Saussurea involucrata (SAIN), also known as Snow lotus (SI), is mainly distributed in high-altitude areas such as Tibet and Xinjiang in China. To identify novel targets for the prevention or treatment of lung adenocarcinoma and lung squamous cell carcinoma (LUAD&LUSC), and to facilitate better alternative new drug discovery as well as clinical application services, the therapeutic effects of SAIN on LUAD&LUSC were evaluated by gene differential analysis of clinical samples, compound target molecular docking, and GROMACS molecular dynamics simulation.Through data screening, alignment, analysis, and validation it was confirmed that three of the major active ingredients in SAIN, namely quercetin (Q), luteolin (L), and kaempferol (K), mainly act on six protein targets, which mainly regulate signaling pathways in cancer, transcriptional misregulation in cancer, EGFR tyrosine kinase inhibitor resistance, adherens junction, IL-17 signaling pathway, melanoma, and non-small cell lung cancer. In addition, microRNAs in cancer exert preventive or therapeutic effects on LUAD&LUSC. Molecular dynamics (MD) simulations of Q, L, or K in complex with EGFR, MET, MMP1, or MMP3 revealed the presence of Q in a very stable tertiary structure in the human body.There are three active compounds of Q, L, and K in SAIN, which play a role in the treatment and prevention of non-small cell lung cancer (NSCLC) by directly or indirectly regulating the expression of genes such as MMP1, MMP3, and EGFR. In 2021, among many types of cancers, lung cancer is still among the tough, not only because its mortality is as high as 22% in both men and women [According to the microscopic morphological characteristics of lung cancer cells, lung cancer can be divided into two types: small cell lung cancer (SCLC) and non-small cell lung cancer (NSCLC) . In prevCurrently, the world's targeted therapeutics for NSCLC have issues, including high R&D cost, a relatively expensive market price, and a long administration cycle. Therefore, these restrictions do not allow every NSCLC patient to use these drugs normally. Lung adenocarcinoma (LUAD) and lung squamous cell carcinoma (LUSC) are the two most common types of NSCLC, among which, LUAD accounts for far more cases than LUSC, and has become the major type of targeted therapy for NSCLC.Saussurea involucrata (SAIN) is mainly distributed in high altitude areas such as Xinjiang and Tibet in China. Research on the pharmacological effects of SAIN started in 1980  and has Network pharmacology is a new discipline that is based on the theory of systems biology to select specific signal nodes for multi-target drug molecule design . Networkhttps://tcmsp-e.com/) [Traditional Chinese Medicine Systems Pharmacology Database (TCMSP) (-e.com/)  is one oAmong them, the DL value for this system is calculated following Eq. , and to https://www.drugbank.ca)database [In the equation, x represents the descriptive index of all ingredients in SAIN, and y represents the descriptive index from the drug bank  database [The structural formula of the active ingredients of SAIN obtained above Fig. c was plodatabase  for targdatabase  was usedhttps://www.ncbi.nlm.nih.gov/geo/) database [http://gepia.cancer-pku.cn/) database [To further screen the active ingredients and their targets that were initially screened, a large number of clinical case samples of LUAD&LUSC were obtained from the GEO (database . Differedatabase . In addihttps://david.ncifcrf.gov/) database [To evaluate the mutual influence among the targets screened above, a protein interaction network and an active ingredient target pathway network were constructed. The biological processes and pathways that each target participates in in vivo were explored, and data of target genes were retrieved through the David  database [http://cello.life.nctu.edu.tw/) database [http://busca.biocomp.unibo.it/) database [In recent years, subcellular localization prediction has been a more popular method of subcellular localization. Existing data to create a database of the sequence relationships of the target sequences and subcellular structures of various genes and their regulation can accurately predict the location of the target protein on various organelles and cell membranes, and has multiple advantages. Currently used subcellular localization prediction tools include (1) the PSORT II  Thedatabase  uses thedatabase ; (3) Thedatabase  employs database , 25.Combined with the analysis of biological processes, using PSORT II, CELLO, and BUSCA databases for subcellular location prediction, respectively, and to compare the prediction results of the three tools, the intersection part was selected and the main location of the target protein in the cell was obtained.In clinical studies, to evaluate the efficacy of a drug and know the survival data, such as the survival time of patients after surgery, our analysis of these survival data is called survival analysis.After a series of screening and analysis of the ingredients and action targets of SAIN, prognostic overall survival analysis was performed on the gene IDs of the targets of the final active ingredient actions in SAIN, so as to explore the length of time that patients can survive when drugs act on these targets over time.Based on molecular docking studies, differential gene analysis, and the prediction of subcellular localization and survival analysis, the results were validated with molecular dynamics (MD) simulations, a means to computationally model the motion of a small molecule in an organismal environment .MD simulations were performed with GROMACS software , thereby12 ps). In addition, the root mean square deviation (RMSD) of the MD simulation results analysis and visualization were performed using a GROMACS inbuilt program with the RMSD formula as follows (3).After state equilibration of all environments, we performed 50 ns MD simulations of the ingredient target complex system using epidermal growth factor receptor (EGFR) with L, Q, matrix metalloproteinase 3 (MMP3) with Q, hepatocyte growth factor receptor (MET) with L, and matrix metalloproteinase 1 (MMP1) with L, Q, and K, in which stored conformations were calculated every 10 ps , and N refers to the number of atoms.In this equation, RIn this study, a total of 55 known active ingredients in SAIN were collected from the TCMSP database, including alkaloids, lipids, flavonoids, and flavonoids. Subsequently, six potent drug-resistant ingredients from 55 compounds were screened under the following screening conditions of OB ≥ 30%&DL ≥ 0.18&logPo/w ≤ 5. Details of the screening process of these six components, Flazin (F), Q, K, L, Alloisoimperatorin (A), and Hispidulin (H), are shown in Table By merging 1023 targets screened from the STP database and 764 LUAD and LUSC targets screened from the TCMSP database, a total of 9 targets with six ingredient roles was obtained. The nine protein targets interacted with the ingredients of six SAIN, and an ingredient target network was constructed using Cytoscape, resulting in an ingredient target network characterized by 15 nodes and 24 edges , 90 kDa heat shock protein ΑA1 (Hsp90AA1), MMP1, and EGFR.https://portal.gdc.cancer.gov/) database [To ensure the accuracy of the experimental data, further screening for ingredients and targets was performed. In this study, data from a total of 22,589 LUAD and 22,697 LUSC related disease genes was obtained through the GEO database and R 4.0.4, TCGA data through the GDC  of these data and the patient samples to obtain the gene expression matrix of two groups, LUAD & Normal and LUSC & Normal, corresponding to the nine targets. In this study, 15 samples from each of the two groups within the two cohorts were selected, including 30 clinical samples from each of the LUSC & control group in LUAD and LUSC, and the gene differential heat maps of LUAD Fig. B and LUS2FC value, and Q value of 1 and 0.01 were selected by the difference method [The results of gene difference analysis showed that the difference of Hsp90AA1 between LUAD and LUSC was least obvious, therefore, this was discarded. The gene IDs of the remaining eight targets were TPM analyzed by GEPIA database, input gene ID, one-way analysis of variance (ANOVA) with Loge method , and theWhen combining the correspondence between components and targets, and the results of gene difference analysis and TPM analysis, the data showed that the expression and changes of MMP2 and PTGS2 in group T were consistent with that in group N, therefore, they were discarded.The SAIN components with major effects on LUAD and LUSC were Q, l, and K, and the genes with major effects on LUAD and LUSC were MMP1, MMP3, EGFR, MET, NAD (P) H: quinone oxidoreductase 1 (NQO1), and myeloperoxidase (MPO).For the analysis of six genes, we concluded that the expression of two genes, EGFR and MMP3, were much more effective in LUSC than in LUAD, whereas MET had the opposite effect. Although the other three genes  showed consistent expression in the occurrence and development of LUAD and LUSC, MPO was of interest as this gene showed full-stage high expression in cases in the N group and low expression in cases in the T group. Therefore, we speculated that overexpression of MPO in tissues might be effective in inhibiting the development of LUAD and LUSC.Based on the above-mentioned analysis, three targets, included Hsp90AA1, PTGS2, and MMP2 were excluded, and previous studies have shown that Hsp90AA1 and the isotype Asp90AB1 may be required for the treatment of two subtypes of breast cancer (MCF-7 and BT-474) . PTGS2 iThe remaining six targets  were subjected to undergo BP analysis Fig. a, KEGG eTo achieve credibility and statistical significance of the data, we performed GO (BP) analysis and KEGG enrichment analysis at FDR ≤ 0.05. Referring to the results of KEGG enrichment analysis, and to make it easy to understand, we used Cytoscape to associate the three components, six targets, and 20 pathways to draw a component target pathway diagram  network diagram, targets were sorted into EGFR, MET, MMP1, MMP3, NQO1, and MPO based on the number of regulatory pathways and corresponding components, and pathways were ranked into pathways in cancer, transcriptional misregulation in cancer, hepatocellular carcinoma, bladder cancer, and EGFR tyrosine kinase inhibitor resistance. According to the degree of correlation adherens junction, IL-17 signaling pathway, melanoma, non-small cell lung cancer, relaxin signaling pathway and microRNAs in cancer, etc. However, although these pathways contribute to both LUAD and LUSC, the strength of the contribution is still indistinguishable, and therefore, further analysis and validation  are needed.After a series of analysis, screening, and validation efforts as mentioned above, we identified the target sites where the three components  act separately, where the three components can act on multiple targets, where, Q can act on MMP1, MMP3, EGFR, MPO, and NQO1; L can act on MMP1, EGFR, and MET; and K only acts on MMP1.https://www.rcsb.org/) database [After obtaining this information, the