The FTIR indicated that the films contain various functional groups, such as alkane (C-H), hydroxyl (-OH), carbonyl (C=O), carbonate (CO32−), and carboxylic acid (-COOH) that can act as biosorption materials. According to the findings, the developed film exhibits a notable enhancement in its water barrier properties, thereby leading to improved adsorption capacity. The batch experiments showed that the film obtained the maximum removal percentage at pH = 8 and 6 g of biosorbent dose. Notably, the developed film could reach sorption equilibrium within 120 min at the initial concentration of 80 mg/L and remove 99.95% of Cd(II) in the aqueous solutions. This outcome presents potential opportunities for the application of these films in the food industry as both biosorbents and packaging materials. Such utilization can significantly enhance the overall quality of food products.The conversion of waste into a valuable product is regarded as a promising alternative to relieving the burden of solid waste management and could be beneficial to the environment and humans. This study is focused on utilizing eggshell and orange peel enriched with banana starch to fabricate biofilm via the casting technique. The developed film is further characterized by field emission scanning electron microscope (FESEM), energy dispersive X-ray spectroscopy (EDX), atomic force microscopy (AFM), X-ray diffraction (XRD), and Fourier transform infrared spectroscopy (FTIR). The physical properties of films, including thickness, density, color, porosity, moisture content, water solubility, water absorption, and water vapor permeability, were also characterized. The removal efficiency of the metal ions onto film at different contact times, pH, biosorbent dosages, and initial concentration of Cd(II) were analyzed using atomic absorption spectroscopy (AAS). The film’s surface was found to have a porous and rough structure with no cracks, which can enhance the target analytes interactions. EDX and XRD analyses confirmed that eggshell particles were made of calcium carbonate (CaCO Since the 1960s, agricultural production has increased over threefold, primarily due to the expansion of cultivated land and technological advancements during the green revolution. These developments have led to higher yields, which have helped to meet the demands of a growing global population. According to the Food and Agriculture Organization (FAO) 2017 report, the world presently produces approximately 23.7 million tons of food daily [3), and protein acid mucopolysaccharides [2), thiol (-SH), and amide (-CONH2) functional groups that can be employed to bind heavy metal ions [Food-processing by-products of eggshells are among the most significant by-products, with eight million tons annually discarded and harming the environment. Eggshells are particularly relevant since they are abundant waste generated by the food industry. They are economical and environmentally friendly due to their availability and lack of toxic or hazardous constituents. They are as effective as activated carbon, which is more expensive. Adsorption properties of chicken eggshells include created porosity, calcium carbonate CaCO, and procharides . This prtal ions . Wang ettal ions  preparedtal ions  investigtal ions  utilizedOrange peel, a common agricultural waste, mainly consists of cellulose, hemicellulose, pectin, and lignin components with various O/N-containing functional groups and pyranose/benzene rings . It is eThe utilization of biosorbents in powder form can make it challenging to separate the phases after biosorption. To address this issue, physical modifications of these materials present a promising alternative. One possible solution is the development of biosorbent films, which can effectively remove metal ions by combining the two biomaterials mentioned above and facilitate phase separation after biosorption . Native In this study, an eggshell/orange waste-based biosorbent film enriched with banana starch was fabricated, and its physicochemical properties were characterized. The physical and chemical attributes of the film, including thickness, density, structure, porosity, color, functional groups, and water resistance, were examined. Additionally, the film’s efficacy in removing metal ions was evaluated under various conditions, such as pH, biosorbent dosage, contact time, and initial ion concentration.Musa acuminata x balbisiana) was purchased from fresh mart Korporasi Pembangunan Desa (KPD), Likas, Kota Kinabalu, Sabah.Raw eggshell and orange peel waste were collected from households and a nearby restaurant in Kota Kinabalu, Sabah, respectively. Green banana Saba , sieved through a 125-micron sieve using a vibrating sieve shaker , and fine powder was obtained. Fresh eggshells were washed in water to remove impurities from raw materials and then dried in an oven at 50 °C for 5 h. The dried eggshells were crushed and sifted through a 125-micron sieve .Musa acuminata x balbisiana) was isolated using the dry extraction method, where the bananas were peeled, sliced into 2 cm slices, soaked in a 2% w/v citric acid solution for 5 min, and blended for 2 min. The banana pulp and the residual solution were centrifuged  for 5 min at 7500 rpm at room temperature, and the supernatant was discarded. The white starch sediments were dried for 18 h in a universal oven at 55 °C and sieved with aperture sizes of 125-micron [The starch from unripe banana Saba pulp  was mixed in 30 mL of distilled water and stirred for 1 h at room temperature with a magnetic stirrer to fully wet the eggshell powder particles. Following that, 6 g of banana starch flour (3%) was dissolved in 170 mL distilled water and gelatinized for 5 min at 80 °C using a hot plate . Afterward, the eggshell powder dispersion was added dropwise to the incomplete gelatinized starch solution, and magnetic stirring was performed for 30 min. The solution was heated for 30 min at 80 °C and stirred at 400 rpm to allow complete gelatinization of the banana starch before being cooled to room temperature. After that, 1 g of orange peel powder  was added to the eggshell powder‒banana starch solution and thoroughly mixed. The final eggshell–orange peel powder–banana starch solutions were then poured into Petri dishes and allowed to dry for 24 h at room temperature. The development of the film is illustrated in −1.The FESEM images of banana starch, eggshell powder‒banana starch, orange peel powder‒banana starch, and eggshell–orange peel powder–banana starch film was obtained from field emission scanning electron microscopy equipped with energy-dispersive X-ray spectroscopy (FESEM-EDX) . The film samples were coated with gold using a sputter coater  before scanning by FESEM-EDX. The surface roughness of the film was characterized by a high-resolution atomic force microscope (AFM) (Bruker MultimodeE4-Sys(8E/8J), Billerica, MA, USA) in tapping mode under ambient temperatures (22 °C). X-ray diffraction of the films was recorded by an X-ray diffractometer. The radiation used was Cu K-alpha whereas nickel metal was used as a beta filter. The range of diffraction angle was 10–80° . The presence of functional groups in the films was determined by the FTIR spectrometer  in the spectrum range of 4000–400 cmi) (2 cm × 2 cm) was estimated. The films were dried for 24 h at 105 °C, while the final weight (Wf) was measured and recorded. The density was evaluated using Equation (1) below [i is the initial weight of the film before drying (g), Wf is the final weight of the film after drying (g), A is the area of the film (cm2), and t is the film thickness (mm).The thickness of banana starch, eggshell powder‒banana starch, orange peel powder‒banana starch, and eggshell–orange peel powder–banana starch films was measured at five random points using a digital micrometer  with an accuracy of 0.001 mm. The average value was then calculated. Next, the original weight (W1) below :Density The color of the films was determined by a colorimeter  and expressed as the average L value (lightness), a value (redness/greenness), and b value (yellowness/blueness). The yellowness index and whiteness index were calculated using Equations (2) and (3). The total color difference (ΔE) was also calculated by Equation (4) .Yellown1 is the weight of the film, W2 is the sum of the ethanol and the immersed film, and W3 is the weight of residual ethanol after the removal of the film.A liquid displacement method was used to calculate the percentage of film porosity. The displacement liquid was chosen to be ethanol. This method involved immersing the various dried film formulations in absolute ethanol for 24 h. After reaching equilibrium, the films were removed, and the weight of residual ethanol was recorded . The por1), and each film was dried at 105 °C until reaching a constant weight (W2). Moisture content was measured according to Equation (6) [The weight of each film (2 cm × 2 cm) was measured to obtain the initial sample weight (Wtion (6) :Moisture3) was recorded. Therefore, the water solubility of the film (%) was determined using Equation (7) below:For the water solubility test, each film was then immersed in 50 mL of ultrapure water and kept at room temperature for 24 h. After hydration, the wet film was gently wiped using filter paper and dried in an oven at 105 °C for approximately 24 h, and the final weight (Wi) before being submerged in 20 mL of water in a 50 mL container. The container was closed and left at room temperature for 1 h. After 1 h of immersion, film samples were removed, wiped with tissue paper to remove the excess water on the surface, and their wet weight (Wt) was recorded, followed by water absorption calculation using Equation (8) below [The water absorption (or swelling) of the film was calculated as the percentage of water absorbed by the film after 1 h of immersion in water. A film sample (2 cm × 2 cm) was weighed to determine the initial weight (W8) below .Water a2), Δt is the test time (day), x is the thickness (m) of the film, and ΔP is the differential of water vapor pressure through the film (Pa). A driving force of 2339 Pa was applied as a differential vapor pressure of water.The water vapor permeability values were obtained using the ASTM E96 method known as the “cup method” through a specifically developed permeability cell . Each 400 and Ce are the initial and final metal ion concentrations (mg/L), V is the volume of the solution in liters, and m is the weight of the dry adsorbent in grams.The batch adsorption experiments were performed to investigate the kinetic absorption of cadmium(II) metal ions onto the eggshell–orange peel powder–banana starch film by studying the effects of the adsorbent dosage, pH, contact time, and initial concentration. The metal ions standard solution (1000 mg/L) was used to prepare 100 mg/L of metal ions stock solution. In this study, the adsorbent dosage varied from 1.2 g to 6 g. The pH was varied from 2 to 10, and it was adjusted using 0.1 M HCl and 0.1 M NaOH solution. The contact time varied from 15 to 120 min. After a predetermined time was reached, the adsorbate mixture was withdrawn and filtered. Metal ions were initially concentrated at 5 ppm to 100 ppm. Finally, the amount of metal ions left in the filtrate was determined using an Atomic Absorption Spectrophotometer (AAS). After the adsorption process, the removal percentage (%) and adsorption capacity (mg/g) were calculated using Equations (11) and (12) :Removal p < 0.05).The results will be expressed as the means ± standard deviation (SD) of 5 replicate (n = 5) measurements to ensure the accuracy of data. IBM SPSS Statistics 27 will be used to analyze the data. The physicochemical properties data were analyzed using one-way analysis of variance (ANOVA) with a post hoc Tukey test to measure significant differences  from eggshell powder agglomerating on the starch matrix. The agglomeration leads to poor eggshell powder dispersion, which causes roughness on the film surface [The optical, sensory evaluation, and physical appearance of banana starch, eggshell powder–banana starch, orange peel powder–banana starch, and eggshell–orange peel powder–banana starch films are shown in  surface .The color of films is a crucial factor in their overall appearance and consumer acceptance. L, a, and