The experience of infertility and its treatment engenders considerable stress and is often described as an emotional rollercoaster. A mobile health  app may be a novel solution to address the psychoeducational and psychosocial support needs of fertility patients because of its potential to reduce stress and increase patient empowerment. There are a few fertility-related apps that provide information and support to both men and women undergoing fertility treatment; however, none have documented their development and evaluation process.Infotility, designed to meet the psychoeducational and psychosocial support needs of men and women undergoing fertility treatment.This study aims to describe the development and evaluation process of a bilingual mHealth app, Infotility app, we adhered to the Medical Research Council guidelines for the development and evaluation of complex interventions. First, we conducted literature reviews and needs assessment surveys of fertility patients and health care providers who informed the content and design of the app. Second, we tested the intervention with a small group of end users who provided feedback on the design and appropriateness of the app’s content. Third, we evaluated the uptake and usability of the app using a pre-post study design. Finally, we updated the app’s content based on participants’ feedback and searched for partners to disseminate the app to the broader public.To develop the This study is the first to describe the development and evaluation process of an mHealth app for men and women undergoing fertility treatment. The app met its goal in providing fertility patients with a clinician-approved, portable resource for reliable information about medical and psychosocial aspects of infertility and its treatments and a confidential peer support forum monitored by trained peer supporters. Participants rated the engagement, functionality, information, and esthetics of the app positively, with an overall app quality mean score of 3.75 (SD 0.53) and a star rating of 3.43 (SD 0.75), with a total possible score and star rating of 5.00.By documenting the systematic development and evaluation of the mHealth app for men and women undergoing fertility treatment, this paper can facilitate the replication of the study intervention and the development of similar mHealth apps. Infertility is defined as the inability to achieve pregnancy after 12 months of unprotected sexual intercourse or the inability to reproduce either as an individual or as a couple -5. AlthoReviews of psychosocial interventions for fertility patients indicate that they are effective at reducing depressive symptomatology, anxiety, and stress associated with infertility -13. ReseMobile health  is the provision of health services and information using a mobile device, such as a smartphone ,21. GeneAlmost 70% of Canadian adults aged 18 years and older report owning a smartphone, and the rates of internet use and smartphone ownership continue to increase worldwide . TherefoTo the best of our knowledge, there are a few fertility-related apps that provide information and support to both men and women undergoing fertility treatment, but none have documented their development and evaluation process. Improved documentation of app development will allow future researchers to develop similar mHealth apps. It will also help in knowledge transfer, which may be especially useful for the more innovative aspects of mHealth, such as design principles, the presentation of information, and technical features.Infotility, a bilingual mHealth app designed to meet the psychoeducational needs of both men and women undergoing fertility treatment. Infotility contains information about treatments and test procedures, financial and legal aspects of fertility treatment, fertility health and risks to fertility, mental health and wellness, and a confidential forum monitored by peer supporters. In developing this intervention, we adhered to the Medical Research Council (MRC) guidelines for the development and evaluation of complex interventions [Infotility app based on the following recommended steps from the MRC guidelines:Accordingly, this study describes the development process for ventions . As recoDevelopment of the intervention: literature review of existing interventions, needs assessments to determine stakeholders’ perspectives on the content of the interventionFeasibility and piloting: testing procedures, estimating recruitment and retention, and determining sample sizeEvaluation of the intervention: pre-post study exploring fertility patients’ experiences using the appImplementation: dissemination, surveillance and monitoring, and long-term follow-upfertility/fertility and infertility/infertilité. The search revealed numerous menstrual tracking apps and 2 sperm home testing kit apps, Trak: Sperm Health and Fertility (Sandstone Diagnostics) and YO Sperm Analyzer . In a further search of the gray literature, we found that one menstrual cycle app, Glow, was developing a component for men that would include fertility-related information, but this was not yet available for review [To determine whether there were existing mHealth apps that provided fertility information to both men and women, we reviewed the Apple iTunes and Google Play stores between October and December 2016, using the keywords r review . Our resgood, and the quality of information on the fertility clinic websites received a grade of fair. Furthermore, the North American organizations’ websites required an average reading level of 12.9 years of education, and the fertility clinic websites required an average level of 14.3 years, far above the grade 5-8 reading level recommended for health information material [Infotility, indicating a lack of web-based sources of high-quality information