCC within the parotid gland had the best prognosis. This has previously been shown in some cohorts but not in all studies since, in other studies, subsite did not influence the prognosis ,25,31,32Of note, the frequency of perineural growth in our cohort was in line with that shown previously by others ,17,33,36Notably, there are some limitations in this study. Firstly, although we have many patients, the study is still a retrospective one, and not all patients were followed for >15 years. Furthermore, patient treatment varied to some extent, although most patients received multimodal treatments. Finally, the follow-ups of the patients were not identical, which potentially could, in some cases, depending on the follow-up, affect the DFS data; still, this is also the case for many other cohorts reported by others. However, this was not the case for the OS data, which were derived through the Swedish death registry.MYB or MYBL1 genes, overexpression of MYB-NFIB transcripts, or mutations that activate the NOTCH pathway can be of value for prognostication and/or specific therapies [Other limitations are that we do not include studies of immunohistological or molecular biomarkers in this study, of which some have been described before to be of specific value and where some could be of use for targeted therapies ,44,45,46herapies ,41,42,43herapies . These aherapies . Moreoveherapies .In summary, we confirmed that AdCC is more common in female patients; it appears in adult patients, most often in their fifth decade, but can even appear in younger and elderly aged patients. The strongest prognostic factors are the stage of the disease, as well as the subsite, with the best prognosis of AdCC in the major salivary glands. Furthermore, multimodal treatment was superior to single-treatment modalities.Contrary to what others have shown, we could not find any significant correlation in survival in regard to perineural invasion and radical surgery. Furthermore, we found that other common prognostic factors, such as smoking status, age, and gender, often applicable for other cancer types, should not be used as prognostic factors in the AdCC of the head and neck. This study underlined the need to in the future find new molecular prognostic markers and additional treatment options for this disease and identify patients with poor prognosis upfront since, so far, systemic oncological treatments do not show sufficiently promising results ,39,48.In this retrospective study, we confirmed that AdCC was more common in female patients, often occurring in the fifth decade, although it can appear in younger and older ages. In our cohort, the strongest favourable prognostic factors were early disease stage (stage I and II) and major salivary gland subsite, with the best prognosis in the AdCC of the parotid gland. Furthermore, multimodal treatment was superior to single-treatment modalities.In contrast to some other reports, we did not report any significant correlation between perineural invasion, radical surgery, and survival.However, in addition, similar to other studies, we confirmed that other common prognostic factors, such as smoking status, age, and gender, should not be used as prognostic factors in the AdCC of the head and neck region.


Data on the presence and extent of cardiovascular disease (CVD) risk in primary hyperparathyroidism (PHPT) are conflicting. In our study, we aimed to investigate the increased CVD risk in patients with PHPT by carotid intima-media thickness (CIMT), epicardial adipose tissue (EAT) thickness, and serum levels of endocan and nesfatin-1.Patients with PHPT (n = 44) and age- and sex-matched healthy control subjects (n = 40) were enrolled in this study. Demographic data of the participants were questioned. Serum endocan and nesfatin-1 concentrations were assessed using commercially available ELISA kits. Noninvasive measurements of CIMT and EAT thickness were made with high-resolution ultrasonography and B-mode echocardiography.There was no statistically significant difference in serum endocan and nesfatin-1 levels and EAT thickness in the PHPT group compared to controls. CIMT was statistically significantly higher in the PHPT group compared to controls (p = 0.001). A negative correlation was found between PTH and low-density lipoprotein cholesterol level (p = 0.001) but no significant relationship was found between other parameters.We found that CIMT is increased in patients with PHPT and consequently, CVD risk is high in these patients. More comprehensive studies are needed to identify other markers that predict increased CVD risk in patients with PHPT. Primary hyperparathyroidism (PHPT) is the most common cause of hypercalcemia detected in outpatients  and is cEndothelial dysfunction is considered an early feature of developing atherosclerosis and is characterized by the promotion of vascular dysfunction and progression of atherosclerosis . CarotidEndocan  is a soluble proteoglycan (50 kDa) , secreteNesfatin-1, a 82 amino acid polypeptide, was first discovered in 2006, found to be expressed in the hypothalamus, and involved in regulating food intake , 16. NesThe aim of our study was to evaluate the clinical relevance of serum endocan and nesfatin-1 levels, EAT thickness, and CIMT as markers of increased cardiovascular disease (CVD) risk in patients with PHPT.In this case-control study, 44 patients with clinical evidence of PHPT, i.e. those with hypercalcemia and high or inappropriately normal PTH levels, and 40 healthy control subjects were enrolled from October 2019 to October 2020.Study participants were selected from patients diagnosed at the Department of Endocrinology and Metabolism at Necmettin Erbakan University Meram Medical School. Necmettin Erbakan University Ethics Committee approved the study with the approval no 2019/2092 and the date 20.09.2019. The study complied with the Ethical Principles of the World Medical Association Declaration of Helsinki. Written “Voluntary Informed Consent Form” was obtained from the patient and the control group who agreed to participate in the study. Demographic and clinical information was collected regarding patients’ sex, age, and biochemical examination.2, arterial blood pressure, waist and hip circumferences) and laboratory measurements . Subjects with clinical evidence of CVD , any other major disease , DM, recent history of trauma or surgery, or pregnancy were excluded. In addition, those younger than 18 years old and those over 65 years old were excluded from the study. Demographic data of the groups are shown in The participants were recruited from PHPT patients firstly admitted to our department and from healthy volunteers who were admitted for a routine medical assessment. All participants were evaluated by medical history , physical examination , plasma aliquots were stored at −80 °C  until analysis.Ten milliliters of peripheral venous blood samples