b values were measured to describe a three-dimensional color space. L indicates lightness and reads from 0 (black) to 100 (white). A positive a value indicates redness, while a negative a value indicates greenness; a positive b value represents yellowness, while a negative b value represents blueness . The degp > 0.05) between banana starch (−5.68 ± 0.30) and orange peel powder–banana starch (−5.52 ± 0.44) film. However, the addition of eggshell powder yielded a slightly higher a value in eggshell powder–banana starch (−3.86 ± 0.15) and eggshell–orange peel powder–banana starch (−3.86 ± 0.11) films compared with the control banana starch film. The L and b values were significantly different when compared between the films (p < 0.05). The control banana starch film (93.32 ± 1.53) had the highest L value, followed by orange peel powder–banana starch (84.90 ± 2.75), eggshell powder–banana starch (72.50 ± 1.70), and eggshell–orange peel powder–banana starch (61.06 ± 1.17) films. It was observed that the addition of eggshell powder made the eggshell–orange peel powder–banana starch film darker and had the lowest L value compared with the control banana starch film. In addition, the eggshell–orange peel powder–banana starch film (54.47 ± 0.86) also had the lowest whiteness index value compared with other films. Incorporating polymer with orange peel contributed to a yellower and darker brown composite film.Considering the a value, it was observed that the a values showed no significant difference (p < 0.05) with the addition of orange peel powder. The results showed that eggshell–orange peel powder–banana starch (54.43 ± 0.57) and orange peel powder–banana starch (33.11 ± 1.18) films had the highest yellowness index values compared with control banana starch (17.09 ± 2.61) and eggshell powder–banana starch (26.68 ± 1.69) films. These study results were similar to other studies that observed that films containing orange peel powder had a yellowish color owing to the existence of carotenoid pigments in the orange peel [On the contrary, the control banana starch film (11.14 ± 1.54) had the lowest b value, while the orange peel powder addition increased the b values of the orange peel powder–banana starch (19.66 ± 0.15) and eggshell–orange peel powder–banana starch (23.26 ± 0.33) films. The b value indicated that the yellow color intensity of orange peel powder–loaded films increased when compared with control banana starch and eggshell powder–banana starch films. In addition to that, the yellowness index values of the films changed significantly . In contrast, the inner layer consists primarily of uncalcified fibrous membranes composed mainly of organic compounds [In terms of cross-section, the banana starch film  and average roughness (Ra) values in 3 and contained a significant amount of carbon in the graphite.The elemental composition analysis of the films was determined using EDX. The major elements found in the films are carbon (C) and oxygen (O). The EDX results indicate that 85.6% carbon, 12.5% oxygen, and 0.2% potassium were detected in the banana starch film a. AccordThe orange peel powder–banana starch film c containThe amorphous and crystalline states of films composed of banana starch, eggshell, and orange peel powders were investigated by XRD analysis. For the banana starch film, starch particles have a semi-crystalline nature, as shown in 3 at room temperature, and it is found in eggshells and other rigid materials [3–MgCO3), with the absence of a calcium oxide (CaO) peak [3.Similar XRD peaks for orange peel powder were found by Akinhanmi et al.  at 2θ = aterials . The XRDaO) peak . This co−1 were identified as complex vibrational -OH stretching of hydrogen-bonded hydroxyl group [−1 were typical of -CH bond stretching of the alkanes group [−1 were the effects of vibrational C=O stretching of carbonyl groups of amide I resulting from water adsorbed in amorphous amylose regions, while bands at 1362.74 cm−1 and 1364.61 cm−1 were in the region of amide III. Bands in the amide III region were caused by C-N bond stretching and N-H bond inflection. Those bands indicate residual proteins in the starch film [−1 are caused by starch stretching of the C-C and C-O groups. The peaks at 1077.52 cm−1 and 1075.65 cm−1 were attributed to the C-O bond stretching of carboxylic acid (-COOH) groups, which has a major influence on the adsorption process and the effectiveness of adsorbing target analytes through ion exchange. The bending of COH and -CH groups caused by the cellulose component resulted in the peak at 1340.37 cm−1 of the orange peel powder–banana starch film  from 0.02 ± 0.01 to 0.07 ± 0.01 mm. The eggshell–orange peel powder–banana starch film presented the highest thickness value (0.07 ± 0.01 mm). The thickness of the control banana starch film was 0.02 ± 0.01, whereas the thickness of the eggshell powder–banana starch film was increased to 0.05 ± 0.01 mm due to the presence of CaCO3 particles in the eggshell powder, which improved the intermolecular bonding between ESP and starch film matrix [The thickness, density, porosity, and water barrier property values of the films are shown in m matrix . It was m matrix  findingsm matrix . Thus, tp < 0.05) with the addition of eggshell and orange peel powders. No significant difference (p > 0.05) was observed between the density of eggshell powder–banana starch (0.13 ± 0.03) and orange peel powder–banana starch (0.20 ± 0.08) films. However, the control banana starch film (0.26 ± 0.14) had the highest density, which might be due to a more compact structure of the starch film, which can be seen in the cross-section image  from 36.52 ± 1.82% to 82.53 ± 3.94% with the addition of eggshell powder and orange peel powder. This is due to the eggshell powder containing high CaCO3 concentrations, high porosity, and availability of functional groups [It is essential to determine the porosity percentage of the films in order to measure properties, such as water absorption and water vapor permeability. Furthermore, an ideal biosorbent film requires porosity for effective adsorption. Here, the porosity percentage of the films was evaluated, and the results are shown in l groups , which il groups  and Dey l groups , chickenp < 0.05) to 9.98 ± 0.46 and 10.23 ± 0.40, respectively compared with control banana starch film because of the discontinuity of the starch matrix, thus making space for water to escape from the structure of the starch [Moisture content, water solubility, water absorption, and water vapor permeability of films were measured to determine the film’s water barrier properties. Moisture content is the quantity of moisture present or absorbed by the film from the environment and released as vapor at high temperatures (80–100 °C) . It is ee starch . The inte starch .p < 0.05) upon adding eggshell powder in both eggshell powder–banana starch (13.06 ± 1.31%) and eggshell–orange peel powder–banana starch (13.58 ± 1.01) films. In this study, the water solubility of banana starch and the composite films followed the same pattern as the moisture content. This showed that eggshell powder reduced the hydrophilicity of films. In this case, the hydroxyl groups (-OH) of degraded starch interacted with the functional groups of ES molecules, resulting in a cross-linking network between them. Furthermore, eggshell powder–banana starch and eggshell–orange peel powder–banana starch films were less attractive to water molecules because of the reduced number of free -OH groups, which also slowed down the release of free polymer chains from starch to water, and caused eggshell powder–banana starch and eggshell–orange peel powder–banana starch films to be less soluble in water than banana starch films. A slight decrease in orange peel powder–banana starch film was due to essential oil compounds in the orange peel powder particles that were insoluble in water. Moreover, this decrease was also caused by cellulose insolubility in orange peel powder [The water solubility of the film is an extremely critical and important parameter, especially if the film is directly exposed to water . The conl powder .p < 0.05) to 88.64 ± 8.87% and 93.88 ± 28.48% for the eggshell powder–banana starch film and eggshell–orange peel powder–banana starch film, respectively. Water adsorption decreased significantly with eggshell powder loading due to the hydrophobic nature of eggshell powder particles as well as their interactions with the banana starch film matrix (decrease in the number of free hydroxyl groups) [As banana starch has free hydroxyl groups (-OH), it can exhibit high water adsorption, swelling, and solubility, resulting in one of the major disadvantages of banana starch composite films. The percentage of water adsorption of the films can be found in  groups) .−1 m Pa (×10−12) of water vapor permeability, which was increased to 6.47 ± 2.59 gs−1 m Pa (×10−12) in the eggshell–orange peel powder–banana starch film. The hydrophobic nature of eggshell powder resulted in a significant reduction in water adsorption due to the reduced amount of free OH groups that can form tortuous film structures, which increased the effective diffusion path length of water. On the other hand, adding eggshell powder particles could create channels or microvoids at the interface of the matrix, increasing water vapor permeability and providing large direct paths for water molecules [Film water vapor permeability refers to the impedance of the material to water vapor from the environment. Relatively speaking, the banana starch film showed a 2.20 ± 0.41 gsolecules . This reThe pH of a solution is a fundamental parameter that determines its removal efficiency (%) due to the fact that the pH of a solution affects the active sites on the biosorbent. Initially, the pH of the aqueous solution was 2.3. Here, the pH of the 5 mg/L of Cd(II) ion solution varied from 2 to 10 at a constant 1 g of biosorbent dose and 60 min contact time to evaluate the optimum pH for the removal of Cd(II) at room temperature. As the pH increased, the removal efficiency (%) increased and the maximum value was obtained at pH 8, which, then decreased drastically at pH 10 a. SimilaNext, the eggshell–orange peel powder–banana starch film has been examined for Cd(II) ions removal with contact times ranging from 15 to 120 min at fixed intervals of 15 min. The optimum contact time for the removal of Cd(II) ions was observed at 120 min c. The biIn this research, the eggshell–orange peel powder–banana starch film was prepared by a solution-casting method. According to FESEM analysis, the eggshell powder particles dispersed and adhered well to the starch matrix. In addition, the incorporation of orange peel powder improved the structure of eggshell powder particles with no agglomeration occurring, and eggshell–orange peel powder–banana starch films exhibited a porous surface with no cracks. Based on the AFM analysis, the XRD analysis revealed that the film has a semi-crystalline structure containing the main peaks at 2θ = 29.65° and 2θ = 29.49° due to the presence of calcite from eggshell particles. Furthermore, FTIR analysis showed that the eggshell–orange peel powder–banana starch film has many functional groups that contributed to the formation of hydrogen bonds and the compactness of composite films, as well as its potential to produce a strong absorption band that is strongly correlated with carbonate minerals in composite films. By integrating eggshell and orange peel powder, the eggshell–orange peel powder–banana starch film exhibits improved thickness, density, porosity, moisture content, water solubility, absorption, and vapor permeability when compared with banana starch films. Eggshell and orange peel powder can improve the mechanical strength, barrier properties, and hardness of the films without using cross-linking agents. In addition to that, the removal efficiency experiments conducted obtained the optimum pH at pH 8, 6 g of biosorbent dosage, 120 min of contact time, and 80 mg/L of initial concentration of Cd(II) ions. The biosorbent film successfully removed 99.69 mg/L of Cd(II) ions. Hence, this eggshell–orange peel powder–banana starch film is suitable to be used for the adsorption of target analytes, such as toxins or dyes that are present in food products.