about reproductive health that might be easily understood by the general population.As part of a project to assess fertility-related information geared specifically for men, our research team performed an analysis of fertility-related health information found on the websites of fertility clinics and major North American organizations . We assematerial ,38. The threads) between users. Users were required to make an anonymizing username and icon , and many forums had rules related to posting, such as the prohibition of using derogatory terms or naming specific professional or clinics. Most sites also offered freely available informational content, such as their own description of fertility or pregnancy, explanations of terms or procedures used during infertility treatment, and tools for tracking ovulation. Fertility forums existed in French or English, and some, such as Reddit [In parallel, our research team conducted an internet search to review how infertility blogs and forums offered social support, how they were managed, and what information and features were available to users. Some of the reviewed web-based platforms offering peer support were RESOLVE, Reddit, Association Infertilité Québec, and Fertility Matters Canada. The search showed that infertility forums posted public (openly visible) and private (member log-in required) conversations on a variety of subjects surrounding the experiences of infertility. Moderators or administrators were available to provide feedback on some conversations  in the field of reproductive health. Identifying their needs and values  allows for improved buy-in and increased potential for app distribution. To execute a thorough contextual inquiry and use a patient-centered approach to app development, our research team undertook needs assessment surveys of fertility patients and HCPs. All survey questions were designed by our research team, including expert clinicians in the field of reproductive health. To our knowledge, this is the first study to document such a process for a fertility-related app, although mHealth interventions for other conditions have used techniques such as interviews, expert panel consultation, and focus groups to better understand their target populations [Contextual inquiry involves assessing the needs and preferences of end users  and key stakeholders . For ulations ,41.Infotility, as the discrepancy between use of and interest in using a fertility app suggested a lack of publicly available, good-quality web-based resources for fertility patients.A diverse sample of fertility patients was recruited from fertility clinics in Montreal and Toronto to complete the needs assessment survey. A total of 659 patients completed a web-based survey asking them about their experiences of, and preferences for, fertility-related information disseminated through clinical, web-based, and mobile modalities. The sociodemographic characteristics of the survey sample are given in Infotility.Participants were also asked about their preferred fertility app features. The five most endorsed features were as follows: being easy to understand, including a glossary of medical terms, providing information on fertility health care coverage, providing information on reproductive health, and being free of charge . These fInfotility app and informed the design of the forum.The needs assessment survey also examined the fertility patients’ interest in online peer support and their preferences for various features of an online peer support forum . The majTo obtain the perspectives of those who have frequent contact with fertility patients in a variety of capacities, our team conducted a needs assessment survey of fertility HCPs, including physicians, nurses, mental health and wellness professionals, and administrative staff. Eligible participants were recruited at 6 sites in Montreal and Toronto, and a total of 127 participants completed a web-based survey. The survey asked fertility HCPs about features they believed a fertility mobile app should include and the types of information that fertility patients typically requested.The majority of HCPs thought that patients would be interested in using a high-quality mobile app that provides fertility-related information and support. With respect to the app features, the ones that were most highly endorsed by HCPs included being easy to understand, providing information that promotes reproductive health, containing a glossary of medical terms, and offering links to stress reduction tools . Most ofInfotility app.The survey also showed that HCPs most frequently provided patients with information on tests and procedures, medications, and explanations of conditions . CompariInfotility app, our research team conducted a literature review on the topics related to infertility by searching web-based scholarly databases  for scientific literature published from 2000 to 2017. We also consulted gray literature, such as articles published in popular news media  to capture personal experiences of fertility patients.To write the content for the Infotility app. For each content topic, we created brief summaries of the scholarly and gray literature and collated this information into reports. These reports were then sent to members of the team and advisory committee who specialized in the content area and fertility patients for feedback. For example, a section on the causes of male factor infertility was sent to a urologist, whereas a section on the psychosocial aspects of infertility was sent to a clinical psychologist specializing in fertility counseling. These specialists ensured the clinical relevance and accuracy of the content. The summaries, once approved, formed the basis for the app content, which was edited and presented in clear and accessible language.On the