structures of the 6 components were plotted using ChemDraw ultra 12.0 software , saved adatabase . PDB fildatabase  , MET , MMP1 , MMP3 , MPO , and NQO1 . The larger the value in this coordinate, the greater the affinity for docking, and the greater the affinity (interactions existing between ligand and receptor), thereby demonstrating that the tighter the binding of the component to the target, the more effective the component is. However, to guarantee the availability and reference value of the data, we set the coordinates  according to the structure size of the ingredients. Therefore, the coordinate values that were used in this study were appropriate for the ingredients. The best value was − 10.1 kcal/mol and the worst was − 7.9 kcal/mol.Based on the molecular docking results, items with affinities ranging from values  were used, and the 3 SAIN components and 6 targets for which detailed results of molecular docking are given in Table To probe the specific location in the cell of the six proteins that were screened, the PSORT II, CELLO, and BUSCA databases were used for subcellular localization predictions and predictions from three databases PSORT II Tables , 4 and 5Subcellular localization prediction showed that MMP1, MMP3, NQO1, EGFR, MET, and MPO were found in the cytoplasm, and among them, MMP1, MMP3, NQO1, and MET were also found in the mitochondria, in addition to MMP3. The other five proteins were all found in the nucleus.The purpose of survival analysis is to provide a patient with the option to continue treatment before undergoing surgery or other treatments, and is derived from the analysis of genetic data associated with the disease when the patient can survive after treatment with the corresponding target .Survival analysis of these six targets showed that all six genes showed statistical significance in the regulation of LUAD (P < 0.05), while only EGFR and MMP3 were statistically significant in the regulation of LUSC (P < 0.05), which was consistent with our previous TPM analysis Fig. .Fig. 8ReRMSD data are an important basis for measuring the stability of the system and can be used to measure the stability of the tertiary structure of a protein after incorporating small molecules . To makeEGFR, NSCLC targets have been used in clinic, and the RMSD change trend and starting value in the time period of 0–50 ns are similar to those of the MMP3 protein. In addition, EGFR and MMP3 exhibit a very stable conformation (average RMSD < 0.15) after forming a complex under the action of L or Q. Similarly, for clinical use with the target MET, its complex formed under the action of L was relatively stable, but the MMP1 protein had a stronger structural stability than MET when in complex with L or Q. When K is in a complex with MMP1, the stability of the complex in the human setting is general, but it does not show major unusual fluctuations Fig. .Therefore, L, Q, and K, the active ingredients of SAIN, may play an important role in improving or treating NSCLC (LUAD and LUSC) after acting on the targets EGFR, MET, MMP1, and MMP3.Compared with LUAD, LUSC has a unique pathological morphology  in NSCLC, therefore, no targeted therapy has been developed for LUSC due to few oncogenic aberrations that can target LUSC.Fibroblast growth factors (FGFRs) belong to the family of receptor tyrosine kinases (RTKs) along with EGFR, which comprises the four members FGFR 1–4. In our study, we observed amplification or mutations of FGFR1-4 in NSCLC, which play a crucial role in tumor development and maintenance. In 2016, a gene sequencing study that included 4853 cancer patients revealed that 7.1% of cancer patients had abnormalities in both FGFR 1–4 genes. The most commonly found amplification of the FGFR-1 gene accounted for 50% . A largeMatrix metalloproteinase 3 (MMP3) is the third member of the matrix metalloproteinase (MMP) family, and studies have shown that it plays many roles in healthy humans and patients, such as promoting epithelial mesenchymal transition, increasing the levels or activity of pulmonary profibrotic mediators, or decreasing antifibrotic mediators, and promoting abnormal epithelial cell migration and other abnormal repair processes . In addiIt is well known that insulin enhances the proliferation, migration, and drug resistance of NSCLC cells by activating the PI3K / Akt pathway. In previous studies, it has been shown that insulin can upregulate gene expression of MMP3 in NSCLC cells, and that its expression can be inhibited by PI3K / Akt pathway inhibitors .In previous studies, it has been shown that the genes and proteins of FGFR-1 and MMP3 are highly expressed in esophageal squamous cell carcinoma, and may be associated with esophageal cancer invasion and metastasis .Our findings showed that MMP3 positively regulated NSCLC, especially LUSC by participating in transcriptional misregulation in cancer, the IL-17 signaling pathway, and the rheumatoid arthritis pathway. Furthermore, molecular docking results showed that Q could bind to MMP3 protein with high binding affinity of -8.9 kcal/mol. Therefore, we speculated that there may be consistency or homology between MMP3 and FGFR-1 in treating LUSC. MMP3 may serve as a biomarker for the diagnosis and prognosis of LUSC . HoweverThe latest NSCLC guideline 2021 V2 edition issued by the national comprehensive cancer network (NCCN) indicated that genes associated with targeted therapy of NSCLC include EGFR, KRAS, ALK, ROS1, MET, BRAF, RET, and NTRK . HoweverReceptor tyrosine kinases (RTKs) are high affinity cell surface receptors for many hormones, cytokines, and polypeptide growth factors. Of the 90 unique tyrosine kinase genes identified in the human genome, 58 encode RTK proteins. RTKs have not only been shown to be key regulators of normal cellular processes but also play a key role in the initiation and progression of many types of cancer .EGFR and MET belong to members of the RTK family, and MET, the tyrosine kinase transmembrane receptor for MET, is a protein product encoded by the c-MET proto oncogene that has been of interest in the clinic as a potential therapeutic target in multiple tumor types .Gefitinib, Erlotinib, Afatinib, Osimertinib, Dacomitinib, Lcotinib, and Brigatinib, among others, monoclonal antibodies are comparatively rare and mainly include Necitumumab, Amivantamab, and Ramucirumab, of which Amivantamab targets the EGFR exon20 insertion [Currently, a variety of targeted drugs have been developed for NSCLC targeting EGFR mutations and MET exon14 alterations, among which, drugs targeting EGFR mutations are mainly classified into two major classes: small molecule tyrosine kinase inhibitors (TKI) and monoclonal antibodies, and the TKI class mainly includes nsertion .Crizotinib, Cabozantinib, MGCD265, AMG208, Altiratinib, Golvatinib) and selective MET inhibitors . Monoclonal antibodies can be further divided into Anti-MET antibodies  and anti-HGF antibodies .Drugs targeting alterations in MET exon14 are two major classes of TKIs and monoclonal antibodies, multi kinase inhibitors, including TKIs  had significantly shorter prognostic survival relative to patients with MET mutations (P < 0.02).Smoking confers an increased risk of lung cancer, and in an earlier study, no significant difference by NQO1 genotype was found in a large cohort of patients with combined smoking and nonsmoking lung adenocarcinoma. The data showed that smokers with combined MPO genotype had a lower lung cancer prevalence than nonsmokers .MPO is a member of the heme peroxidase superfamily and is mainly expressed in neutrophils and monocytes . It has High expression of MMP1 has potential in NSCLC treatment.Molecular docking of C-T revealed that components Q, L, and K could bind to MMP1 protein with better affinity than any other component, Q , L , and K , respectively. Our survival analysis of LUAD and LUSC patients after comparing MMP1 overexpression revealed that the overexpression of MMP1 exhibited a worse prognostic survival compared with the survival time of patients after an EGFR mutation. Moreover, PPI network analysis showed that MMP1 formed three triangular structures with EGFR, MMP3, MET, and MPO Fig. d, suggesMMP1, like MMP3, belongs to the MMP family. Only few studies have been performed on MMP1 because the expression of MMP1 in rodent orthologs is not conserved . HoweverTherefore, combined with the above-mentioned results, we speculate that MMP1 may be a novel target for NSCLC treatment, and l, Q, and K may be the relevant lead compounds.In this study, we screened the three active ingredients Q, L, and K from SAIN. However, as to whether these three ingredients have curative effects on NSCLC, experiments in cell systems or animal experiments are needed for further verification. Before performing in vitro and in vivo validation, extensive experimental validation for the treatment of NSCLC on several of these components was found in the literature, therefore, we did not perform in vitro or in vivo validation.L —5,7-dihydroxy-4-chromenone) is a natural flavonoid compound, and it has been reported that the effects of L on NSCLC are mainly reflected in (1) in lung cancer A549 cells and nuclear H460 xenograft mice. The expression of L in melanoma 2 (AIM2) was significantly reduced at the mRNA and protein expression levels, which inhibited AIM2 inflammasome activation, and in turn induced G2/M phase cell cycle arrest and inhibited the epithelial mesenchymal transition (EMT) process in NSCLC . (2) At Q —3,5,7-trihydroxy-4-chromenone) and L are structurally similar, the only difference being that Q has more than one hydroxyl group in position 3 of the chromoenone parent nucleus. Epidemiologically, studies have shown that Q has the effect of preventing lung cancer, which is mainly reflected by (1) Q can significantly enhance tumor necrosis factor-related apoptosis inducing ligand (TRAIL)—induced cytotoxicity in NSCLC cells, thereby accelerating the death of NSCLC cells , 63. (2)In previous studies, it was shown that dietary flavone K —4-chromenone) can effectively prevent and treat lung cancer, mainly through the following mechanisms: (1) K inhibits the apoptosis of H460 cells (NSCLC cells) by inducing the overexpression of tumor suppressor gene antioxidant enzyme (Sod-2) . (2) K mIt is well known that the complexity of NSCLC etiology does not allow us to explain it by the alteration of a single gene, therefore. The treatment of lung cancer is not achieved by one means, but requires combination therapy of multiple means and multiple targets. Although the three components Q, L, and K in SAIN can do so by binding to MMP1, MMP3, EGFR, and MET, and are capable of acting as inhibitors by participating in EGFR tyrosine kinase inhibitor resistance, adherens junction, IL-17 signaling pathway, NSCLC, and the relaxin signaling pathway, exerting their functions together to prevent and treat NSCLC (LUAD and LUSC). Nobody can predict which genetic mutations are responsible for NSCLC, and therefore, a concerted effort from researchers in all fields is required for the complete cure of NSCLC.