This study examined intention for international assignment among workers in Ghana by modelling the role of motivators, demotivators and cultural disposition on such intentions. The cross-sectional survey design was used to sample 723 workers drawn from Northern Ghana. Data were collected with a self-administered questionnaire. The Partial Least Square-Structural Equation Modelling was used to analyse the data collected. The study found from individual workers’ and developing economy perspectives that cultural disposition influences motivation for accepting international assignments and expatriates’ intention to accept international assignments. Motivation and demotivation among workers were also found to have had a statistically significant relationship between expatriate intention and significantly mediated the relationship between cultural disposition and expatriate intention to participate in international assignments. Cultural disposition was, however, found to have a non-significance relationship with expatriates’ intention to accept an international assignment. It is therefore recommended that human resource managers should make international assignments attractive for workers and expose workers to cross-cultural training through job rotations, working in teams and experiential training. It is expected that such opportunities prepare individuals for an international assignment. The competitive business environment continues to compel organisations to spread their activities abroad for growth. Multinational and transnational organisations have resulted in deploying workers/managers to international locations to push their organisational goals and objectives . AssigneMeanwhile, the ability of organisations to achieve targets associated with international assignments largely depends on the success of assignees on the international assignment . SeveralMotivation or demotivation is not enough to explain the success of expatriates. For this reason, cultural disposition was found to have played a critical role in the success of international assignees . CulturaGhana hosts branches or headquarters of several multinational and transnational organisations. Therefore, the human resource of these organisations can be described as either host country, home country, or third-country national. The filling of vacancies in overseas subsidiaries will continue to be an important issue for international human resource managers for the growth of their organisations , 13. WhiIn this regard, workers’ intention towards an international assignment is key for international human resource managers to recruit for international assignments , 15. WorMeanwhile, earlier studies by –23 have The novelty and motivation for this study are not limited to the individual perspective but also to bring to the fore how cultural disposition, motivating, and demotivating factors from a developing economy perspective are influencing acceptance of international assignments. For this reason, this study sought to contribute to the literature on international assignment and international human resource management by examining the intention for international assignment among workers in Ghana. This study specifically modelled the role of motivators, demotivators, and cultural disposition in predicting intention to accept an international assignment from individual and developing economy perspectives. Thus, the role of factors that could serve as motivators and demotivators, as well as the cultural disposition of workers, were examined from workers’ perspectives in terms of how these factors could influence their intention and performance. The next sections of the paper focus on the theoretical review, conceptual model and hypotheses development. Other issues addressed were the methodology, results and analysis, discussion of the results, implications, conclusions and recommendations.power distance, individualism, masculinity; uncertainty avoidance; and long-term orientation [power distance, relates to power distribution between subordinates and superiors or society. The subordinates and superiors are the same in low power distance society. However, in a high-power distance society like the study context (Ghana), power is unevenly distributed or centralised among a few people. Hence superiors are different from subordinates because the superiors have power, and subordinates need to accept and respect it [This study was guided by the Hofstede’s Cultural Model. The cultural model propounded by Geert Hofstede in 1980 was based on five pillars-entation , 29. EacThe second pillar of Hofstede’s Cultural Model—Individualism/Collectivism, explains how individuals relate to a group. A society where individuals tend to focus on their own interests and that of the immediate family relates to an individualised culture [masculinity or femininity, deals with what motivates people. In masculine society, people strive to be the best; they portray values such as competitiveness and performance in that masculine have sympathy for the successful achievers, However, in feminine culture, people have a concern with relationships and quality of life [ culture . However of life .Uncertainty Avoidance- relates to the level to which individuals in society welcome uncertainty [short/long-term orientation, is also explained the extent to which society shows a future-oriented perspective versus a short-term point of view. Thus, short-term profit concentration characterised society with short-term orientation whiles people of long-term orientation emphasise future growth. The Hofstede’s cultural model with the five dimensions revealed that the Ghanaian society that serves as the study context is largely inclined towards a high-power distance culture, collectivism culture, feminine culture, high uncertainty avoidance culture, and short-term orientation culture [The fourth dimension-ertainty . In high culture , 29.The discussion in this section will focus on the key variables of the study, which are cultural disposition, motivation, demotivation, and intention to accept an international assignment among workers. The review for each subsection will be associated with the specific hypothesis related to it.Culture relates to a way of life and is described as “the collective programming of the mind which differentiates one group from the other” . CultureH1: Cultural disposition has a statistically significant effect on the intention to participate in an international assignment.1. H1: Cultural disposition has a statistically significant effect on motivation to accept an international assignment.2. job-related factors comprising role conflict, role novelty, role clarity and role direction, organisational factors including organisational culture novelty, social support from co-workers and superiors, and logistical support. Other categorisations were positional factors—hierarchical level, functional area and assignment vector; non-work factors-culture novelty and spouse/family adjustment; and individual factors including self-efficacy, relational and perceptual skills, previous international assignments, and language fluency [Demotivators to accepting international assignments are factors that make both companies and employees disinterested in expatriation. For this reason,  identifi fluency . If thesH1: Demotivation among workers toward international assignments has a statistically significant effect on the intention to participate in an international assignment.3. Several studies have found that there are many factors that motivate workers to accept international assignments , 29, 31.H1: Motivation to accept international assignments among workers has a statistically significant relationship with the intention to participate in an international assignment.4. H1: Motivation to accept international assignments among workers statistically significantly mediate the relationship between cultural disposition and intention to to participate in an international assignment.5. Based on the review, a conceptual framework was designed to guide the study, as shown in The study used a cross-sectional survey design . A sampl2), effect size (F2), and the importance and performance map analysis (IPMA), among others. All these qualities were utilised to make the results of this study very robust.Data were collected, using a self-administered instrument measured on a four Likert point scales where 1 = strongly disagreement, 2 = disagreement, 3 = agreement and 4 = strongly agreement. The questionnaire had two sections. Section one dealt with the biodata of respondents, and section two focused on the five hypotheses guiding the study. The questionnaire obtained a reliability value above the 0.70 thresholds which confirmed that the instrument was good to be used for the data collection. Cronbach alpha values obtained for cultural disposition was .703, motivation was .793, Demotivators was .853, and lastly, intention for international assignment was .868. Data were collected from July 2021 to November 2021. Ethical considerations such as respondents’ anonymity, freedom to withdraw, confidentiality, freedom to participate, and informed consent were observed . Writtenocio-demographic characteristics of respondents. The socio-demographic characteristics considered in this study, as presented in ocio-demographic characteristics were marital status, international and local languages spoken, and preferred continent for international job/assignment. The results in ocio-demographic characteristics revealed that the majority of the respondents were 30–39 years (48.5%), were male workers (62.0%), Ghanaians by birth (99.3%), public sector workers (82.4%), and never had an international working experience (82.3%). Additionally, the majority of the respondents had tertiary education (88.8%), were married with Kids (54.8%), were fluent in the English language (93.5%), could speak the Dagbani (32%) and Twi local (30.8%) languages, and preferred Europe (48.1%)for their international assignment or job. Though the demographic characteristics are not directly related to the study hypotheses, readers need to understand the characteristics of respondents prior to the presentation of the main findings of the study in the next section.The first part of the results presented in this section is the sThe estimation of the internal consistency measure of the model was initially carried out with the use of the PLS algorithm for confirmatory factor analysis. The individual items forming each construct or variable in the study were used for the measurement, as seen in the reflective model presented in The PLS path model’s internal consistency measures were further measured with four indices: rho A, Composite Reliability, Cronbach’s Alpha and Average Variance Extracted (AVE) . ResultsHeterotrait-Monotrait Ratio (HTMT) was used to ascertain the exclusivity of each construct in the model, as recommended by . The resThe inner VIF (variance inflated factors) was used to check the existence of multicollinearity since its existence can fluctuate or affect the results. The recommendations of  of VIF vBefore results for path analysis are presented, a bootstrapping sequence of 5000 samples utilised in the PLS according to the recommendation of  was carr2. The adjusted r-square in β = 0.393, t = 10.235, p = 0.000) for hypothesis two. There was a significant statistical relationship between demotivation for international assignment (DEMOT) and intention to participate in an international assignment (INTPERF) at  for hypothesis three; and motivation for expatriation (MOT) and expatriate’s intention to participate in an international assignment (INTPERF) at  for hypothesis four of the study. The last hypothesis was supported because it attained statistical significance. That is, motivation (MOT) statistically and significantly mediated the relationship between cultural disposition (CD) and expatriate intention to participate in an international assignment (INTPERF) for hypotheses five at . Meanwhile, the study found a non-statistical significant relationship between cultural disposition (CD) and expatriate intention to participate in an international assignment (INTPERF) at  for hypothesis