basis of the literature review as well as the responses from the needs assessment surveys, our team developed a range of content categories for the Infotility app included a variety of informational topics such as content related to reproductive health, the psychosocial challenges of infertility, and the legal and financial aspects of fertility treatment  to be different for men and women.How to get pregnantReproduction 101All about eggs and ovulationTracking your ovulationFrequently asked questions about getting pregnantCauses and diagnosesFemale factor infertility causesRisks to female fertilityMasturbationOther ways to provide a sperm sampleCauses of male infertilityRisks to male fertilityAm I at risk for other health problems?Treatment optionsOvulation inductionIntrauterine inseminationIn vitro fertilizationSperm, embryo, or egg donationUsing a donor or surrogateWhen to consider using donor eggs, sperm, embryos, or surrogatePreparing for donationPros and cons of donationChallenges of egg, sperm, and embryo donationMedical steps and additional informationGenetic testingHow does genetic testing work?What are the tests?Multiple pregnancy lossesCauses and treatments of multiple pregnancy lossesStopping treatmentWhy do people stop treatment?If you decide to stop treatmentFertility laws and health care coverageAssisted Human Reproduction ActWhat expenses are covered?Surrogacy and gamete donation lawsOn embryos as property and human lifeYour relationshipsKeeping your couple healthyHow do I talk about infertility?Physical well-beingExercise and fertilityNutrition for fertilityEnvironmental risks to fertilityMental well-beingTaking care of your body and mindDealing with pregnancy lossWorking with your health care teamChoosing the clinic that’s right for youPreparing for medical appointmentsQuestions you may want to ask your doctorGetting a second opinion: When and why?International Committee for Monitoring Assisted Reproductive Technology and the World Health Organization Revised Glossary on Assisted Reproductive Technology Terminology as a reference [Infotility app content and edited the glossary to ensure its readability.In addition, our research team developed a glossary of key fertility-related terms using the eference . We thenInfotility app is consistent with more flexible recommendations that content be developed at a reading level 1 to 3 grades lower than the mean education level of the target population [To serve the bilingual population of Montreal, Quebec, the app had to be available in both English and French. Therefore, once finalized, the written content was translated into French. The reading level of the content was assessed to ensure acceptability and appropriateness for the target audience. The English content was assessed using the Flesh Kincaid grade level , and thepulation .Infotility app integrated an online peer support forum Connect that allowed users to confidentially post about their experiences, communicate with each other via discussion posts, and ask private questions of a peer supporter. Screenshots of the peer support forum are provided in In addition to providing information on the psychosocial and medical aspects of infertility in both English and French, the Infotility was chosen for the app and the name Connect was chosen for the forum as both are short, unique, and easy to remember. Moreover, Infotility reflected the main purpose of the app, that is, providing information to fertility patients, and Connect embodied the spirit of the forum—connecting people via the internet. As the app had to be bilingual, these names were also chosen because they had suitable French equivalents—Infotilité and Connecte.To pick a name for the app and the peer support forum, members of the research team were polled, and the suggested names were voted on. Ultimately, the name Infotility was informed by the principles of user-centered design, which focuses on the needs of the user at all phases of development [chunks and was tied together with an appealing theme to keep the app cohesive. The major organizing sections of the app were What you need to know, focusing on informational aspects of going through infertility and its treatment, and What you can do, focusing on actionable items, such as exercising for fertility.To design a user-friendly mHealth app, members of our research team participated in a 2-day workshop organized by an independent app design company. During this workshop, we completed a number of design activities, including persona development , brand conceptualization, journey mapping of the user, and the creation of hypothetical wireframes (screen blueprints). We then supplied the ideas generated at the workshop to a different app design company with which we collaborated in the development of the app’s user experience , user interface (how the app interface functions and how the user interacts with it), and information architecture (how the app’s content is structured). elopment . With thInfotility. For the mascot, we chose a sperm whale. Once a color scheme and font were approved, the app design company produced graphics that either complemented or replaced the text in accordance with the guidance provided by the research team, which often included the whale mascot in different scenarios. Examples of the Infotility mascot and graphics are given in flip side, which allowed users to view the opposite sex’s app content. When a user clicked the flip side function, the app pages were animated to flip to see the opposite sex’s information.Our research team also worked with the app design company to create a theme and a mascot unique to Infotility app was made available on a web-based platform. This prototype allowed us to discuss the flow and organization of information. Once the organization was approved, the