MYO7A, USH1C, CDH23, PCDH15, and USH1G (SANS) for Usher type 1; USH2A, ADGRV1, and WHRN for Usher type 2; CLRN1 for Usher type 3. USH is inherited in an autosomal recessive pattern. Digenic, bi-allelic, and polygenic forms have also been reported, in addition to dominant or nonsyndromic forms of genetic mutations. This narrative review reports the causative forms, diagnosis, prognosis, epidemiology, rehabilitation, research, and new treatments of USH.Usher syndrome (USH) is the most common genetic condition responsible for combined loss of hearing and vision. Balance disorders and bilateral vestibular areflexia are also observed in some cases. The syndrome was first described by Albrecht von Graefe in 1858, but later named by Charles Usher, who presented a large number of cases with hearing loss and retinopathy in 1914. USH has been grouped into three main clinical types: 1, 2, and 3, which are caused by mutations in different genes and are further divided into different subtypes. To date, nine causative genes have been identified and confirmed as responsible for the syndrome when mutated:  Human communication is, to a large extent, based on our “far senses”: hearing and vision . The useMYO7A, USH1C, CDH23, PCDH15, and SANS for Usher type 1; USH2A, ADGRV1, and WHRN for Usher type 2; CLRN1 for Usher type 3.Usher syndrome (USH) is the most common deaf–blind syndrome, with 50% of deaf-blindness in persons younger than 65 years of age. It is a genetic condition that includes hearing loss, retinopathy (retinitis pigmentosa), and vestibular areflexia with different entities and onset ,3,4. It CIB2 (USH1J) is no longer considered responsible for Usher syndrome and was recently excluded from Usher genes by Booth et al., 2018 (https://www.usher-syndrome.org/ accessed on 21 December 2021) [er 2021) .ESPN (USH1M), HARS (USH3), CEP78 , CEP250 , ABDH12 (USH3), and ARSG , and three loci, namely, USH1E, USH1H, and USH1K. In addition, PDZD7, a modifier gene, is considered responsible for Usher type 2 when associated with mutations in other Usher genes, such as USH2A, ADGRV1, and WHRN. Nonsyndromic recessive and dominant hearing loss without retinopathy caused by USH genes has also been reported [Other genes and loci have been related to the disease; however, their roles are not clear and must be confirmed in further studies: reported .CIB2 is also being questioned by Booth et al., 2018 [USH is the most common cause of syndromic hearing loss after Pendred syndrome ,11,12 anl., 2018 , even thFor the purpose of this review, it is important to consider that the syndrome is divided into three clinical subtypes , identified by clinical investigation, and that different subtypes correspond to different responsible genes, identified by genetic investigation. However, genetic investigations are essential to confirm or reject the clinical diagnosis. The introduction of next-generation sequencing has improved the identification of new genes and mutations ,18. NeveUSH can be considered a ciliopathy ,21 becauThe terminology might be quite confusing because the structures of inner ear cells have been called stereocilia (sing. stereocilium) and kinocilia (sing. kinocilium) . HistoloUSH belongs to a group of ciliopathies affecting nonmotile or sensory cilia, which include Bardet–Biedl syndrome, Alström syndrome, Meckel syndrome, Joubert syndrome, and Leber congenital amaurosis (primary nonmotile ciliopathies). Despite sharing overlapping features, these syndromes are very different, and it is rare for the same gene to be involved in two different conditions. This suggests a strong specific causative relationship between the genotype and phenotype.Even if both microtubules and actin filaments are involved in different ciliopathies, USH seems to interfere exclusively with sensory cells that express actin filaments in specific segments ,32,33,34Despite symptoms following the distribution and expression of different proteins in different organs, the variability in expression of similar dysfunctions can be remarkable, even among siblings . PenetraThe scope of this narrative review is to provide an overview of the current clinical and genetic knowledge concerning the epidemiology, diagnosis, prognosis, rehabilitation, and treatment of USH. It intends to provide clinical features and genetical understanding, helpful to several specialists, to sustain a multidisciplinary approach and successful management of the syndrome. It is targeted to professionals, researchers, and students with interest in the field of otology, audiology, and genetics. Reported variants should be intended as examples and they do not refer to the prevalence of the variants. Unless otherwise specified in the text, they were selected from the literature for teaching purposes and to clarify what is eventually reported in the text. Figures and tables should be also intended as explicative, simplified, and helpful for readers in understanding the genetics, clinical aspects, and pathophysiology of USH. Genotype/phenotype correlations have been described following the most common accepted criteria available in the literature; however, exceptions are possible and partially reported in the text, even if they do not necessarily reflect the direct experience of the authors. Finally, the authors herein provide available solutions for the most effective rehabilitative approach in the management of USH following national guidelines, personal experience, and scientific literature; however, rehabilitation may be influenced by local laws, national guidelines, and health institutions with different approaches to the management of the syndrome. To the best of our knowledge, an international consensus statement on diagnosis, treatment, rehabilitation, and follow-up of USH has not been published to date.A literature search was carried out in medical databases, such as “PubMed.” The keywords “Usher”, “syndromic hearing loss”, “blindness”, “retinitis pigmentosa”, “retinal dystrophy”, “ciliopathies”, and “deafness” were used, and 450 English articles from 1988 to 2021 were selected and analyzed. It is important to emphasize that this report is not a systematic literature review. The text has been formatted based on the following main categories: genetics, epidemiology, diagnosis, rehabilitation, treatment, and some future perspectives. Of the 450 articles, 128 full texts, best suited to our purposes, were selected and included in this review.Even if kinocilium may present a motile structure (9 + 2), it is considered a nonmotile cilium, lacking inner dynein arms . DegenerIn the eye, mutations in Usher genes are responsible for affecting light-sensing rods and cones, thus leading to the degeneration of the retina with pigment deposits, a condition named retinitis pigmentosa (RP). In RP, the retina’s light-sensing rods and cones slowly lose their properties and functions, starting at the outer edges.Compromised photoreceptors, retinal pigment epithelium cells, and Müller cells are thought to be the cellular basis underlying the pathogenesis of RP ,44,45.Usher proteins are widely expressed in the retina and particularly in the connecting cilium, periciliary membrane, calyceal process, inner and outer segment, basal body, and synapse. Mutations are responsible for progressive degeneration and loss of functions of those structures. In particular, the rods are first involved in the process, thus leading to difficulties in seeing in darkness. Degeneration of cones often starts at the outer edges, causing a “tunnel view”, and subsequent degeneration causes loss of central vision .ABHD12, ADGRV1, ARSG, CDH23, CEP250, CEP78, CIB2, CLRN1, DFNB31, ESPN, HARS, MYO7A, PCDH15, USH1C, USH1G, and USH2A. In addition, one modifier gene (PDZD7) was identified in 2015. Three new loci, USH1E [https://sph.uth.edu/retnet/sum-dis.htm#Agenes accessed on: 21 December 2021). Thus, genetic heterogeneity of this syndrome and some of the genes can also be found in nonsyndromic hearing and nonsyndromic RP forms. The large heterogeneity and rarity of USH often results in late or incorrect diagnosis in subjects with a mild phenotype [To date, USH has been associated with 16 genes : ABHD12,i, USH1E , USH1H [i, USH1E ,33, and i, USH1E , have beMYO7A, USH1C, CDH23, PCDH15, and SANS for Usher type 1; USH2A, ADGRV1, and WHRN for Usher type 2; CLRN1 for Usher type 3.To date, nine of the aforementioned genes have been identified and confirmed as causative genes: MYO7A alleles associated with differing phenotypes, (2) alleles responsible across different genes, or (3) phenotypic heterogeneity due to variable degrees of penetrance and expressivity. However, penetrance in USH type 1 and 2 is considered almost complete (99–100%).Genetic heterogeneity can also arise from (1) various mutations in the same gene in different individuals, such as USH1C, USH1G/SANS, PCDH15, CDH23, and MYO7A) and Usher protein complex 2 . These complexes are involved in tip links, lateral links, top connectors, and ankle links  seem to be involved in hearing loss when mutated, while only MYO7A has been associated with USH. Structural proteins play important roles in the functions and movements of actin cilia. In the inner ear motor, some Usher proteins are hypothesized to be part of an Usher protein network constituted by USH1C, USH1G, CDH23, and MYO7A, which mediate mechano-transduction in cochlear hair cells, vestibular hair cells, and photoreceptors (primarily the rods). Furthermore, mutated MYO7A causes USH1B, the most common form of USH1. Mutations in this gene can also be found in rare cases of nonsyndromic hearing loss (DFNA11 and DFNB2). Myosins are mechano-chemical proteins characterized by the presence of domains that interact with other proteins, with structural properties that allow ciliary movements in actin filaments.This gene is one of the most common and is frequently involved in Usher syndrome. It belongs to a superfamily of motor genes that encodes large proteins, the so-called myosins. They are known to play a role in many motile functions in mammals. Different myosins have different functions in many organs and they may interact with actin filaments to provide specific and specialized functions in hearing and vision. Some myosins .Lastly, l myosin ,49,50,51no acids . InteresReported pathological variants are p.R150X (USH 1B), p.Q234X (USH 1B), p.R212H (USH1B), p.R212C (USH1B), C168X (USH1B), p.G214R (USH1B), p.A397D (USH1B), p.R244P (DFNB2), p.M599I (DFNB2), p.R395H (DFNB2), C31X (USH1B), C628X (USH1B), and 9-BP DEL exon 22 (DFNA11) ,54,55. IMYO7A mutations among Usher patients are responsible for congenital severe-to-profound hearing loss, equilibrium disorders, and early onset of RP. Exceptions are reported where the most of pathological variants are usually responsible for profound congenital hearing loss with the absence of vestibular function. RP is also severe and rapidly progressive, with early onset [As widely reported in the literature, ly onset ,57. Bilaly onset ,59,60. Ily onset .This gene encodes a structural protein called protocadherin and is a member of the cadherin superfamily. Protocadherin belongs to the family of integral membrane proteins that mediate calcium-dependent cell–cell adhesion. It plays an essential role in the maintenance of normal retinal and cochlear functions. It is a crucial part of the tip link structure (tip link complex) and interacts with cadherin-23 to form tip links that are extracellular filaments that connect stereovilli in the inner ear. The tip link complex is located in the apical part of the hair cells. Mutated proteins cause defective tip links and affect the functions of the stereocilia, particularly the mechanoelectrical transduction . FurtherPCDH15 encodes for 33 exons and 1995 amino acids. R245X is considered a founder mutation responsible for approximatively 50–60% of USH1 in the Ashkenazi Jewish population [pulation . Other rpulation , c.del14pulation , p.K808Xpulation , p.R134Qpulation , and S64PCDH15 mutations were associated with poor CI performances and should be screened through next-generation sequencing for prognostic purposes to explore cochlear implantation outcomes [Chen ci Wu, in 2015, reported that children with outcomes .PCDH15 is widely expressed in the brain and nerves, and it is thought that mutations in PCDH15 also involve the neural partition of the cochlea. In 2021, Nisenbaum et al. included PCDH15 mutations among children that had no successful outcome post CI. This would be a strong recommendation for genomic screening among CI candidates with USH before surgery [PCDH15 mutations. surgery . These pThis gene encodes harmonin, an anchoring scaffold protein that is also hypothesized to be a part of the Usher protein network. The gene was identified in the short arm of chromosome 11 ,69,70. MLocalized on the long arm of chromosome 17, this gene is responsible for the transcription and encoding of a small protein named USH type-1G protein. The encoded protein is an anchoring/scaffolding protein that interacts with harmonin and is also a part of the Usher protein network in hair cells. The gene is found in the USH1G subtype ,73,74.CDH23 is located in 10q21–q22, a region containing the human deafness loci DFNB12 and USH1D. CDH23 contains 69 exons and encodes for 3354 amino acids. CDH23 is required for proper organization development of stereocilia in the cochlea and vestibule. It is also part of the Usher protein network, USH1D, which is the second most common genetic type of USH1.This gene is a member of the cadherin superfamily, whose genes encode calcium-dependent cell–cell adhesion glycoproteins. These are transmembrane proteins that are thought to be involved in stereocilia organization and hair bundle formation. It is involved in tip links, top connectors, and lateral links, and when mutated, is responsible for USH1. The gene Pathological variants responsible for USH1D are p.Q1496H, p.R1746Q, p.E1006K, p.E2520K, c.2289 + 1G > A, and p.Q492X .The following variants are responsible for DFNB12: p.D1243N, p.D1400N, p.D2148N, p.D1341N, p.V586M, p.R301Q, and p.P240L. Cochlear implantation has provided successful outcomes worldwide.This gene is located on chromosome 15q25.1 and encodes a calcium-binding regulatory protein. These proteins are involved in intracellular calcium homeostasis. It is also involved in the maintenance of photoreceptor and hair cells. Mutations in this gene are responsible for DFNB48 and USH1J. It was previously reported to be responsible for USH1H but was subsequently identified as a different gene and therefore named USH1J, with the gene in the locus USH1H still unknown. The protein localizes to the stereocilia of inner ear hair cells and photoreceptors and is postulated to be a component of the Usher protein network ,75. Its This gene encodes a multifunctional actin-bundling protein called espin. It plays a major role in regulating the organization, dimensions, dynamics, and signaling capacities of actin filament-rich microvilli in mechanosensory and chemosensory cells. It is required for the assembly and stabilization of stereocilia in parallel actin bundles. Mutations in this gene are associated with autosomal recessive sensorineural deafness (DFNB36) with or without vestibular involvement and USH1M ,76. HoweThree new loci were identified in different families, after mutations in known genes for USH were excluded. They were named USH1 E, H, and K, and cryptogenic studies have revealed that these three loci map to chromosomes 21, 15, and 10, respectively . To dateUSH2A, which is localized to the long arm of chromosome 1. It is a structural protein expressed in the basement membranes of the cochlea and retina. Usherin potentially plays an important role in the homeostasis of eye and ear functions. It is also thought to be a part of other genes in the Usher protein network. Furthermore, Usherin is necessary for the function and organization of the periciliary membrane complex in photoreceptors by regulating intracellular protein transport. The USH2 protein network consists of USH2A, GPR98 (ADGRV1), WHRN, and PDZD7 [USH2A are usually responsible for moderate-to-severe hearing loss and because of the absence of progression, bilateral hearing aids are usually beneficial. USH2A mutations are the most frequent worldwide. Reported variants are p.Cys934Trp, p.(Thr65Ilefs*80), p.R34X, p.R63X, p.W3955X, and p.R4608X [Usherin is a protein encoded by nd PDZD7 . The prop.R4608X ,79,80,81p.R4608X .ADGRV1, also known as GPR98 or VLGR1, encodes a calcium-binding G protein-coupled receptor. The encoded protein contains a 7-transmembrane receptor domain, binds calcium, and is widely expressed in the central nervous system, eye, and ear. It has an essential role in the development of hearing and vision. The protein is required for the formation of the ankle link complex in the hair cells (The gene ir cells . In addiWHRN) is a protein-coding gene. Diseases associated with WHRN include deafness, autosomal recessive hearing loss (DFNB31), and USH2D [WHRN is important for the maintenance of a periciliary membrane complex that seems to play a role in regulating intracellular protein transport in photoreceptors [EPS8 encodes an epidermal growth factor protein that is also reported to be responsible for DFNB102 and syndromic hearing loss  [This gene is thought to function in the organization and stabilization of stereocilia (stereovilli) elongation and actin cystoskeletal assembly. Mutations in this gene have been associated with autosomal recessive nonsyndromic deafness and USH. Whirlin  ,45,85,86This gene encodes a ciliary protein homologous to proteins that are mutated in patients with USH, and mutations and translocations involving this gene have been proposed to be associated with USH2A and DFNB57 . It is cCLRN1 mutations have also been reported in a potential digenic deafness associated with MYO7A [This gene encodes a protein (clarin) that may be important in the development and homeostasis of the inner ear and retina. It is thought to play a role in the excitatory ribbon synapse junctions between hair cells and cochlear ganglion cells and presumably also in analogous synapses within the retina. It acts as a modulator of transduction activity. The gene was found to be connected to the USH3A subtype ,96,97,98th MYO7A ,101,102.th MYO7A .HARS is located on chromosome 5q31 and encodes an aminoacyl-tRNA synthetase. Mutations in this gene have been hypothesized to be linked to USH3B and Charcot–Marie–Tooth Disease . The protein encoded by this gene is a cytoplasmic enzyme that belongs to the class II family of aminoacyl-tRNA synthetases. The enzyme is localized in the cytoplasm, and it is responsible for the synthesis of histidyl-transfer RNA, which is essential for the incorporation of histidine into proteins [proteins .HARS mutations. In 2012, Puffenberger et al. reported partial restoration with hearing aids or cochlear implant [Few data are available in the literature on cochlear implantation outcomes among patients with  implant . Its rolABHD12 gene encodes an enzyme that is involved in the hydrolysis of 2-arachidonoyl glycerol (2-AG), the main endocannabinoid lipid transmitter that acts on cannabinoid receptors CB1 and CB2. It was originally localized in Norwegian families, and in 2012, a homozygous ABHD12 mutation was identified and reported in a Lebanese family with USH3-like findings and cataracts [This gene is located on the short arm of chromosome 20 and is an acronym for polyneuropathy, hearing loss, ataxia, retinitis pigmentosa, and cataract due to an inborn error in endocannabinoid metabolism. The ataracts . Its rolCEP250 gene (chr. 20q) encodes a core centrosomal protein required for centriole–centriole cohesion, thus playing an important role during the interphase of the cell cycle.New forms of a potential “atypical USH,” with mild sensorineural hearing loss and different retinal degeneration, have recently been found in some families. Centrosomal proteins are proteins that are localized in the centrosome or centriolar satellites. Centrosomes and centriolar satellites seem to play important roles in the cellular cycle and are responsible for the correct matching of chromosomes during mitosis and meiosis. However, they are also involved in the maintenance of regular function and organization of primary or motile cilia, which are located in the basal body of cilia and microtubules. These proteins may be considered structural proteins and their role can explain their involvement in several ciliopathies ,106, affCEP250 mutations include cone–rod dystrophy, hearing loss 2, and USH. Its possible role in USH is not yet fully understood [Diseases associated with derstood .This gene encodes a centrosomal protein of 78 kDa that is required for the regulation of centrosome-related events during the cell cycle and is required for ciliogenesis. Naturally occurring mutations in this gene cause defects in primary cilia that result in retinal degeneration and sensorineural hearing loss. This can be associated with photoreceptor degeneration hearing loss and may be a new form of USH ,109,110.ARSG encodes the protein arylsulfatase G, which hydrolyzes sulfate esters from sulfated steroids, carbohydrates, proteoglycans, and glycolipids. They are involved in hormone biosynthesis, modulation of cell signaling, and degradation of macromolecules. This protein is localized in the lysosomes. In 2018, Khateb et al. reported mutations in this gene in a family with “atypical” Usher [l” Usher . Subsequl” Usher ,113,114.USH2A gene accounting for 80–90% of cases [USH1B and USH1D) and Louisiana, USA (USH1C), where USH1 is more common than USH2. Furthermore, isolated communities and cultural causes often result in deaf-by-deaf marriages [USH is a rare condition in the general population. However, it should be considered a common condition for professionals, geneticists, ophthalmologists, otolaryngologists, and audiologists, since mutations in genes responsible for Usher are the most common cause of ciliopathies and deaf-blindness. The prevalence rate is not well described globally, and large variations in prevalence have been reported, probably due to a lack of diagnostic and rehabilitation resources. Nevertheless, the prevalence has been estimated with greater accuracy in Great Britain, Sweden, Norway, Finland, Denmark, Italy, the Netherlands, Australia, and the United States. In Asia and Africa, only a few reports have been published, but the prevalence in most countries and ethnic groups has been estimated. Considering these discrepancies, the global estimation is 1/30,000 inhabitants, which should be considered as a low average because several studies have reported a wide range of prevalence that varies from 1 to 17 per 100,000 inhabitants . A Swediof cases . In USH1arriages . USH3 isarriages . Sweden arriages . This isarriages . An overClinical USH diagnosis is essentially based on the association between hearing loss and RP, where hearing loss is congenital, and RP is apparent in childhood or young adulthood . To dateA neonatal audiological diagnosis should include otoacoustic emission (OAE), auditory brainstem response (ABR) with threshold measurements, auditory steady-state response (ASSR), and stapedial reflexes to determine the degree of hearing loss and rule out auditory neuropathy. The localization of hearing loss in USH is cochlear, with loss of both outer and inner hair cells. Later in childhood and during the life course, the addition of pure tone audiometry and speech audiometry should be included. The differences between USH1, USH2, and USH3 are as follows :USH1: Congenital profound bilateral deafness.USH2: Congenital moderate-to-severe bilateral hearing loss. In most cases, stable hearing loss occurs during the first 3–4 decades. Hearing loss has a sloping pattern: in most cases mild to