one.The results for the path analysis, as presented in PLS Importance Performance Map Analysis (IPMA) was conducted in this study to further check the PLS estimates of the structural model variable relationships, and the results are presented in This meant that the size of the total unstandardised effect increased the performance of the target construct when there was an increase in certain predecessor construct’s performance. The results, as presented in 2 in the PLS path model. Additionally, [ionally, , 41 beliThe discussion of the results session focuses on the five hypotheses guiding the study based on the three independent variables of the study  related to the dependent variable-intention to accept an international assignment. The findings for hypothesis one, that there was a non-statistical significant relationship between cultural disposition and expatriate intention to participate in an international assignment, can be explained further. The result suggests that an expatriate’s experience in working in different cultures in terms of weather, food, and clothing, and ability to work with people of different cultures were good for an expatriate assignment but do not solely influence their intention. The result suggests that cultural disposition alone is not enough to influence the intention of expatriates to accept an international assignment. Thus, from the individual workers’ and developing economy perspectives, a cultural disposition is not enough to ensure significant relations with an intention to accept expatriate assignment. The results thus disagree with that of , who fouIt is important to note that the non-significant relationship established between cultural disposition and expatriate intention in hypothesis one is further and better explained by hypothesis five. The findings for hypothesis five suggest that motivation statistically and significantly mediates the relationship between cultural disposition and the expatriate’s intention to participate in international assignments. The results mean that expatriates need to be motivated to take up an international assignment in addition to their cultural disposition before they can accept an international assignment. Thus, an employee must be convinced or motivated that in addition to cultural disposition, an international assignment will help him/her to meet career goals, bring him/her recognition, opportunities, and social rewards, will empower him/her for future higher assignments, to experience higher performance on the international assignment. The results mean that motivation is a potent mediator between cultural disposition and acceptance of an international assignment from an individual and developing economy perspectives. The findings agree with the findings of  that expFindings for hypothesis two, that there was a statistically significant relationship between cultural disposition and motivation for an international assignment, need further explanation. The results can be explained that expatriates will be motivated to take up an international assignment when they have experience in working in different cultures, are able to work with people from different cultures and when one has the ability to learn other languages. Thus, motivation for an international assignment is highly dependent on one’s cultural disposition. To increase workers’ motivation for international assignments in other parts of the world, employers will need to pay attention to exposing workers to different cultures. This could take the form of organising cross-cultural training for workers expected to take up international assignments. This finding of the study equally corroborates the findings of  that culThe findings that demotivation among workers’ assignments significantly predicted the intention to take up an international assignment have several dimensions to be explained. The results suggest that there are factors that can cause disaffection toward opting for an international assignment. Thus, expatriates’ intentions and performance could suffer depending on the level of dissatisfaction. A low dissatisfaction could lead to a low effect on intention, and a high dissatisfaction could lead to a high effect on the intention of expatriates. Thus, expatriates’ intentions could be affected if the worker’s spouse cannot accompany them on an international assignment and cannot get the right person to take care of the family at home while on an international assignment. Other dissatisfiers that could influence acceptance for expatriate assignment and intention to accept an international assignment were the negative impact of an internal assignment on children’s education and not being able to readjust after the expiration of an international assignment. The findings of this study agree with the findings of , 39 thatThe last finding of the study, that motivation for expatriate assignment significantly influences intention to participate in an international assignment, also need to be explained further. The results mean that workers will be motivated to take up an international assignment if motivators are attached to the appointment. Thus, if a worker is forced or coerced to take up an international assignment against their will, this could affect the intention and performance. The results further suggest that it is not enough to use an organisational perspective to determine intention for international assignments as captured in previous studies. Rather, individual workers’ motivation for international assignment is key for successful international assignments among expatriates. Thus, the findings of  that motThe findings of this study have several theoretical implications for Hofstede’s Cultural Model. This study is premised on a national culture that is generally characterised by high power distance culture, collectivism culture, feminine culture, high uncertainty avoidance culture and short-term orientation culture, as captured in the five dimensions of the theory. These characteristics need to be considered and respected by human resource managers when recruiting and training people for an international assignment in Ghana or sending a Ghanaian on an expatriate mission. This is because the findings of this study have confirmed certain hidden characteristics in theory. These are cultural matters in international business. There is a statistical difference between the populations of two countries or ethnic groups. The dimensions reflect stable national differences, implying that cultures tend to move together in the same cultural direction. Thus, cultural adaptation and integration become easier for an expatriate assignment in similar cultures.The findings of this study have practical implications for human resource managers of multinational organisations. The human resource of every organisation remains one of the most important factors for international organisations. The first implication of this study relates to the relevance of cultural disposition for intention and expatriate performance. It suggests that human resource managers need to expose their workers to other cultures to prepare individuals to accept and work in other cross cultures. Cross-cultural exposures can come in the form of job rotations, transfers and teamwork. These can help to expose the individual to local cross-cultural elements, which could serve as a launchpad for accepting to work on an international assignment.Another implication of the results of this study also relates to the motivation level of workers to accept an international assignment. It calls for ensuring that better packages are associated with international appointment. This could relate to remuneration, jobs for spouses, provision for children’s education, intense cross-cultural training and allowing workers to have international exposure by visiting the country of the international assignment before finally taking the appointment. Closely related to the motivation was also the demotivation for international appointments. Failure on the part of human resource managers of international firms to provide adequate information on the international appointment and exposure of workers to other cultures can result in two things. That is, it can lead to an unwillingness to accept an international assignment and greater chances of expatriate failure or poor performance. The policy implication of the findings of this study was that culture, motivation and demotivation should be taken very seriously by all multinational organisations for greater acceptance and for an international assignment.This study examined the motivation and demotivation for accepting expatriate assignments among workers in Ghana. Previous studies have examined these factors from organisational perspectives. However, the present study examined these factors from individual workers and from developing economy perspectives. Therefore, it can be concluded from the individual and developing economy perspectives, based on the findings of this study, that cultural disposition influences motivation for accepting an international assignment. Motivation and demotivation among workers were also found to have had a statistically significant relationship between expatriate intention and significantly mediated the relationship between cultural disposition and expatriate intention to participate in an international assignment. However, cultural disposition was found to have a non-significance relationship with expatriates’ intention to accept an international assignment. The contribution of this study to knowledge is from individual and developing economy perspectives. That is, cultural disposition alone is not potent to relate very well to acceptance of international assignment among individual workers in a developing economy like Ghana. Rather, cultural disposition becomes a significant factor when associated with motivators.These conclusions call for a recommendation for managers of multinational organisations and human resource managers. Therefore, it is suggested that human resource managers expose workers to cross-cultural training through job rotations, working in teams, and experiential training. It is expected that such opportunities will reduce culture shock and prepare individuals for an international assignment. It is also recommended that international assignments should be made very attractive to be able to appeal to workers to be willing to accept such job openings. Expatriates should get more recognition, opportunities, social rewards, professional skills, attractive remuneration and other benefits, among others, attached to the expatriate job. The expatriate should also be prepared well for repatriation after the end of an international assignment.Additionally, human resource managers should deal with demotivators with an international assignment. These demotivators relate to alienation from family, not getting the right person to take care of the family while on the international assignment, and differences in religious beliefs between host and home countries. This can be addressed by ensuring that expatriates are sent to their country or continent of their choice or similar exposure. Allowing a spouse to accompany the expatriate and providing jobs for spouses, as well as paying academic bills for children’s education for the expatriate in the foreign country, will be very helpful in addressing some of the challenges that relate to demotivation.This study was limited to a quantitative approach and failed to capture the qualitative dimensions. The focus of this study was on the general motivation and demotivation among workers in Ghana toward an international assignment. It did not focus on only workers already on an international assignment. Future studies can pursue these dimensions. The analysis of this study did not consider the demographic characteristics of respondents in terms of gender and sector of employment. Other further studies can consider these perspectives. A comparative study between two or more countries will also be very revealing.S1 Appendix(DOCX)Click here for additional data file.S2 Appendix(DOCX)Click here for additional data file.S1 Data(CSV)Click here for additional data file.