app company consulted 2 male end users and 3 female end users who had undergone or were undergoing fertility treatment. These users provided feedback on the usability of Infotility and the design and appropriateness of the content. On the basis of this feedback, our research team adjusted the design, language, and tone of the app.An interactive prototype of the Infotility app for 8 weeks and completing questionnaires both before and after using the app.The sample size for the evaluation of the intervention was informed by guidelines for pilot studies of web-based interventions, which recommend at least 20 users . To accoInfotility app using a pre-post study design.The primary goal of the study is to create an app that is user friendly, provides peer support, and contains reliable and easy-to-understand information about all aspects of infertility and its treatment. In the final steps of the study, we evaluated the uptake and usability of the Infotility app. Eligible participants met the following criteria: they were aged ≥18 years, were in a heterosexual relationship, read English and/or French, had access to the internet, and identified as male or female. In the initial stages of recruitment, we limited our inclusion criteria to only those undergoing in vitro fertilization for the first time. However, based on recommendations from our clinician partners, we expanded the inclusion criteria to recruit any fertility patients at any stage of treatment. There was great interest in the study among patients, and in the interest of being inclusive to all those who wished to participate, we did not limit the number of people who consented to participate in the study, even after our goal of 50 women and 50 men was achieved. This also allowed us to recruit a diverse sample and mitigate participant dropouts. When we felt we had a sufficient number of participants enrolled in the study to account for attrition over the 8-week study period, we stopped recruitment and determined April 30, 2019, as the study end date.Fertility patients were recruited from fertility clinics in Montreal and Toronto from October 2018 to December 2018 to test the Infotility app, participants were asked to complete a number of intake questionnaires measuring demographic characteristics, fertility treatments and diagnoses, fertility-related quality of life, psychological distress, and lifestyle habits, which took approximately 30 minutes to complete. Of the 387 who consented, 26% (65/250) men and 74% (185/250) women completed the intake questionnaires and visited the Infotility app at least once. Participants’ sociodemographic characteristics are given in Infotility for 8 weeks and could use the app as much or as little as they liked during the study period. Once using the app, participants could choose whether to access the peer support forum. After 8 weeks of using Infotility, of the 250 participants who used the app, 22.1% (38/172) men and 77.9% (134/172) women completed the follow-up questionnaires measuring participants’ evaluations of and experiences using the app, in addition to the same measures administered at intake. Participants who completed the study were sent a Can $25 (US $32) gift card. For the purposes of this paper, data evaluating participants’ experiences using the Infotility app, including the peer support forum Connect, are presented.A total of 969 people  were approached by recruiters. Furthermore, 661  agreed to be screened for eligibility, 505  were eligible to participate, and 387  consented to participate in the study. Before being given access to the Infotility app during the 8-week study period. We gathered several key performance indicators to assess the frequency and patterns of app use, including the number of page views and total time spent on the app.Google Analytics was used to collect data on how participants used the subjective quality mean score. The research team chose the uMARS because it is a valid (α=.90) and reliable (test-retest reliability after 3 months = 0.63-0.85) measure of user satisfaction with mHealth apps and tailored toward the experiences of patients rather than professionals who work in technology or health care [Participants were sent the user version of the Mobile Application Rating Scale (uMARS) to evaluate their satisfaction with the app and whether their needs and preferences were met . The uMAlth care . Three aThe Peer Support Evaluation Inventory (PSEI) was used to evaluate user satisfaction with the peer support forum. The PSEI was developed by our research team and adapted from a measure by Dennis . The PSEInfotility app useful and accessible to a sample of participants undergoing fertility treatment. Descriptive statistics of the uMARS and PSEI subscales present participants’ overall ratings of the Infotility app and peer support forum. Bivariate analyses were used to determine whether there were any associations between the uMARS scores and app use. Qualitative responses to the three open-ended questions were read by 2 researchers, and common themes about the strengths and weaknesses of the app were identified and presented as supplementary data to the quantitative findings.Quantitative analyses were used to evaluate whether we achieved our goals of making the Infotility app. Participants rated the engagement, functionality, information, and esthetics of the app positively, with an overall app quality mean score of 3.75 (SD 0.53) and a star rating of 3.43 (SD 0.75), with a total possible score and star rating of 5.0. When asked whether they would recommend the app to other people who might benefit from it, 49.7% (94/189) responded “definitely” or “there were many people I would recommend this app to.” When asked how many times they would use the app in the next 12 months, 5.7% (11/191) said