moderate in the low frequencies and severe to profound at higher frequencies.USH3: Congenital hearing loss, which is usually mild during childhood with a typical sloping pattern. The hearing loss is more variable, which differs from USH2 in that it is progressive with acquired severe-to-profound hearing loss usually in the third decade.USH1: Vestibular investigation is an essential part of the diagnosis since all children suffer from bilateral vestibular areflexia. In small children, a rotatory test in an office chair using video Frenzel goggles reveals absent horizontal nystagmus during rotation. Assessment of motor milestone development shows delayed gross motor development with hypotonia as neonates; the children show delays in sitting and crawling and usually have a walking age of >18 months. Later, during childhood, they present difficulties in walking balance beams and difficulties in learning to ride a bicycle.USH2: Vestibular function is normal with normal motor milestones.USH3: Balance function is usually normal during childhood and early adulthood and is decreased later.Vision loss is caused by a degenerative retinal disorder called “retinitis pigmentosa.” This name goes back to the time at which the findings in the retina were thought to be related to inflammation. Today, we know that RP in USH is a slow retinal degeneration that initially affects the rods. RP in USH should not be compared with other forms of RP since the progression in USH is much slower than in other RPs. There are essentially two known types of photoreceptor cells (rods and cones), and ganglion cells involved in RP, thus resulting in progressive vision impairment. Rods are primarily responsible for nighttime vision, so-called scotopic conditions. The contribution of ganglion cells in RP remains unclear. The rods are located in the periphery of the retina and are also responsible for peripheral vision, while cones contribute to daytime and central vision (photopic conditions). Cones are also responsible for the color vision. RP is quite similar in all Usher types, and individual variation is usually greater than the variation between types. Vision loss in childhood is mild and may go undetected during the first 10 years. The slow degeneration of rods results in minor problems with contrast vision and light sensitivity. Progressive problems with night vision can be detected at around 8–10 years of age. Visual diagnosis should be made as early as possible. It is possible to detect dysfunction of the rods by electroretinography at an early age. Fundoscopy and testing of the visual field in small children are usually not sufficient to detect RP in USH .The next symptom to appear is the so-called scotomas, which are small blind spots where small objects might be difficult to see. This is usually not noted by younger children who obviously do not comprehend how their vision is different from others. However, later in teenage and young adulthood, the degeneration of the rods increases, resulting in large peripheral visual loss and “tunnel vision.” At this stage (20–30 years), the night vision capability is extremely poor. In most cases, cataracts develop around 30–40 years. Several people with USH have preserved some central vision throughout most of their lives, although with visual fields of only 5–10 degrees ,121.In making a correct clinical and genetic diagnosis of USH1, it is important to keep in mind that there exist rare cases characterized by a nonsyndromic deafness with “typical” USH1 mutations.USH1: To date, children with USH1 have often been misdiagnosed as having a nonsyndromic profound deafness. Today, in most industrialized countries, deafness is discovered through universal neonatal screening. Since deafness in USH is always bilateral, early cochlear implantation should be performed (6–12 months) to provide hearing and spoken speech . It is iUSH2A). It has recently been evident that the deterioration of hearing to some extent is dependent on different mutation patterns. Some older adults have shown a combination of congenital hearing loss and age-related hearing loss, which has resulted in profound deafness and cochlear implantation [USH2: The hearing loss in USH2 is so severe that it can be detected by neonatal hearing screening. The hearing loss should be treated as soon as possible after diagnosis with bilateral hearing aids (2–3 months). It is quite easy to fit children with USH2 since hearing loss during childhood and young adulthood is relatively stable. Most subjects with USH2 harbor mutations involving the Usherin gene , might result in falls and fractures. Unlike the rapid progression of hearing loss, RP does not seem to differ from USH1 and 2 .Recently published articles have suggested a new type of USH. To the best of our knowledge, the existence of a fourth type of Usher is not clear and must be confirmed. Usher type 4 has been proposed in a new study among five subjects from three families with atypical forms of Usher. However, further evidence is required to support the introduction of this new type as an atypical Usher form .Deaf-blindness, as well as USH, is the result of the progression in various combined vision and hearing impairments to such an extent that it is difficult for the impaired senses to compensate for each other. However, deaf-blindness is a distinct entity and should not be rehabilitated as a simple coexistence and summation of two single impaired senses (hearing and vision). Since USH limits activities and restricts full participation in society, it also affects social life, communication, access to information, orientation, and the ability to move around freely and safely. To compensate for this loss, the tactile sense becomes important. Furthermore, because vision loss is progressive, the mode of communication must be continuously changed. Communication will always be time-, cognitive-, and energy-consuming. Impaired vision and hearing function increases the need to make use of other sensory stimuli . It limits access to distance information and creates a need to rely on information within the near surroundings. Extensive research in gene therapy is at hand; however, to date, there is no effective treatment beyond clinical trials in preventing or treating hearing, vision, or vestibular loss. Correct and early rehabilitation can prevent many other physical and psychological co-morbidities following progressive deaf-blindness.Most children with USH1 in developed countries are offered cochlear implants (CIs) with high efficacy. In Sweden, the majority of subjects with USH3 are offered CI, usually around 30–40 years . Some peThe hearing loss in USH2 is stable in most cases, and the linguistic outcome is good when hearing aid fitting and audiological rehabilitation start early. The difference in audiological rehabilitation between people with deaf-blindness and people with nonsyndromic hearing loss is that humans always use a combination of hearing and vision, as symbolically illustrated by “One hears with the eye and sees with the ear.” The authors believe that children with USH should obtain sign language as a second language, to have an alternative mode of communication if blindness should occur and tactile sign language has to be used in compliment with hearing.Early diagnosis using electrophysiology will ensure correct and early rehabilitation. Once the diagnosis is obtained, yearly visual examinations should be performed, and pediatric ophthalmologists and optometrists should pay attention to contrast sensitivity, light sensitivity, and scotomas. This will make it easier for schools and families to use correct lighting conditions and contrast. Strong sunlight is often problematic, and sunglasses should be encouraged.Bilateral vestibular areflexia in USH1 results in impaired and delayed motor milestones. Thus, early rehabilitation has to focus on making use of somatosensory and visual signals to compensate for vestibular loss. This can be done in preschools and schools by having extra physical training under the guidance of a physiotherapist.Rehabilitation will benefit from close cooperation between ENT/audiology and ophthalmology/low-vision clinics. Adjustments, especially with special light conditions, must be executed in the home, schools, and later in life, at workplaces.Recent research in Sweden has shown that adults with USH generally have poor physical health compared with a cross section of the Swedish population. The most prominent physical symptoms were fatigue, headache, as well as neck and shoulder pain. Psychological health was also impaired, with the inability to manage problems and lack of social trust. The USH group showed a statistical over-representation of suicidal behaviors ,128.Thus, rehabilitation in USH must focus not only on vision and hearing, but also on the psychosocial consequences of deaf-blindness. Rehabilitation must be multidisciplinary and involve family, school, employer, etc. Rehabilitation is lifelong and increases with age.It must be noted that the epidemiology presented in Gene therapy in USH has undergone significant achievements during the last 5 years. Several different approaches are currently used in different stages of animal and human clinical trials. Most research has focused on the retina and preserving vision. The reasons for this are that CI has been shown to both allow hearing in USH1 and restore hearing in USH2 and 3. Moreover, the retina is easier to access than the cochlea. Nevertheless, gene therapy studies are ongoing and directed towards the retina, cochlea, and vestibular apparatus.Mice and zebrafish are often used as in vivo animal models. Translating results from animal models is often difficult, but the results from current clinical trials will hopefully result in new treatments. Different approaches have been used, such as adeno-associated viral vectors, for in vivo gene transfer. It has the advantage of using a DNA virus that is nonpathogenic to humans. It appears to enable long-term transduction after a single vector administration and has a good safety profile in humans. Some of the USH genes are quite large, and a potential disadvantage can be limited cargo capacity. Clinical trials using dual AAV vectors have been conducted. Another approach is to use antisense oligonucleotides, with clinical application becoming a reality and several drugs already in trials. Nonsense mutations are common in USH, and the drug Ataluren creates a premature stop signal in the translation of the genetic code, which allows the cell to produce a full-length, functional protein.USH2A gene. An excellent review of the gene-, drug-, and cell-based therapies has recently been published by French et al. [The discovery of CRISPR–CAS9 that received the Nobel Prize in 2020 is another method enabling in vitro correction of the c2299delG mutation in the h et al. .USH is one of the most common autosomal recessive syndromes associated with double-sense impairment, hearing, and vision. This combination creates a unique entity of deaf-blindness. Genetics has enabled significant advances, accurate diagnosis, and improved understanding of the pathology and is expected to provide innovative treatments for gene therapy. Next-generation sequencing has also helped in new conceptions and knowledge of the field.The rehabilitation of these patients is complicated and requires specific knowledge and education. Even if bioengineering provides continuous progression in retinal support, the best treatment option remains hearing rehabilitation with hearing aids and CIs. Bilateral devices can partially restore spatial orientation and support residual visual function. Encouraging results have been published on gene therapy in experimental animal models, but this approach has not been translated into current clinical management. Nevertheless, further studies are necessary to develop new strategies and collect information on USH.