P < 0.001), with increased and then decreased vascular stiffness along the proximal transmission to the distal peripheral artery and then to the finger. Adjusted for age and sex, ulPWVs in hypertension exceeded that of healthy individuals, with significant differences between groups aged ≥ 50 years (P < 0.05). The hrPWV/rfPWV  was reduced in hypertension and differed significantly between the aged ≥ 50 years (P = 0.015); the ratio of baPWV  to ulPWV differed significantly between groups (P < 0.05). Hypertension affected the consistency of rfPWV with hfPWV (heart-finger). The findings suggest that segmented ulPWV is instrumental in providing stiffness corresponding to the physiological structure of the vessel. The superimposition of hypertension and or aging exacerbates peripheral arterial stiffness, as well as alteration in stiffness gradient.Theoretically pulse wave velocity (PWV) is obtained by calculating the distance between two waveform probes divided by the time difference, and PWV ratio is used to assess the arterial stiffness gradient (SG) from proximal to distal. The aim was to investigate segmental upper-limb PWV (ulPWV) differences and the effects of hypertension and or aging on each ulPWV and SG. The study collected multi-waveform signals and conduction distances from 167 healthy individuals and 92 hypertensive patients. The results showed significant differences between ulPWVs ( It has been shown that changes in vessel elasticity precede changes in vessel stenosis4. Therefore the PWV technique for non-invasive assessment of vascular stiffness has been a hot topic of clinical research and application since its introduction. In recent years, the assessment of local peripheral vascular stiffness and its role in the arterial stiffness gradient (SG) has gained importance with the deepening of machine studies and the advancement of equipment technologies6. Physiological SG formation is due to the naturally uneven distribution of elasticity in arteries throughout the body. As the distance from the heart increases, the elastin content of the arterial structure decreases, the collagen fiber content increases, and the diameter decreases, resulting in increased stiffness of the aorta to the peripheral arteries. The reduction, disappearance or even reversal of SG is thought to lead to hemodynamic damage in hyper perfused organs such as the brain and kidneys8. Fortier et al.7 applied the ratio of cfPWV to crPWV  to the prognosis of dialysis patients, with the results supporting that the PWV ratio is a better predictor of dialysis mortality than cfPWV. Additional studies support the aortic-peripheral PWV ratio as an independent indicator for evaluating vascular ageing and cardiovascular disease risk10. Although there are opposing viewpoints, the quantification of peripheral vascular stiffness is gradually highlighting its value13.The ulPWV contains information on vascular stiffness from the heart to the axillary, brachial and radial arteries as well as to the terminal circulation of the fingertips. The diameter of blood vessels gradually decreases during the process. For example, the average internal diameter of the brachial artery is approximately greater than 4 mm to that of the small arterial conduit, which averages less than 2.3 mm15. Changes in the composition of the vessel wall and the diameter cause changes in the elasticity of the vessel. Compared to the aorta and lower limb arteries, ulPWV is easier to measure and portable16, however there are fewer studies of segmented ulPWV. Upper limb arteries can be used to evaluate the efficacy of clinical pharmacological interventions in hypertension18 and also to study the effects of exercise or lifestyle on vascular stiffness21, all of which place demands on the methods and data of local peripheral arterial PWV. Although baPWV is widely used in Asia, the accuracy of this index is affected by diseases such as stenosis of the upper limb arteries, and it has also been suggested that baPWV combines the information on peripheral arterial stiffness22. Thus, we propose that there is a value in using PWV to assess upper limb arterial stiffness.Increased vascular stiffness is strongly associated with the onset and progression of cardiovascular (CVD) events, and central aorta such as cfPWV  and baPWV  can be used for risk prediction and prognostic assessment of cardiovascular diseases such as hypertension, coronary artery disease and stroke7. Age does not affect peripheral arterial stiffness as much, but always plays a role in mixing with disease23. Hypertension is a strong independent predictor of risk of cardiovascular events, and since the smaller diameter arteries in the resistance vessels have a key role in controlling systemic blood pressure, alterations in vascular remodeling, particularly in small arteries, are strongly associated with hypertensive disease progression and severity25. Large artery elasticity due to hypertension is thought to be similar to the results of aging27, yet there are fewer PWV studies focusing on the effects of hypertension combined with age factors on peripheral resistance and microvessels. The present study points out that hfPWV (heart-finger PWV), i.e., complete ulPWV, combines the elasticity of the central aorta, middle arteries, small arteries and microvessels. Considering the different compositional ratios of the arterial wall components, such as the content of smooth muscle, collagen fibers and elastic fibers8. We hypothesized that the degree of stiffness in the different segments of the arteries of the upper limbs is not uniform. Therefore, we obtained different waveform data for the upper limb using three signals: electrocardiogram, pressure wave and light volume wave, followed by calculating six ulPWVs based on distance divided by time. Firstly, the differential characteristics of different ulPWV of the upper limb in healthy subjects and their influencing factors were studied. Then, the differences in each ulPWV and SG (PWV ratio) between hypertensive patients and healthy subjects in two age groups were investigated. The SGs of this study were derived from different ulPWVs and ulPWV versus baPWV, the former exploratory study of stiffness gradients during arterial conduction in the upper limb with the brachial, radial arteries as the nodes; whereas the latter may be more focused on the differences in the stiffness of arteries in the upper and lower reaches of the body. Finally different ulPWV consistency analyses resulted in representative indicators.The current study found that higher baseline aortic stiffness is associated with reduced stiffness in muscular conduit arteries, and the relationship affects the circulatory system in a two-sided mannerThe aims of this paper are (1) to analyze the differences in ulPWVs and the influencing factors  in the context of the structure of the corresponding vessels; and (2) to explore the variability of ulPWVs and the associated SGs under the influence of synergistic hypertension and or aging. Both for proposing a segmented approach to the study of ulPWVs and explaining its necessity.20, so that ABI  < 0.9 or > 1.4 was the exclusion criteria for all participants.This was a cross-sectional study that included a total of 167 healthy subjects  and 92 hypertension patients  after excluding data with missing or abnormal waveforms. Basic information on all subjects is shown in Table Baseline clinical data of participants were obtained  when them accepted hemodynamic evaluation, besides, hypertension patients were also inquired duration of hypertension, history of hypotensive drugs taking. BMI (body mass index) was calculated as weight divided by height in square meters. Hemodynamic indicator such as baPWV, blood pressure and heart rate were obtained using an atherosclerosis diagnostic device , which provided bilateral side baPWV measured from the cuffs wrapped on both brachial arms and ankles. Hemodynamic indicators were measured in a quiet test room with similar temperature after 10 min of rest in the supine position.28; then measured the distances from the suprasternal notch to the brachial artery, radial artery, and fingertip as the endpoints, respectively.This study collected waveform signals from different sites of the aorta-upper limb using the multi-channel signal pulse device. The device has an automatic sampling frequency of 200 Hz, and USB full-duplex serial communication interface mode; it is also equipped with five signal interfaces, which are three pulse acquisition channels, one ECG channel, and one volumetric waveform channel. Combined with piezoresistive pulse sensor, leadwire and volumetric waveform finger clip to enable simultaneous acquisition of pulse wave, ECG and finger volumetric waveform signals. Figure 5, so neither was adopted. UlPWV is calculated by dividing the body surface conduction distance (D) corresponding to the multiple waveforms by the pulse arrival time (PAT) or pulse transit time (PTT)5. Each ulPWV, as well as baPWV, was obtained using the mean value of the two-sided measurements30. The six ulPWVs corresponding to different arterial segments were hbPWV , hrPWV , hfPWV (heart-finger PWV), brPWV , bfPWV , and rfPWV , in cm/s in accordance with baPWV  for multiple waveform processing and feature point extraction. Firstly, the multiple waveforms were manually filtered and de-noised for analysis. Then, the peak method was used for ECG-R waveform identification, while the remaining three waveforms used the second derivative maximum and the intersecting tangent to cooperate in identifying the waveform “onset point”. The PAT was taken as the lesser of the two methods, the PTT was taken as the mean of the two methods, and the manual monitoring was done across all multiple waveforms for feature point identification. We also attempted to use the peak or minimum method, but found that the valleys of the actual waveforms were offset and noisy, and that the peak method lost much of the waveform information7. In this study, ulPWV-related SG was considered to contain some aortic stiffness information, combined with the ratio relationship with the local PWV of the neighboring upper limb, which were hbPWV divided by brPWV, hbPWV divided by bfPWV and hrPWV divided by rfPWV, respectively; baPWV, although it contains some peripheral arterial stiffness, it is undeniable that it is mainly aortic stiffness related. Therefore it was taken as the numerator and divided by the three ECG-related ulPWVs , respectively, and the calculation of the specific six SGs were shown in Fig. The energy changes in human haemodynamics transmitted from the aorta to the peripheral arteries are mainly presented through the arterial stiffness gradient, and PWV ratio between the two arterial segments is usually calculated to obtain the SG indext-tests. One-way ANOVA was used to compare ulPWV in healthy individuals in different age groups, all using Bonferroni correction. We used Pearson correlation coefficients to analyze the bivariate correlations between ulPWV and the influencing factors as well as the different PWV, and the Bland–Altman method to analyze the consistency of ulPWV. Independent samples t-tests were used to compare PWV across gender in healthy individuals, as well as PWV and PWV ratio in healthy individuals with hypertension in two age groups. Healthy individuals were matched for age and sex for hypertension using propensity scores, and analyses were performed using SPSS statistical package version 26 , P value less than 0.05 was considered as statistically significant.All values are expressed as mean ± SD. One-way ANOVA was used to compare ulPWV in healthy individuals of different age groups, all with Bonferroni correction. Differences between hfPWV and other ulPWV as well as baPWV were compared separately using paired samples P = 0.407), and the results of the cross-sectional and longitudinal comparisons of the ulPWV in each group are also shown. Comparison of results between age groups showed no significant difference in ulPWV except for bfPWV, which was statistically different (P = 0.027); significant differences were found for all ulPWVs in the same age group . Figure P < 0.001) due to the incorporation of small and medium muscle arteriolar stiffness leading to an increase in hrPWV and hfPWV. When upper limb arteries were observed in segments, brPWV, which consistently corresponded to small arteries in forearm muscles, was the largest, and bfPWV, which combined forearm as well as radial finger segments, was the second largest, with statistically significant differences in both compared to hfPWV (P < 0.001); whereas rfPWV corresponding to radial-finger decreased, and although they corresponded to different vascular physiology, its values were not statistically different from hfPWV. Trends in hbPWV, brPWV, and rfPWV showed a first increase and then a decrease in PWV delivered along the aorta- peripheral arteries-microvascular arterial tree.Table t P = 0.07; signifP < 0.01). Upper limb hbPWV, hrPWV and hfPWV also provided evidence of moderate correlation with blood pressure, while the remaining ulPWVs were weakly correlated