were obtained from all patients and sent to the laboratory for processing. After centrifugation at 4000 rpm for 10 min at 4 °C  and ELISA kit  according to the manufacturer’s standard protocol. The endocan levels were expressed as pg/mL . Serum cCIMT measurements were performed by an experienced cardiologist, blinded to patients’ clinical and laboratory data, using a commercially available ultrasound system with a 2.5–3.5 MHz transducer , according to the consensus guidelines for carotid ultrasound for CVD risk assessment as described previously . UltrasoAfter detailed medical history and physical examination, echocardiography of patients were performed by an experienced cardiologist, blinded to patients’ clinical and laboratory data, using a commercially available ultrasound system with a 2.5–3.5 MHz transducer . A previously validated method was used to assess EAT thickness in captured images . BrieflyStatistical analysis was performed using SPSS 21.0 program. Continuous variables were given as mean ± standard deviation if the distribution was normal, and as median (minimum–maximum) if the distribution was not normal. The Kolmogorov–Smirnov test was used to determine whether the data were normally distributed or not. In the comparison of independent group differences, the significance test of the difference between the two means (independent samples t-test) was used when the parametric test assumptions are provided; The Mann–Whitney U test was used to compare the independent group differences when the parametric test assumptions were not provided. Chi-squared test was used to compare categorical variables between independent groups. The Pearson test was used for correlation analysis between numerical variables with normal distribution, and The Spearman test was used for correlation analysis between numerical variables that did not show normal distribution. For differences, p < 0.05 was considered statistically significant.The study involved 84 cases, including 44 PHPT patients and 40 healthy controls. Of the 44 PHPT patients, 39 (88.6%) were female and 5 (11.4%) were male. Of the 40 control subjects, 36 (90%) were female and 4 (10%) were male. The mean age of the PHPT patients was 49.95 ± 10.55 years, the mean age of the control subjects was 48.42 ± 10.19, and there was no difference between the two groups in terms of age and sex .Waist circumference, hip circumference, waist/hip ratio, low-density lipoprotein (LDL) cholesterol level, and CIMT values were statistically significantly higher in the PHPT group compared to the control group. In addition, as expected, calcium, PTH, and alkaline phosphatase levels were higher and phosphorus levels were lower in PHPT patients than in the control group.Body mass index, systolic blood pressure (SBP), diastolic blood pressure (DBP), urea, creatinine, triglyceride, magnesium, ejection fraction values were higher in the PHPT group compared to the control group, but there was no statistically significant difference. Glucose, HbA1c, high-density lipoprotein (HDL) cholesterol, albumin, C-reactive protein, vitamin D, thyroid-stimulating hormone, and EAT thickness values were higher in the control group compared to the PHPT group, but there was no statistically significant difference.Serum endocan level was measured as 824.8 ± 351 pg/mL and 826.68 ± 373.65 pg/mL in PHPT patients and control group, respectively. Serum nesfatin-1 level was measured as 148.8 ± 4.5pg/mL and 149.14 ± 5.66 pg/mL in the PHPT patients and the control group, respectively. There was no difference between the two groups in terms of serum endocan and nesfatin-1 levels  .In correlation analysis, a negative correlation was found between PTH and LDL cholesterol levels (p = 0.001). No significant relationship was found between other parameters .As a result of our study, we found that CIMT, LDL cholesterol, waist circumference, hip circumference, and waist/hip ratio values were higher in the mild PHPT patients. We found that there was no difference between the PHPT patients and the normal population in terms of other parameters such as endocan, nesfatin-1, and EAT thickness.High calcium and PTH levels in PHPT patients have been shown to negatively affect vascular function, especially by disrupting vasodilation . CIMT isNot only bone and kidneys, but also cardiomyocytes, endothelial cells, and smooth muscle cells express PTH receptors . In someAdipose tissue is considered an endocrine organ that secretes many hormones and adipokines, including leptin, adiponectin, and tumor necrosis factor-α (TNF-α), which have proinflammatory and proatherogenic effects and lead to negative metabolic and cardiovascular consequences , 37. EpiClassically known cardiovascular risk factors include DM, hyperlipidemia, HT etc. In our study, no significant difference was found between PHPT patients and healthy controls in terms of glucose, SBP, DBP, triglyceride, HDL cholesterol levels. We found that LDL cholesterol levels were lower in PHPT patients than in the control group. There are conflicting data in this context in the literature. In a study investigating CVD risk factors in PHPT patients, high SBP, fasting glucose, insulin, and uric acid levels were found. In the same study, it was reported that SBP, DBP, triglyceride, fasting glucose, insulin, and uric acid levels were higher in severe PHPT patients, and SBP and insulin levels were higher in mild PHPT patients . In anotAdvances in biomarker research and recent developments in the field of CVD have led to greater emphasis on more sensitive screening methods and early detection, and improved treatments that result in more positive clinical outcomes . EndocanIn the current study, no significant correlation was found between PTH and CIMT and EAT. However, we found a negative correlation between PTH and LDL cholesterol. We think that the negative correlation between PTH and LDL cholesterol is coincidental due to the small sample size.Some limitations of our study are the small sample size, especially when it comes to men, and the fact that the majority of the patient group consists of patients with slightly elevated calcium levels. In addition, the fact that parameters such as CIMT and EAT were examined instead of more sensitive and specific methods such as coronary calcium scoring as an indicator of CVD risk and that no evaluation was made after surgical and/or medical treatment are among the important limitations of the current study. One of the limitations of our study is that the control group selection was made from healthy controls admitted to the hospital for different reasons.In conclusion, we found that CIMT was increased in patients with mild PHPT, and we, therefore, think that CVD risk may be higher in these patients. Studies with higher number of patients and longer follow-up are needed to determine the factors leading to increased CVD risk in patients with PHPT.