The choice between upfront surgery or neoadjuvant treatments (NAT) for resectable pancreatic ductal adenocarcinoma (R-PDAC) is controversial. R-PDAC with potential nodal involvement could benefit from NT. Ca (Carbohydrate antigen) 19.9 and serum albumin levels, alone or in combination, have proven their efficacy in assessing PDAC prognosis. The objective of this study was to evaluate the role of Ca 19.9 serum levels in predicting nodal status in R-PDAC.Preoperative Ca 19.9, as well as serum albumin levels, of 165 patients selected for upfront surgery have been retrospectively collected and correlated to pathological nodal status (N), resection margins status (R) and vascular resections (VR). We further performed ROC curve analysis to identify optimal Ca 19.9 cut-off for pN+, R+ and vascular resection prediction.Increased Ca 19.9 levels in 114 PDAC patients were significantly associated with pN+ (p <0.001). This ability, confirmed in all the series by ROC curve analysis (Ca 19.9 ≥32 U/ml), was lost in the presence of hypoalbuminemia. Furthermore, Ca 19.9 at the cut off >418 U/ml was significantly associated with R+ . Ca 19.9, at the cut-off >78 U/ml, indicated a significant trend to predict the need for VR .In R-PDAC with normal serum albumin levels, Ca 19.9 predicts pN+ and R+, thus suggesting a crucial role in deciding on NAT. Pancreatic ductal adenocarcinoma (PDAC) is a leading cause of cancer-related deaths. Moreover, according to the projections, it has been estimated that pancreatic cancer incidence is increasing .Surgical resection represents the optimal treatment for patients affected by PDAC , 3.Unfortunately, due to the advanced stage of the disease at first diagnosis, mostly related to the presence of distant metastases or local vascular invasion, only a minority of PDAC patients are eligible for upfront surgery .For this reason, several different programs for pancreatic ductal adenocarcinoma early detection have been evaluated to date, yet it remains a hot-topic for research to improve outcomes. In this field, recent advances are showing promising results in the development of cheap and user-friendly tools, also based on the use of emerging technologies such as nanotechnology , 6.Regrettably, despite being very promising , these tMoreover, even for patients selected for radical resection, the prognosis remains poor due to nodal involvement and the higher rates of local or distant recurrences. In this regard, actual 5-year low survival rates of 17% have been reported, with the grade of lymph node involvement proving to be among the main predictors of survival in resected PDACs For these reasons, chemotherapy and chemo-radiation therapy are often proposed in a neoadjuvant setting, aiming to increase the rate of resectability and achieve better oncological results , 10.Since pancreatic surgery is often burdened by severe morbidity and not-negligible mortality, even in high-volume centers, resected patients often experience a delay in starting adjuvant treatments with consequent impairment of long-term outcomes. Therefore, some authors proposed the use of minimal-invasive approaches with the hope of decreasing postoperative morbidity and reducing the time between surgery and adjuvant treatments .Currently, NAT is offered mainly in borderline resectable and locally advanced pancreatic cancers as it seems to offer a higher rate of negative pathological nodal status, as well as negative margins status , 12–14.In addition to the above-mentioned oncological advantages, it has also been reported that during NAT the performance status of patients with jaundice and/or with relevant weight loss can be improved. Furthermore, Raufi claimed better local control for NAT due to the absence of vascular flow change derived from surgical resection .Due to the lack of reliable tools to predict nodal involvement, some authors suggest the use of NAT in all patients with pancreatic cancer . UnfortuAs reported by Gaskill, NAT can result in the patient losing “the window for surgical cure” .Both computed tomography (CT scan) and magnetic resonance imaging (MRI) can classify pancreatic cancer in four main categories: resectable (R), borderline resectable (BR), locally advanced (LA), and metastatic (UR) . This clIn this scenario, the availability of tools that can predict nodal involvement before any treatment would be desirable.Carbohydrate antigen 19.9 (Ca 19.9) is the only marker approved for clinical use by the Food and Drugs Administration (FDA) for PDAC, especially in the postoperative follow-up period. Unfortunately, the low specificity  and sensitivity 79% (70–90%) prevent the use of Ca 19.9 in the first staging of patients .However, Ca19.9 assessment has been reported to improve patient selection for neoadjuvant therapies or upfront surgery, followed by adjuvant chemotherapy .Furthermore, Ca 19.9 demonstrated its efficacy in combination with PET-CT scan in predicting progression and overall survival in locally advanced PDAC submitted to chemotherapy and radiotherapy .≥7.05) and Ca 19.9 (levels ≥240.55) significantly predicted nodal micrometastases , able to predict nodal positivity in PDAC  , 27 and Chen and colleagues  demonstrShuai-Shuai Xu , investiMoreover, considering that serum albumin, levels reflect the nutritional status of PDAC patients, and in line with evidence that an advanced disease is more likely to be associated with cachexia, special attention has been given recently to the link between Ca 19.9 and serum albumin levels in assessing prognosis of PDAC. In Zhang’s experience, lower levels of serum albumin and higher levels of Ca 19.9 have been reported to be associated with a more severe prognosis in stage III PDAC .The main aim of this study was to evaluate the role of Ca 19.9 serum levels in predicting nodal status in R-PDAC.The primary scope of this observational retrospective cohort study was to analyze the role of Ca 19.9 in predicting the nodal involvement in patients affected by PDAC. Moreover, the effect of serum albumin level (SAL) on Ca 19.9 efficacy in this regard was also evaluated. The secondary objective of the study was to evaluate the link between Ca 19.9 serum levels and the resection margin status, and the need for a vascular resection.Data collected from a prospective database of patients who underwent resective pancreatic surgery at the University Hospital Campus Bio-Medico of Rome between June 2000 and December 2019 has been retrospectively analyzed. The present study was approved by the Local Ethical Committee of the University Campus Bio-Medico of Rome (protocol number 104.20 OSS ComEt CBM) and performed in accordance with the Declaration of Helsinki and in respect of the principles of good clinical practice.Inclusion criteria were age ≥18 years old, diagnosis of pancreatic adenocarcinoma, tumor radiologically staged as resectable by the multidisciplinary pancreatic cancer board of our institution, with available preoperative serum albumin and Ca19.9 levels. Exclusion criteria were: patients aged <18 years, unavailable preoperative SAL and Ca19.9 levels, history of previous NAT, or any other oncological treatment.“Margin status after surgery was defined as negative (R0) in case of free margin ≥1 mm, or positive (R1) in case of free margin <1 mm, and R2 in case of macroscopic tumor invasion .2), comorbidities, American Society of Anesthesiologists score (ASA), and cancer characteristics as tumor location, dimension (T stage), presence of nodal involvement (N+), resection margins positivity (R+), and need of vascular resections (VR), were evaluated. All the pathological reports were re-staged according to the TNM classifications proposed by 7th edition classification of The American Joint Committee on Cancer and the International Union for Cancer Control  the χ2 test for proportions was used, p values <0.05 were considered significant.Multiple logistic regression was used for multivariate analysis performed a using the following dependent variables: nodal status, margin positivity and the need for vascular resection. As independent variables, Ca 19.9, albumin levels, each single pT stage and tumor grading were considered. Nodal status, margin positivity, and need for VR were independent variables when not used as dependent ones. Data was analyzed using Med-Calc 11.6.1.0 statistical package . All probabilities were two-tailed, and p values ≤0.05 were regarded as significant.In the second phase of the analysis, Receiver Operating Characteristic (ROC) analysis was performed, and Area under the Curve (AUC) was calculated to define the cut-off point for the Ca 19.9 marker and its accuracy in node positivity prediction, margin involvement, and vascular resection in patients with normal and low serum albumin levels. The odd ratio has been computed to investigate if a Ca 19.9 level higher than the established cut-off could identify patients at significant risk for N positivity and complications .Of the 510 PDAC patients resected in the period, 165 fulfilled the study inclusion criteria Figure 1The demographic and tumor characteristics of all the series have been reported in According to the size of the tumor and final pathological stage, T3 pancreatic cancers were more represented. In detail, pT1 was staged in 10 cases (6%), pT2 in 35 cases (21.2%) and pT3 in 120 cases (72.8%).The lymph nodal involvement was detected in 122 patients, which represented 73.9% of the whole series.Resection margin positivity was identified in 65 patients (39.3%).Ca19.9 levels were under the normal laboratory values  in 51 cases (31.3%). This group of patients has been identified as the CN Group. Elevated  Ca 19.9 levels have been registered in 114 patients (68.7%). These patients have been categorized as the CH Group. The two groups were homogenous with regard to age and the prevalence of obesity and diabetes. No significant differences have been found in terms of ASA score and tumor location.As shown in In all the series, the CH Group showed a statistically significant higher rate of N+ , while no differences were observed in terms of R+ and VR Table 2.Patients in the CH Group showed a 3-fold higher probability of nodal involvement (OR 3.588) with a positive predictive value (PPV) of 79.85 and a negative predictive value (NPV) of 49% (p = 0.0008).According to the preoperative albumin levels, SAL <3.2 gr/dl was detected in 63 patients. In this group, defined as L-SAL Group, patients were older  and ASA score grades 3 and 4 were significantly more represented . No