with blood pressure. Heart rate correlated only with ulPWV and not with baPWV. There were different degrees of correlation between different PWVs. Three ulPWVs related ECG were correlated with baPWV ; them were also strongly correlated with each other; hfPWV was strongly correlated with bfPWV  and moderately correlated with rfPWV , and bfPWV was strongly correlated with rfPWV , which may be related to the specificity of the microvessels of the radial-finger.Figure P = 0.038, P = 0.011 and P < 0.001, respectively); when aged ≥ 50 years, there were statistically significant differences in each of the ulPWVs in hypertensive patients compared with healthy individuals of the same age , suggesting that the stiffening of all segments of the upper limb arteries was more pronounced in hypertensive patients of this age group compared with healthy individuals of the similar age. It was also observed that each ulPWV and baPWV was increased in hypertensive patients aged < 50 years (mean age 39.37 ± 6.61 years) compared with healthy people aged ≥ 50 years (mean age 53.78 ± 2.29 years), and the differences were statistically significant , suggesting that hypertension in combination with aging leads to a more prevalent and pronounced stiffening of arteries in all segments of the upper limbs in patients than in healthy individuals of the same age; hypertension and aging may be underlying different biological expressions that affect arterial stiffness. Table P = 0.015). This suggests that the superimposition of hypertension and aging leads to a reduction in the stiffness gradient of muscular medium and small arterial conduction to the radial finger segments. All three SGs of baPWV divided by ulPWV were greater than one and increased in hypertensive patients compared with healthy individuals, with all differences between groups significant . This suggests that the effects of hypertension resulted in increased baPWV and each ulPWV at both ages, but the increase in brachial-ankle artery stiffness was greater than that of the upper-limb arteries.Based on the results of ulPWV comparisons among healthy individuals of different ages and sexes, and considering the age profile of hypertensive patients, the present study was conducted using the age of 50 years as the cut-off, and propensity scores were used to match sex and age. The basic characteristics of healthy individuals and hypertensive patients in both age groups (age < 50 years and age ≥ 50 years) are shown in Table P < 0.0001), and the agreement between hrPWV and hfPWV was better in both groups , suggesting that hrPWV can represent hfPWV to some extent, but not hbPWV. In line with the previous Fig. P = 0.0612), but poorer in hypertensive individuals (P = 0.0179), suggesting that the terminal microvessels corresponding to rfPWV need to be evaluated separately.Figure This study demonstrates that multiple ulPWVs can be derived to segment the characteristics of the arterial stiffness index of the upper extremity by calculating the conduction times from the heart to the brachial artery, radial artery, and fingertip, respectively. It was found that (1) the vascular stiffness assessed by ulPWV correlates with the physiological structure of the elastic aorta, large and small muscular arteries, or microvessels counterparts; (2) UlPWV is less affected by age than baPWV, and there are differences in correlation of the two types of PWVs with blood pressure and heart rate; (3) UlPWVs and associated SGs can be used as an assessment of changes in vascular stiffening and stiffness gradients in upper limb arteries affected by hypertension and or aging.32. This study firstly focuses on the PWV of different segments of arteries in the upper limb of healthy individuals, and all ulPWVs are smaller than the combined stiffness of the aorta and peripheral arteries, baPWV, and change more steadily with age. This suggests that arteries in the upstream of the human body are less stiff than those in the downstream, which is in line with the fact that the lower limbs of the body are subjected to higher hydrostatic pressures than those of the upper limbs33. However ulPWV even tended to decrease with age, a paradox that has also been confirmed in other studies35. It has been proposed that peripheral muscular arteries may be designed to match the increased stiffness of the large central arteries by enhancing their own compliance to accept the transmission of blood volumes with increased pulsatile pressure, but this alteration affects the myocardium and microcirculation in a two-sided manner7. Also the decrease in rfPWV and bfPWV with age may be due to the specificity of the small vessels of the microcirculation, whose values are close to those of hrPWV and hfPWV, which are easily neglected if the stiffness of the arteries of the upper limbs is assessed as a whole11. Kavroulaki et al.36 found that blood flow to the fingers was rather reduced in premenopausal women and that younger women had a tendency to peripheral vasoconstriction. The peripheral vessels of the fingertips became progressively thinner, and the spectral waveforms of the fingertip arteries were all monophasic38. This suggests that factors such as vessel structure and internal diameter need to be taken into account when assessing the stiffness of microvessels using PWV39. The ulPWV of the aorta-peripheral middle and small arterioles-microvessels increases and then decreases, also emphasizing that changes in the wall composition and reductions in vessel diameter from proximal to distal of the arterial tree can lead to changes in vascular elasticity15. In healthy people ulPWV is similarly affected by blood pressure, although less so than the relationship between baPWV and blood pressure. The correlation between heart rate and ulPWV is stronger than that of baPWV, and some studies have shown that "active" or natural state heart rate is associated with arterial stiffness, implying that when heart rate is chronically fast, it may lead to degenerative changes in the arteries40. This "circulatory fatigue" is better reflected in ulPWV, which could inform future studies on the mechanisms affecting arterial stiffness in the upper limb.Aortic PWV is recognized as a reliable assessor and predictor of cardiovascular events and mortality, but the lack of a clear relationship between peripheral arterial stiffness and cardiovascular outcomes. This may obscure the characteristics of the stiffness of small arteries in the peripheral muscles and the physiological role that they play in the regulation of the pressure of the circulatory pulsation41. The present study firstly clarifies that hypertension causes an increase in each ulPWV and baPWV compared to healthy individuals of the same age, suggesting that hypertension affects vascular stiffness in a systemic manner. Furthermore the significance of the increase in ulPWV was more prevalent in hypertensive patients aged ≥ 50 years than in hypertensive patients aged < 50 years. This may correlate with the involvement of ulPWV in reflecting the progression of hypertension, especially in the smaller diameter arteries of the resistance vessels, whose vascular changes are highly correlated with the severity of hypertension41. In addition, the difference between hypertensive patients aged < 50 years and healthy individuals aged ≥ 50 years seemed to reflect the relationship between aging and hypertension in the context of vascular structural alterations. Su et al.42 found that Klotho protein cycling levels (anti-aging gene expression) were lower in nonelderly hypertensive patients than in elderly non-hypertensive individuals, which was consistent with the performance of ulPWV and baPWV in this study. It suggests that hypertension may have a greater impact on vascular structural alterations than aging, and it also suggests that ulPWV may serve as an outgrowth of vascular gene expression. Structural–functional changes in different vessels will inevitably bring about changes in SG, and examining the differences in the ratios of neighboring ulPWVs (SG 1–3) as well as the ratios of baPWV to the three ulPWVs (SG 4–6), respectively. In hypertensive and healthy individuals, it was found that the difference between hrPWV/rfPWV was significant in hypertensive patients with aged ≥ 50 years and in healthy individuals. It is suggested that hypertension combined with aging may amplify alterations in the stiffness gradient of cardiac-radial PWV conduction to radial-finger PWV, whose values decrease or even disappear indicating alterations in microcirculatory pulsatile pressures and hemodynamics thus leading to organ damage43. The absence of differences in the other ASGs does not imply that there is no change in vascular structural function, but rather suggests that hypertension causes physiological degradation of the large arteries similar to that of aging, and that vascular parallel remodeling of the muscular arteries of the upper limbs may have occurred41. Differences in vascular remodeling of conduit arteries and peripheral radial arteries under the influence of hypertension, with intima-media thickness of the latter found not to be significantly related to local pulse pressure45. This may explain the manifestation of hbPWV/brPWV and hbPWV/bfPWV and emphasize the heterogeneity of the microvessels at the finger tips. SG 4–6 were all > one and significantly different. This may correlate with differences in the vascular physiology of the upstream and downstream arteries, which are subjected to different pressures over time33; there are differences in the changes in stiffness of aortic-lower limb and upper limb arteries that are induced by high blood pressure and or ageing, and that the ratios of baPWV to ulPWV help to visualize these exacerbated differences41.The main pathological hallmark of hypertension, a key risk factor for cardiovascular disease, is the increase in peripheral vascular resistance due to structural and functional changes in large conducting and small resistance arteries43. Different ulPWVs have differences that reveal, to some extent, the physiological properties of the central aorta to the peripheral vasculature that gradually stiffen due to changes in the composition of the vessel wall (decrease in elastin and increase in collagen and smooth muscle cells)43. Although rfPWV and hfPWV values are close, the underlying vascular physiology is very different. The study utilizes ulPWV to complement the stiffness information of the upper limb arteries, making it possible to evaluate the overall degree of atherosclerosis in the presence of hypertension and or aging factors. Then, it explores the changes in ulPWV-involved SGs in response to physiological and pathological factors, providing information for the discovery of potential indicators for vascular health assessment. Consistent evaluation suggests that hrPWV can be used as a proxy for upper extremity arterial stiffness, but not for hbPWV, while rfPWV deserves separate evaluation.The strength of this study is the segmented study of ulPWV using multiple signals, which takes into account the different requirements of the PAT and PTT algorithms during multiple ulPWV calculations and proposes a segmented approach to measure ulPWV47. In addition, pathologies other than hypertension deserve to be explored48. PWV is widely used as an assessment tool for vascular stiffness, but it needs to be clear that vascular aging and arterial stiffness are not identical and that the two are in a mismatched symbiotic relationship49. UlPWV is expected to inform the application of ultrasound technology on a large sample basis in the future, with both working together to assess structural and or functional changes in the vascular system.There are some limitations to be mentioned. Firstly, hand microcirculation is not necessarily an endpoint, and in this study rfPWV was measured only using fingertip volume wave as a relative endpoint. Furthermore, there are many and confounding factors affecting vascular stiffness, and only age, blood pressure and gender were considered in this study; it needs to be made clear that there may be interactions between these factors, and that other factors such as smoking, obesity and lifestyle deserve to be investigated in depthIn conclusion, different ulPWVs in the aorta-upper limb segment closely correlate with their corresponding vascular structures, with increasing and then decreasing stiffness along the proximal to distal peripheral arteries and then to the fingers, with specificity for rfPWV. Different ulPWV reflects the effect of hypertension and or aging factors on vascular stiffness, and the superposition of both risk factors leads to an increase in ulPWV and a more pronounced attenuation of hrPWV/rfPWV. Also ulPWV exploratively constructs a ratio to baPWV, and hypertension may cause a faster increase in the degree of combined aortic-lower limb arterial stiffness than in upper limb arteries. Although assessment of upper limb peripheral arterial stiffness is not as important as the aorta, the vascular physiology behind it and changes in the arterial stiffness gradient deserve attention.