they would use it more than 50 times, 25.6% (49/191) said 10 to 50 times, 42.9% (82/191) said 3 to 10 times, 19.3% (37/191) said 1 to 2 times, and 6.2% (12/191) said they would not use it. When asked if they would pay for the app, approximately 50.2% (95/189) said “Definitely not,” and 2.1% (4/189) said “Definitely yes.” A subsample of 106 Infotility users used the Connect forum. On average, Connect users rated the supportive interactions of peer supporters 2.91/4 (SD 0.84), the relationship qualities 2.95/4 (SD 0.49), their perceived benefits 2.92/4 (SD 0.74), and their satisfaction with support received 2.89/4  and the amount of time spent on the app . In addition, scores on the engagement subscale were correlated with the amount of time spent on the app, with a P value approaching significance, . This means that participants who felt the app functioned well and was easy to learn and navigate visited more pages and spent more time on the app, and participants who felt the app was more engaging spent more time on the app. Participants’ scores on the esthetics and information subscales were not significantly correlated with app engagement.Infotility app. Overall, participants expressed that they appreciated the app: the “information is clear and easy to find” (Participant #03-0046), “it’s a good tool to help and inform about infertility” (Participant #03-0014), and using the app was “more reassuring than googling a question” (Participant #03-0120). Some participants had suggestions for ways to improve the app, such as including more interactive features, communication with medical professionals, and informative videos:Qualitative responses to the three open-ended questions administered at follow-up highlight some important findings about the strengths and limitations of the An app usually should have some sort of interactive feature that brings you back, such as a fertility medication tracker, symptoms tracker, etc.Participant #03-0283It would be nice if this app was different, in the way that, it was live and interactive with specialistsParticipant #03-0248I think I would be happy to see short videos with the doctors of the clinic giving advices or telling a bit about their experience and statistics in infertility treatmentParticipant #03-0052There was also a desire for more in-depth information that was updated and customized to individual participants and personal testimonies from others:No newsfeed feature. Update dashboard with new content/information based on my preferences. Why? To draw my attention, make me want to log in more often. I would see the same info each time I open the app. I would only log in if I’m looking for something in particular.Participant #03-0038There is a need for medical information that may or may not apply to you. Maybe cases? Personal stories? What happens to other people?Participant #03-0104Connect forum was perceived as confidential and safe, and peer supporters helped keep conversations respectful and on track [Finally, many participants expressed that the peer support forum was their favorite part of the app and that using it reduced feelings of isolation, helped them manage stress, and provided valuable information. The on track .Infotility app was developed by our research team and was informed by extensive literature reviews and needs assessment surveys of fertility patients and HCPs. The content of Infotility was reviewed and approved by physicians, nurses, psychologists, and experts in the field of fertility to ensure its clinical relevance and accuracy. Infotility was designed by an app design company who worked alongside our team to ensure that the app was user friendly and esthetically pleasing. In addition to providing over 40 articles on the psychosocial and medical aspects of infertility, the Infotility app included a confidential peer support forum monitored by trained peer supporters.To the best of our knowledge, this is the first study to describe the development and evaluation process of an mHealth app providing information and support to both men and women undergoing fertility treatment. The Infotility app, our team adhered to the MRC guidelines for the development and evaluation of complex interventions, which provided a structured framework on how to approach the development, piloting, evaluation, and implementation phases of the study. By providing a complete description of all the steps of the app development process, this study can facilitate future replications of the study intervention and the development of similar mHealth apps.In developing the Infotility. By recruiting a large and sociodemographically diverse sample, we were able to gain insights into fertility patients’ experiences searching the internet for fertility-related information and their preferred features of a fertility app. Furthermore, obtaining the perspectives of fertility HCPs provided valuable insights into the types of information fertility patients most often requested and whether their needs were met.The needs assessment surveys of fertility patients and HCPs were a crucial step in identifying the informational and psychosocial needs of the end users of Infotility with respect to both its content and design. These results were especially helpful when deciding whether to include certain features on the app, which are costly and time consuming to develop. For example, the peer support forum and the detailed medical glossary were features of the Infotility app that took much time to develop and design. Despite this, we felt justified in including them on the app and confident in dedicating the time and resources to develop them based on the overwhelming evidence from our needs assessment surveys that these features would be beneficial to fertility patients. Furthermore, needs assessment surveys can