statistically significant differences were detected in the two groups, in line with the prevalence of obesity and diabetes. The N-SAL Group showed a significantly higher tumor rate located in the body or the tail of the pancreatic gland . According to the pathological stage, no significant differences were found in terms of T stage. SAL did not show any significant association with the N, R+ and the need for VR Table 3.Notably, Ca 19.9 serum levels were significantly associated with N+ (p <0.001) when serum albumin was normal.In this subgroup of patients, higher Ca 19.9 levels were also significantly associated with higher rates of VR (p = 0.03). Notably, these findings were not confirmed in the case of hypoalbuminemia Table 4.At the multivariate analysis, Ca 19.9 >37 and pT3 result was associated with significantly higher odds of lymph-nodes positivity. These results are shown in At the multivariate analysis, Ca 19.9 was not found to be an independent predictor of margin positivity and need for VR.ROC curve analysis performed in all the series showed how Ca 19.9, at the cut-off >33 U/ml, was associated with N+ with a sensitivity of 83%, a specificity of 43% (p = 0.002), a positive predictive value (PPV) of 80%, and a negative predictive value (NPV) of 50% Figure 2No significant association was found with the need for VR. On the contrary, margin positivity after surgical resection was observed for Ca 19.9 at the cut-off >730 U/ml , despite low PPV and NPV (63 and 66% respectively) Figure 3In the N-SAL group, the ROC curve analysis confirmed that Ca 19.9 at the cut-off level of 32 U/ml was able to predict lymph nodal positivity with a sensitivity of 83% and specificity of 57% (p <0.001) Figure 4At the cut-off level >418 U/ml, Ca 19.9 also predicted positive margins after surgical resection with high specificity (87%) and low sensitivity (36%) (p = 0.014), PPV 58%, and NPV 68% Figure 5Notably, according to ROC curve analysis, Ca 19.9 at the cut-off >78 U/ml showed a significant trend for predicting the need for VR  Figure 6In the L-SAL group, ROC curve analysis notably showed that Ca 19.9 failed to predict N+, R+ and the need for VR.Radical resection retains a fundamental role in the treatment of PADC, still representing the optimal standard of care.PADCs are commonly defined as Resectable (R), Borderline Resectable (BR), Locally Advanced (LA), or Un-resectable (UR), based on radiological findings performed for tumor staging .This classification is mainly attributed on the basis of the presence of local vascular invasion or distant metastases detected during the radiological clinical staging.According to Kim , almost Considering the promising results obtained after NT in patients with advanced disease, some authors propose chemotherapy before surgery even in patients who may be candidates for first-line resection , 14.Consequently, upfront surgery for R-PDAC has now become controversial, especially in cases with lymph nodal involvement that could mostly benefit from NT.Moreover, the Heidelberg group recently reported how lymph nodal involvement is the main factor impacting the survival of patients affected by pancreatic cancer . In thisUnfortunately, it has been widely reported that even if nodal positivity is one of the main factors influencing the prognosis of PDAC patients, there are limited possibilities for identifying positive lymphnodes with common radiological investigations. These tools offer information regarding the size and the morphology of the lymphnodes, but, as reported by Shin, the accuracy of preoperative radiologic imaging to assess N+ is poor .On this basis, one of the challenges to win in the fight against this dreadful disease is the identification of tools able to predict the nodal status before any treatment. The availability of tools with the ability of identifying lymph node metastases in R-PDACs would allow the selection of a subgroup of patients who, even if resectable, could benefit from an NAT instead of upfront surgery in order to achieve better of the prognosis.In this present experience, we reported that Ca 19.9, the only approved marker in clinical practice for pancreatic cancer, is able to predict the N+ in R-PDACs.According to ROC curve analysis results, the optimal cut-off of Ca 19.9 to predict N+ in our series was 33 U/ml. As this cut-off is in line with the cut-off of 37 U/ml, suggested in literature , without impacting R. Notably, in addition to what Mattiucci already highlighted, based on our findings, the predictive efficacy of Ca 19.9 regarding N+ would be lost in the presence of hypoalbuminemia.Taking into account that a more advanced disease should be associated with worse nutritional status , and conSubsequently, this study revealed that, although there was a significant link between Ca 19.9 and lymph node involvement, and therefore with a more advanced stage of disease, this significance was not confirmed in patients with low albumin levels.Therefore, unlike what Zhang reported, our results do not seem to confirm that a worse nutritional state corresponds to a more advanced disease; in fact, according to our findings, we could hypothesize that albumin may affect the predictive capacity of Ca 19.9.Excluding patients with hypoalbuminemia, which our study revealed to correspond with the oldest patients and to those with higher ASA scores, and in disagreement with Mattiucci and Zhang , 31 and Taking into account that the margin status positivity is one of the predictors of early recurrence after pancreatic cancer surgery, the utility of Ca 19.9 has already been demonstrated in a previously published paper on this topic. Fiore et al. in their experience, reported that Ca 19.9 levels higher than 698 U/ml were able to identify early progression of pancreatic cancer in patients who had undergone radical resection. In these patients, the odds to develop a recurrence were six times higher .These findings disagree with what was reported by Mosquera in a retrospective review on 181 pancreatic cancer patients who had undergone radical pancreaticoduodenectomy, did not find any significant association between the R+ and preoperative levels of Ca 19.9 .Notwithstanding the possible association between Ca 19.9 and margin status detected at ROC curve analysis, these findings were not confirmed by the multivariate analysis.For all these reasons, the clinical use of Ca 19.9 in daily practice cannot be taken into account to assess the risk of margin positivity after pancreatic surgery.In view of the trend towards a significant correlation (p = 0.059) between higher rates of VR for Ca 19.9 levels >78 U/ml, it is our opinion that a more extensive series could confirm this link and therefore lead to a positive consideration of Ca 19.9 as also assisting in predicting more locally advanced disease in terms of local vascular invasion.Nonetheless, it has to be taken into account that the decrease of Ca 19.9 levels has been used to plan arterial vascular resection for locally advanced pancreatic cancer after NAT, as well as to predict progression of the disease after treatment in advanced cases , 40.To the best of our knowledge, this study would be the first reporting on the possible role of Ca 19.9 in predicting the need for VR in R-PDACs.The effect of albumin on the predictive ability of Ca 19.9 reported in this experience is in line with the evidence that albumin improves the diagnostic accuracy of Ca 19.9 in detecting PDAC .For instance, in the Herreros-Villanueva experience, biomarkers panel, including Ca 19.9 and albumin, showed higher sensitivity in detecting PDAC, particularly in its advanced stage.Nonetheless, in 2014 Pant  reportedIn our experience, serum albumin levels did not show any significant association with N, R+ and with the need for VR.These results are in part in agreement with what was reported by Feng  who condThe author noted that baseline albumin levels are not associated with patient prognosis.Furthermore, albumin, an endogenous antioxidant, recognized as a risk factor for poor prognosis in pancreatic cancer , in our Its retrospective design limits this study; moreover, it is not possible to exclude potential biases from a single-center experience and, patients considered eligible for the analysis were considered over a long time span.The relation between Ca 19.9 and PDAC has been widely investigated in the literature. The majority of the studies currently published on this topic focus on the relation between Ca 19.9 and prognosis or progression after therapy or on the risk of recurrence of PDAC.Only a minority of the studies focus on the relation between Ca 19.9 and NAT for resectable PDACs, with varying results and conclusions being reported.Katz , in his On the contrary, in 2016 researchers at the Mayo Clinic  demonstrMore recently, these guidelines have been put into question. Authors, such as Kim in 2020 , studyinOur findings are the result of the analysis of a series of patients undergoing upfront surgery, based only on radiological evidence, and suggest the role of Ca 19.9 in improving PDAC staging, identifying a subgroup of patients that, although considered radiologically resectable, had a more advanced disease, and therefore would have benefited from NAT.Our results, in contrast with those reported by Kim  and onlyNotably, we found that serum albumin levels influence the ability of Ca 19.9 in predicting N. Based on this new outcome, it is our aim to assess a multi-center study in order to validate the role of Ca 19.9 in radiologically resectable PDAC patients with normal serum albumin levels.The strengths of this study lie in the analysis of unselected PDAC who received upfront surgery, and in the fact that all the procedures were performed by the same expert pancreatic surgeon with well-standardized surgical technique avoiding possible bias due to different types of lymphadenectomy.The results obtained could represent a step forward in using Ca 19.9 as a simple, cost-effective, and user-friendly tool in the therapeutic choice for patients affected by PDAC with normal albumin levels.In this study, increased preoperative levels of Ca 19.9 predicted the presence of nodal involvement in patients affected by PDAC and with normal albumin levels who received radical resection. In addition, according to our findings, the margin status and the need for VR could also be predicted by analyzing preoperatively the levels of Ca 19.9.These represent the results of a pilot investigation that could lay the basis for a validation study carried out in a multi-center context in order to confirm these findings.The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation.The studies involving human participants were reviewed and approved by Ethical Committee of the University Campus Bio-Medico of Rome. Written informed consent for participation was not required for this study in accordance with the national legislation and the institutional requirements.Conceptualization, AC, DC, and VV. Methodology, AC, DC, and MF. Formal analysis, AC and SA. Data curation, TF, AC, and SA. Writing—original draft preparation, AC, DC, TF, VV, SA, RC, and MF. Writing review and editing, AC, SR, SA, and RC. Supervision, SR, RC, and DC. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