The increased cardiovascular (CV) risk among patients with autoimmune rheumatic diseases, such as arthritides and connective tissue diseases, has been extensively documented. From a pathophysiological standpoint, systemic inflammation in the context of the disease can lead to endothelial dysfunction, accelerated atherosclerosis, and structural changes in vessel walls, which, in turn, are associated with exaggerated CV morbidity and mortality. In addition to these abnormalities, the increased prevalence of traditional CV risk factors, such as obesity, dyslipidemia, arterial hypertension, and impaired glucose metabolism, can further worsen the status of and overall prognosis for CV in rheumatic patients. However, data on appropriate CV screening methods for patients with systemic autoimmune diseases are scarce, and traditional algorithms may lead to an underestimation of the true CV risk. The reason for this is that these calculations were developed for the general population and thus do not take into account the effect of the inflammatory burden, as well as other chronic-disease-associated CV risk factors. In recent years, different research groups, including ours, have examined the value of different CV surrogate markers, including carotid sonography, carotid–femoral pulse wave velocity, and flow-mediated arterial dilation, in the assessment of CV risk in healthy and rheumatic populations. In particular, arterial stiffness has been thoroughly examined in a number of studies, showing high diagnostic and predictive value for the occurrence of CV events. To this end, the present narrative review showcases a series of studies examining aortic and peripheral arterial stiffness as surrogates of all-cause CV disease and atherosclerosis in patients with rheumatoid and psoriatic arthritis, as well as in systemic lupus erythematosus and systemic sclerosis. Moreover, we discuss the associations of arterial stiffness with clinical, laboratory, and disease-specific parameters. The majority of rheumatic diseases are characterized by chronic and systemic inflammatory processes with autoimmune origins. Although the exact pathophysiological mechanisms associated with these diseases are not fully understood, it is assumed that interactions between predisposing genetic factors and triggering environmental parameters can lead to a dysregulation of the immune system and generalized tissue damage, in addition to the effect of various autoantibodies and other soluble mediators .Systemic inflammatory diseases, such as arthritides, connective tissue diseases, and vasculitides, have been found to be associated with increased cardiovascular (CV) risk, as well as with higher CV-associated morbidity and mortality rates ,4,5,6,7.In the general population, CV risk can be calculated via traditional assessment scores ) based on CV risk factors, such as hyperlipidemia, arterial hypertension, body mass index (BMI), and nicotine consumption ,16,17. HStiffness of the large arteries is one of the best-validated CV surrogates in the general population, showing a high positive predictive value for future CV events, next to traditional CV risk factors  14,23].,23.14,23Arterial stiffness is modifiable and can independently predict CV risk in the general population. It can be measured using several methods, such as oscillometry (pulse wave velocity (PWV); gold standard), echocardiography , aortic distensibility, pulse wave analysis ), and pressure–strain elastic modulus (PSEM)  24,25,2,27,28,29In contrast to parameters such as blood pressure, lipids, or glucose levels, which correspond to the instantaneous intensity of CV risk factors (and can thus fluctuate significantly over time), arterial stiffness reflects the long-term effects of established and unknown risk factors, as well as the individual genetic predisposition of each person . In partIn recent years, our research group and others have examined aortic stiffness, as measured by cfPWV, in the context of various systemic rheumatic diseases, including RA , mixed cIn the present work (part 1), we discuss prototype arthritides, such as RA and PsA, as well as connective tissue diseases with increased CV risk and high CV mortality rates, such as SLE and SSc. In the second part of the review, we focus on data regarding arterial stiffness in patients with further rheumatic diseases, such as systemic vasculitides.For this narrative review, a search strategy was developed to enable us to identify the most important literature on the topic. An exhaustive search was performed on PubMed/Medline and Google Scholar using a keyword combination according to the Boolean operators: “arterial stiffness” AND (rheumatoid arthritis OR psoriatic arthritis OR systemic lupus erythematosus OR systemic sclerosis) (1044); as well as “aortic stiffness” AND (rheumatoid arthritis OR psoriatic arthritis OR systemic lupus erythematosus OR systemic sclerosis) (734); as well as (“pulse wave velocity”) AND (rheumatoid arthritis OR psoriatic arthritis OR systemic lupus erythematosus OR systemic sclerosis) (1346). This produced a total of 3124 publications. Limiting the results to publications from the past two decades left us with 3101 articles across all keyword combinations. We then manually excluded irrelevant and duplicated papers, as well as papers without full text, by skimming over the titles and, where necessary, the abstracts. Moreover, we ensured that this methodology was in accordance with that described by Gasparyan et al. (narrative review) .Arterial stiffness refers to the loss of arterial compliance. It is a major independent risk factor for CV complications leading to systolic hypertension and increased pulse pressure in the microvasculature of target organs . MoreoveThe process of arterial stiffening is characterized by alterations in the extracellular matrix composition involving the fragmentation of elastin fibers, the deposition of stiff wall materials, such as collagen fibers, and the cross-linking of collagen molecules by advanced glycation end-products (AGEs) . Such paHowever, in addition to structural stiffening, functional vascular stiffening caused by endothelial dysfunction also plays an important role. NO synthesis and endothelial NOS activity (and content) can be decreased by pathophysiologic mechanisms that are associated with wall architecture changes and thus further promote arterial stiffening . Even ifPulse wave velocity (PWV): The most widely used measure of arterial stiffness is an oscillometric marker called PWV. PWV reflects the speed of arterial pulse waves traveling along the aorta and other parts of the arterial tree and is usually calculated by dividing distance by the pressure wave transit time at the two points of the measured arteries ,42. For The augmentation index (AIx): Another technique uses applanation tonometry, which is widely used to evaluate the central pressure and wave reflections through the non-invasive use of a marker called AIx . AIx, meThe aortic stiffness index (AoSI): This parameter can be measured by Doppler echocardiography at the level of the aortic root by assessing systolic (AoS) and diastolic (AoD) aortic diameters 3 cm above the aortic valve. It uses the following formula: AoSI = ln(SBP/DBP)/(AoS − AoD/AoD) (where SBP = systolic blood pressure and DBP = diastolic blood pressure) ,45.The stiffness parameter beta, or β-stiffness index, is a local elastic parameter that is usually assessed by carotid ultrasound in the longitudinal plane coupled with arterial pressure data derived from applanation tonometry. It is calculated using the following formula: β-stiffness index  =  ln(SBP/DBP)/[(Ds − Dd)/Dd]  . Thus, tThe pressure–strain elastic modulus (PSEM): PSEM is a variation of AoSI and is calculated using the same formula as AoSI. However, it includes pressure values converted from mmHg to Pascal units .Aortic distensibility is another echocardiographic measure that is used to describe arterial stiffness. It is calculated using the following formula: aortic distensibility = (2×)/(AoS − AoD)/AoD/(SBP − DBP) .2] + b  [The cardio-ankle vascular index (CAVI) was developed to further improve the PWV method by making it less dependent on arterial pressure. To this end, the brachial–ankle PWV is measured and inserted into the following equation: CAVI = a[(2ρ/(SBP − DBP)) × ln(SBP/DBP) × PWVdensity) .Arterial stiffness can be assessed using a variety of methods . The mean = 17,635 participants), the 5-year overall net reclassification index for coronary heart disease and stroke in intermediate risk subjects was 14.8% and 19.2%, respectively [According to the position paper from the European Society of Cardiology’s working group on peripheral circulation, which was endorsed by the Association for Research into Arterial Structure and Physiology (ARTERY) Society, measurements of carotid–femoral (aortic) stiffness using cfPWV and of brachial–ankle stiffness using baPWV can be useful for primary and secondary CVD prevention in the general population  . Regardiectively . Regarding baPWV, a meta-analysis including 8,169 participants showed that an increase in the baPWV of 1 m/s was associated with increases of 12%, 13%, and 6% in CV events, CV mortality, and all-cause mortality, respectively . Thus, tPWV measurements of other arterial segments  as other markers of aortic stiffness, such as CAVI or echocardiographic indices, are presented in the same guidelines as additional promising biomarkers ,54. Howep < 0.001) and cIMT (p < 0.001) were predictive of CVD events, as were age (p = 0.01), statin (p = 0.01), and glucocorticoid use (p = 0.01). However, AIx was nonsignificant (p = 0.19). Two further prospective studies evaluated the predictive value of arterial stiffness for the occurrence of digital ulcerations and disease progression in patients with SSc and are included in Prospective data on the diagnostic accuracy of arterial stiffness in patients with rheumatic diseases are scarce. The vast majority of the existing studies examine the associations of arterial stiffness at one time point during the course of the disease, and thorough longitudinal data examining the predictive value of this marker are lacking. In the setting of RA, we were able to identify only two prospective studies that related arterial stiffness measures to future outcomes ,57 Tabl. In the RA is a common chronic inflammatory disease, which affects mostly individuals during late adulthood . This diPatients with chronic RA disease courses are more likely to have stiffer arteries compared to healthy controls, as indicated by studies on PWV ,66,67,68One of the main contributors to arterial stiffness in RA patients and healthy subjects is increased age, which has been shown to be significantly associated with higher levels of arterial stiffness in multiple RA cohorts, as well as in subjects without autoimmune diseases ,70,71,72p = 0.03 after adjustment for age in a study of 90 RA patients) and the erythrocyte sedimentation rate (ESR) [adj = 0.034) [p = 0.045) in a cohort of 214 patients, supporting a possible pathophysiological association between vascular stiffening and pain [Furthermore, several RA disease activity and chronicity parameters have been shown to be associated with higher levels of arterial stiffness, even though data on these associations are partially contradictory ,69,72,74te (ESR) , as wellte (ESR) ,74. Simite (ESR) . Two furte (ESR) ,71. Inte= 0.034) . Taverneand pain .p > 0.05). Exercise