provide insights into what you should not spend time and resources developing when the target audience informs you that they do not feel the need for certain features or topics. For example, we decided not to include celebrities’ stories of dealing with infertility because they were rated as one of the least desired features by the surveyed fertility patients and HCPs. The results from the needs assessment surveys allowed our team to feel confident and justified throughout the entire app development process.The results of the needs assessment surveys guided our team throughout the entire development process of Infotility app using the uMARS and qualitative interviews.The second stage of the MRC guidelines involves pilot-testing to determine the feasibility of complex interventions. This study assessed the feasibility of recruitment and retention of male and female participants and evaluated fertility patients’ satisfaction with the Recruitment of patients in waiting rooms of fertility clinics proved feasible: of 969 people approached by recruiters, 505  were eligible to participate and 39.9%  consented to participate in the study. However, recruitment of participants in fertility clinics might have excluded those with lower socioeconomic status who may not be able to afford fertility treatment. Nevertheless, within the limits of recruiting individuals who seek fertility treatment, we were able to obtain a sample that was diverse with respect to participants’ household income (with about 30% below the median Canadian family income), ethnicity, immigrant status, and religion . RecruitIt is also worth noting that in line with the previous research regarding the lack of male participants in reproductive research , our teaInfotility app, including the peer support forum Connect. In general, participants enjoyed using Infotility and rated the informational side of the app and the peer support forum positively. The results showed that those who spent more time on Infotility were also those who rated the app higher on functionality  and engagement . Our findings suggest that when developing mHealth apps, researchers and medical professionals should make the app engaging through interactive features and feedback and implement quality assurance procedures to address any technical issues that, if not resolved, may affect the level of trust among users and lead to user discontinuation [The evaluation of an mHealth intervention before disseminating it to a larger population or to the general public is necessary to ensure that it will be beneficial to its end users and successful in its proposed objectives. The pre-post study design proved to be effective in capturing fertility patients’ experiences interacting with the inuation .Infotility and what they felt the strengths and weaknesses of the app were. In addition, tracking participants’ actual app use data through Google Analytics was highly informative and allowed our team to examine participants’ self-reported data within the context of the pages they accessed on the app.The collection of both qualitative and quantitative data for the pre-post app evaluation provided nuanced and in-depth information about the app users’ experiences using Infotility and whether they visited the app multiple times throughout the 8-week study period. Data showed that most participants used the app within the first 2 weeks of the study period, which might help explain the high attrition rate of the study. Although high attrition is common in studies of mHealth interventions [By tracking participants’ actual app use data through Google Analytics, we were also able to gain insights into the amount of time participants spent on ventions , our finInfotility could be improved by including more interactive features that bring you back , more in-depth information on certain topics that were not extensively covered in the app, and summaries of current research in accessible language. Implementation of these features will help make future versions of the Infotility app more comprehensive and interactive, thereby potentially improving the rates of app engagement and user satisfaction.Careful analysis of participants’ app use along with their qualitative and quantitative feedback is critical to improving user experiences of future versions of the mHealth app. For example, future iterations of Infotility app through a pre-post study design was necessary to facilitate the fourth stage of the MRC guidelines, which is implementation that includes dissemination, surveillance, and long-term follow-up.Finally, the evaluation of the Infotility accurate and up to date. Upon completion of the study, the entire content of the app was reviewed and edited by our research team based on feedback from the participants and by a knowledge translation consultant with expertise and personal experiences in the fertility field. Changes were made through a content management system, which is a user-friendly and accessible program that allowed our team to edit the app content in real time, without the need to outsource this task to the app company.Conducting repeated reviews of scientific literature is necessary to keep the content of Infotility to the broader public. We will identify potential app host partners, such as nonprofit health care organizations and health research institutes, whose strategic plan’s objectives fit the mission of Infotility. We will then contact these organizations with a proposal and an estimated budget required to keep Infotility up to date, including the costs of literature and policy reviews, summarizing the information in lay terms, content translations and integration, and technical costs associated with domain registry and website hosting. On the basis of the results of the pre-post study, we can confidently conclude that fertility patients in Quebec and Ontario appreciated and enjoyed using the Infotility app, which will make the app more attractive to potential partners. Building a long-term partnership will help ensure that the Infotility app continues to provide accurate and reliable information to fertility patients.As this study is now complete, our team will search for partners that can maintain and disseminate Infotility app succeeded in its goal to provide men and women undergoing fertility treatment with information and support through a user-friendly, credible, and single-source tool. The development and evaluation of Infotility highlighted the important aspects of the app creation process, which may be beneficial for researchers and medical professionals who wish to create similar mHealth apps in the future.Overall, the