Physical inactivity is a major contributor to the development and persistence of chronic diseases. Mobile health apps that foster physical activity have the potential to assist in behavior change. However, the quality of the mobile health apps available in app stores is hard to assess for making informed decisions by end users and health care providers.This study aimed at systematically reviewing and analyzing the content and quality of physical activity apps available in the 2 major app stores (Google Play and App Store) by using the German version of the Mobile App Rating Scale (MARS-G). Moreover, the privacy and security measures were assessed.A web crawler was used to systematically search for apps promoting physical activity in the Google Play store and App Store. Two independent raters used the MARS-G to assess app quality. Further, app characteristics, content and functions, and privacy and security measures were assessed. The correlation between user star ratings and MARS was calculated. Exploratory regression analysis was conducted to determine relevant predictors for the overall quality of physical activity apps.information , engagement , aesthetics , and functionality  were obtained. An efficacy study could not be identified for any of the included apps. The features of data security and privacy were mainly not applied. Average user ratings showed significant small correlations with the MARS ratings . The amount of content and number of functions were predictive of the overall quality of these physical activity apps, whereas app store and price were not.Of the 2231 identified apps, 312 met the inclusion criteria. The results indicated that the overall quality was moderate . The scores of the subscales, that is, Apps for physical activity showed a broad range of quality ratings, with moderate overall quality ratings. Given the present privacy, security, and evidence concerns inherent to most rated apps, their medical use is questionable. There is a need for open-source databases of expert quality ratings to foster informed health care decisions by users and health care providers. Physical inactivity is a significant risk factor for noncommunicable diseases such as cancer, diabetes, cardiovascular diseases, or chronic respiratory diseases and is estimated to cause 6%-10% of these diseases worldwide . InsuffiEvidence indicates that regular physical activity results in physical, social, and mental health benefits such as better quality of sleep, lower depressive symptomatology, higher well-being, and a reduced risk of a large number of noncommunicable diseases -7. MobilRegarding the quality of apps, Schoeppe and colleagues  used theBesides the evaluation of theory-based content, applied techniques or functions, and effectiveness, it is important to consider the risks of mobile health app use, such as inadequate protection of data and privacy or lack of informed consent ,25. ManyThe aim of this study was to conduct a systematic and objective investigation of the physical activity apps available in 2 major app stores by using the German version of MARS (MARS-G). The MARS-G is a multidimensional instrument specifically developed to assess app quality on the dimensions engagement, functionality, aesthetics, and information quality . FurtherWhat is the quality of the apps promoting physical activity regarding engagement, functionality, aesthetics, and information?What are the general characteristics, content, functions, privacy, and security measures of the apps promoting physical activity?Are the user ratings in agreement with the expert quality ratings?Which app features can predict app quality?A web crawler (automated web search engine) was used to scan the European Google Play store and App Store to search for eligible apps. The search was carried out on February 20, 2018 by using the following search terms: (1) active, (2) endurance, (3) exercise, (4) fitness, (5) gymnastics, (6) muscle, (7) shape, (8) strength, (9) training, and (10) workout. The search string to identify apps targeting physical activity was developed in an expert discussion (EMM and HB). The web crawler searches for each term and app store. Duplicates were automatically removed. After identification, a two-step procedure was applied by 2 independent researchers: (1) checking eligibility based on app title and description and (2) checking eligibility based on information in the downloaded app. In the first step, all identified apps were screened for whether their title, description, and images indicated that the app was developed for promoting physical activity ; the app was available in German or English; the app was downloadable through the official Google Play store or App Store; the app could be used without further equipment, devices, or programs; and the app was primarily developed for adults. In the second step, all downloaded apps were assessed in detail to check whether they met the abovementioned eligibility criteria. If apps did not work after the download (checked with 2 different mobile phones) or were explicitly developed for children , they were excluded. The other exclusion criteria were (1) app bundle, (2) only working with additional device , or (3) targeting specific person groups .Each app was rated by 2 independent raters between February and October 2018. All raters undertook a free online training   and (9) privacy and security features [The MARS includes a multidimensional quality rating consisting of 4 dimensions: engagement , functionality , aesthetics , and information quality  ,31. Herefeatures ,31. Privfeatures ,31. The P values were adjusted using the procedure proposed by Holm [To evaluate consistency, the ICC between the raters was calculated for quality assurance. Rater agreement was examined by ICC based on a two-way mixed-effects model . An ICC  by Holm . To dete by Holm -40. DichThe search in the Google Play store and App Store yielded 6159 apps without duplicates. Screening resulted in the inclusion of 1817 apps. After downloading and assessing the eligibility criteria in detail, 1495 apps had to be excluded. The remaining 312 apps were included in the analyses  were available in Google Play store and 169 (54.2%) were available in the App Store. The average user’s star rating was 4.29 (SD 0.70) (range 0-5). The costs for the included apps ranged from free for 96.8% (302/312) of the apps to €10.99 . Regarding the store categories, the majority of the apps (300/312) were listed under health and fitness (multiple categories were assigned in stores). The further assigned categories were sports (n=83), lifestyle (n=69), business (n=4), entertainment (n=3), medicine (n=2), social (n=2), food and drink (n=1), and travel (n=1). Apps provided a broad range of functions . Most apOf the 312 assessed apps, 67 (21.5%) had an imprint/contact information, 60 (19.2%) provided a visible privacy policy, 25 (8.0%) were only accessible with a personalized log-in, 20 (6.4%) utilized a passive informed consent , 15 (4.8%) contained an active informed consent , 16 (4.8%) had a password option, and 5 (1.6%) gave information about the financial background or made conflicts of interest transparent. No app had embedded emergency features .The ICC agreement between the raters was high . The average overall quality of the apps for physical activity was 3.60 (SD 0.59) (range 1-4.75) with average quality of information  and engagement . Aesthetics  was good and functionality was excellent . Of all the 312 included apps, 10 (3.2%) reached a MARS score of above 4.5. The evidence item  indicated that no app was scientifically evaluated. The MARS quality ratings are summarized in Small correlations were found between the user ratings in the stores and the MARS. The correlations are summarized in Exploratory regression analysis indicated that app quality could be predicted by the number of functions integrated into the app. Price and store had no predictive value. The results of the regression analyses are summarized in In this study, the quality, general characteristics, privacy and security features, and content/functions of apps that promote physical activity in the commercial European app stores were systematically assessed. The included 312 apps showed a moderate overall quality . Moreover, several apps showed very high ratings, and there was a large range of quality ratings. The assessments of the 10 best-rated apps are described in detail in The apps offered a variety of different functions (15 out of 22 functions were used). On average, 3 functions were applied per app, and the most common ones were exercises, goal setting, and monitoring/tracking. This is partly in line with previous reviews for apps promoting physical activity ,18 or weNo randomized controlled trial evaluating the effectiveness of one of the included apps could be identified. This lack of a solid evidence base for the use of health apps is in line with that reported in other systematic reviews of app quality  -40. ThesAverage user ratings in the stores showed a significantly small correlation with the MARS ratings, which is in line with that reported in previous research ,36. HoweThe only relevant predictor for overall app quality was the number of functions, which is in line with previous results for apps reviews aiming at weight management, diet, physical activity, and sedentary behavior ,22,29. TIn this review, apps were only searched in the Google Play store and App Store and, thus, this review does not cover all the available apps promoting physical activity. However, 90% of all the apps are downloaded in these stores . Owing tThere is a wide range of apps offered to foster physical activity and they show overall moderate quality. High-quality apps have been presented in