was found to be associated with lower CRP, ESR, DAS28, and PWV values, but also with a lower prevalence of hypertension. Moreover, a positive association with higher-density lipoprotein (HDL) was observed [Byram et al. examined the effect of exercise on arterial stiffness in patients with RA . Brieflyobserved . Howeverobserved .p = 0.04), but not on AIx or aortic pressure, after 8 weeks of treatment with either Adalimumab or Etanercept [Another important area of research in RA focuses on the effects of patient medication on arterial stiffness. Some of the studies performed on this topic examine the effects of immunosuppressants or biological agents on patients’ vascular status, while others focus on traditional antihypertensive drugs. For instance, regular therapy regimes for RA using tumor necrosis factor inhibitors (TNF inhibitors) were reviewed with respect to their effect on arterial stiffness. In a small cohort, Maki-Petaja et al. showed a lowering effect on aortic inflammation and stiffness % at baseline, 28.6 (7.6) at 6 months, 29.4 (6.7) at 1 year, p = 0.216) [The effects of other immunosuppressants, such as Rituximab (a B-cell-depleting agent), have also been examined in this regard. Mathieu et al. did not find an improvement in arterial stiffness  after 6 and 12 months of therapy with Rituximab in 33 patients with RA (PWV: 8.1 (3.1) m/s at baseline, 8.1 (2.8) at 6 months, 8.0 (2.7) at 1 year, = 0.216) . Similar= 0.216) . Interes= 0.216) . GC can = 0.216) .Regarding the effect of antihypertensive drugs on arterial stiffness, Enalapril was found to have no lowering effect on cfPWV in a study of 27 patients with RA who were compared with 26 controls receiving a placebo for 12 weeks . Howeverp < 0.001) and AIx (p = 0.04) with CVD in 138 RA patients [p = 0.009) and cfPWV  were found to correlate with a higher myocardial performance index (a marker for cardiomyopathy) in a study of 40 RA patients evaluated for left ventricle dysfunction in the context of the disease [Follow-up examinations of arterial stiffness are important, as increases in arterial stiffness during a patient’s lifetime are associated with worse CV outcomes . Ikdahl patients . Arteriapatients . Moreove disease .It is well known that in RA, atherosclerosis is accelerated, as systemic inflammation in the context of the disease may promote atherogenic pathophysiologic mechanisms  However,In summary, based on the available evidence, arterial stiffness seems to be significantly increased in RA patients and can be predicted using traditional CV risk factors. This result seems plausible, since RA patients are at high CV risk. Physical exercise, selected immunosuppressants, and some antihypertensive medications may have a positive effect on arterial stiffness and subsequently on arterial health status. However, data on the associations of arterial stiffness with markers of RA disease activity and chronicity are heterogeneous and should be examined further.PsA is another inflammatory musculoskeletal disease with a prevalence of 2–4% in Western adults . ApproxiPatients with PsA often suffer from a number of comorbidities, such as bowel inflammation, skin/nail disease, depression, and osteoporosis . MoreoveIn PsA, aortic PWV is significantly increased compared to healthy controls, even after adjustment for the effect of confounding factors  ,91. Othep > 0.05) [p = 0.024) and arterial stiffness progression in 101 consecutive patients with PsA [Costa et al. and Kristensen et al. found no significant association of aortic stiffness with disease activity as evaluated by DAS28, DAS66, or laboratory inflammation markers, such as ESR or CRP, in two cohorts of PsA patents  ,93. Conv > 0.05) . The cas > 0.05) . Intereswith PsA .n = 34, all p < 0.05) [In the study conducted by Shen et al., among patients with PsA, subgroups with high cfPWV values also showed a higher prevalence of traditional CV risk factors, such as systolic blood pressure, a higher Framingham score, diabetes, and hypertension ( < 0.05) . This fi < 0.05) ,97,98,99 < 0.05) .n = 20 to n = 73 in 4 case control studies). Nevertheless, arterial stiffness also seems to be higher in PsA patients than in the general population, and both CV risk factors and the cumulative disease burden have been shown to predict this surrogate marker. It is hoped that new studies on the topic with more patients and standardized study designs will provide clearer insights in the future.Overall, data on arterial stiffness are limited in PsA, as studies on the topic are significantly fewer in comparison to RA. Moreover, most of the examined cohorts involved low numbers of patients (from Systemic lupus erythematosus (SLE) is an autoimmune inflammatory disease, which often presents with multiorgan involvement . Renal aA large body of evidence indicates arterial stiffness to be significantly higher in patients with SLE compared to healthy controls: patients with SLE have shown significantly higher values in PSEM ,102,103,p = 0.033). This result is important, given that the examined population had a widely normally ranged eGFR [p < 0.001), as well as resting heart rate  [The most important patient characteristics associated with increased arterial stiffness in SLE, as assessed by PWV, include age ,114,115 ged eGFR ,104, SLEged eGFR , inflammged eGFR ,116, ESRged eGFR , and IL-ged eGFR  (PWV: r = 0.024) , have beAIx has also been shown to correlate positively with age , blood pn = 41; p = 0.0017) [n = 30; p < 0.001) [Interestingly, arterial stiffness in the context of SLE seems to also be associated with more prominent atherogenesis. cfPWV correlated with the internal carotid wall thickness ( 0.0017)  and tota< 0.001)  in SLE c< 0.001) . Further< 0.001) . This fi< 0.001) ,104,105,< 0.001)  and with< 0.001) .While arterial stiffness is closely linked to age and seems to be more pronounced in patients with SLE, relative increases in arterial stiffness, assessed by PSEM, showed no difference between 76 SLE patients and 26 age/sex-matched healthy controls in a study conducted by Roldan et al. .n = 76; all p < 0.04) [These tendencies for increased arterial stiffness are noteworthy, as stiffer arteries may be associated with impaired left ventricular (LV) function . Higher  < 0.04) . Interestingly, endothelial dysfunction seems to play a role in the development of arterial stiffness, as patients with SLE display lower flow-mediated dilation (FMD) and higher levels of vascular cell adhesion molecule-1 (VCAM-1) compared with healthy controls ,118. In p < 0.005) [p = 0.51) [Interestingly, findings on the relationship between cardiorespiratory fitness and arterial stiffness in patients with SLE vary depending on the examined cohort and/or the chosen assessment marker of arterial stiffness ,120,121.< 0.005) . Similar = 0.51)  but also = 0.51) ,123. In Another important aspect is the effect of disease-modifying antirheumatic drugs on the arterial stiffness of patients with SLE. In the study conducted by Du et al., lowering disease activity (SLEDAI) in 51 SLE patients was associated with an overall improved CV risk, as evidenced by a reduction in PWV and an increase in HDL over a follow-up period of 1 year . Furtherp = 0.002) [While the cardioprotective properties of lipid-lowering agents (statins) are well evidenced for the general population, the effects of this medication on arterial stiffness in patients with SLE have yet to be fully elucidated. Most importantly, longitudinal data on this topic are scarce. One of the few follow-up studies performed in an SLE cohort showed a statistically significant decrease in aortic stiffness (cfPWV) in the subgroup of patients with abnormal baseline cfPWV values after an 8-week course of therapy with atorvastatin at a dosage of 20 mg  . On the = 0.002) . HoweverAnother topic of frequent scientific discussions is the role of vitamin D (VitD) in SLE disease activity and arterial stiffening. There are reports in the literature that high disease activity (SLEDAI) may be associated with low VitD and, in turn, with a higher PWV and BMI . MoreoveTo summarize the SLE data presented here, the majority of these studies indicated increased arterial stiffness, even if statistical adjustments for the effects of confounding factors  were not performed on every occasion. Interestingly, lowering disease activity can prove important in reducing arterial stiffness and thus the CV risk in SLE patients. One should keep in mind, however, that the thorough assessment and successful treatment of traditional CV risk factors are also essential steps towards improving CV and CVB prognosis.SSc is a connective tissue disease with characteristic skin and organ fibrosis, as well as an obliterating vascular pathology . It can In SSc, data on arterial stiffness are somewhat contradictory: some of the performed studies reported increased arterial stiffness as assessed by PWV ,130,131,p = 0.001) [p = 0.034) [p < 0.05) [p = 0.02 and p = 0.05, respectively) NVC patterns [p = 0.047) and a higher capillaroscopic skin ulcer risk index (CSURI)  [However, arterial stiffness has been found to be associated with various SSc disease- and patient-associated parameters. In addition to age ,135,136,= 0.001) , increas= 0.001) ,132, tre= 0.034) . Disease= 0.034) ,132,136.= 0.034) ,133 and = 0.044) .Notably, another marker of arterial stiffness (AoSI) did not correlate with SSc disease severity as measured by the Medsger score, but it did show associations with echocardiographic markers of impaired left ventricular diastolic function .Regarding the effect of acute inflammatory activity on arterial stiffness, one SSc study reported that cfPWV could be predicted by CRP , whereasp = 0.022) [Patients with lcSSc exhibited higher values of AIx than patients with dsSSc, as shown by Bartoloni et al.  . However= 0.022) . Avenatt= 0.022) .Examining markers of coronary vascular damage  and endothelial dysfunction , Turiel et al. found CFR to be lower and ADMA to be increased in patients with SSc . These fn = 5), Maslyanskiy et al. reported a significant decrease in both PWV and AIx after 6 months of treatment with rituximab [n = 9) by van Roon et al., treatment with Bosentan was also found to significantly decrease the forearm  PWV in patients with SSc after periods of 3 and 12 months. However, cfPWV did not differ between the Bosentan group and the normal care group in the same study [Regarding the effects of medications on arterial stiffness in SSc, the data are inadequate. In a very small study  and disease characteristics. For this reason, carefully designed studies with matched case controls and/or adjusted statistical analyses are warranted. To conclude, markers of arterial stiffness, such as the pulse wave velocity of the aortic vasculature and AIx, have been thoroughly examined in the general population and also in rheumatic populations . Despite the aforementioned limitations, arterial stiffness provides additional information regarding the elastic properties of the examined arteries. Thus, it can be used as an additional (surrogate) marker of arterial status and CVD, in addition to well-established traditional CV risk factors and scores. Alternative markers of arterial stiffness also seem promising; however, further research is needed to determine whether these tools can also be integrated into screening algorithms. Moreover, well-designed longitudinal studies examining patients with systemic inflammatory conditions are needed.