The response to invading pathogens such as viruses is orchestrated by pattern recognition receptor (PRR) and unfolded protein response (UPR) signaling, which intersects and converges in the activation of proinflammatory pathways and the release of cytokines and chemokines that harness the immune system in the attempt to clear microbial infection. Despite this protective intent, the inflammatory response, particularly during viral infection, may be too intense or last for too long, whereby it becomes the cause of organ or systemic diseases itself. This suggests that a better understanding of the mechanisms that regulate this complex process is needed in order to achieve better control of the side effects that inflammation may cause while potentiating its protective role. The use of specific inhibitors of the UPR sensors or PRRs or the downstream pathways activated by their signaling could offer the opportunity to reach this goal and improve the outcome of inflammation-based diseases associated with viral infections. Viruses entering into target cells are promptly recognized by different classes of molecules identified as PRRs, which are mainly represented by the family of Toll-like receptors, nucleoside-binding oligomerization domain containing-like receptors (NLRs), C-type lectin receptors (CRLs), and the cGAS/STING pathway ,2. PRRs In addition to PRR signaling, viral infection activates the unfolded protein response (UPR) . This reInterestingly, viruses may activate UPR through PRR signaling independently of ER stress. For example, TLR2 and TLR4 signaling has been reported to activate IRE1α through TNF-receptor-associated factor (TRAF) 6 and nicotinammide adenina dinucleotide fosfato (NADPH) oxidase 2 (NOX2) . NOX actSome respiratory viruses, such as influenza  or coronFinally, cytokines may be transported far from the site of production by the blood stream, causing damage in several organs and tissues and inducing systemic effects. These events are reported to occur in some patients following infection by the new coronavirus SARS-CoV2, which causes the pandemic disease known as COVID-19 . Although the role of UPR activation in the release of proinflammatory, antiviral, and anti-inflammatory cytokines during viral infection is still under investigation, there are several studies showing that it contributes to inflammation ,33. The Therefore, to mitigate the destructive process of inflammation and improve the efficiency of the immune response, the selective inhibition of UPR sensors or PRR signaling could be exploited. In the first case, pharmacological inhibitors of IRE1α, PERK, and ATF6 molecules such as 4μ8c, Ceapin, or GSK2606414, respectively, could be used, although the side effects that they could cause must be considered ,34. Inde


Colorful displays have evolved in multiple plant and animal species as signals to mutualists, antagonists, competitors, mates, and other potential receivers. Studies of color have long relied on subjective classifications of color by human observers. However, humans have a limited ability to perceive color compared to other animals, and human biological, cultural, and environmental variables can influence color perception. Here, we test the consistency of human color classification using fruit color as a model system. We used reflectance data of 67 tropical fruits and surveyed 786 participants to assess the degree to which (a) participants of different cultural and linguistic backgrounds agree on color classification of fruits; and (b) human classification to a discrete set of commonly used colors  corresponds to natural clusters based on light reflectance measures processed through visual systems of other animals. We find that individual humans tend to agree on the colors they attribute to fruits across language groups. However, these colors do not correspond to clearly discernible clusters in di‐ or tetrachromatic visual systems. These results indicate that subjective color categorizations tend to be consistent among observers and can be used for large synthetic studies, but also that they do not fully reflect natural categories that are relevant to animal observers. Subjective human color classifications continue to be used regularly in assigning colors to organisms of interest. Here, we investigate whether or not subjective human color classifications are consistent among human observers, and whether intraspecific variation in color assignation can affect study results. We first test to what degree participants agree on color classifications, across the sample and between speakers of different languages. We then test whether human classification corresponds to natural clusters of fruit color in the eyes of nonhuman observers using reflectance spectra of the same fruits to model their quantum catch in the eyes of a dichromatic mammal and a tetrachromatic bird. In both, we first look at the classification to the ten commonly used categories  and then look at two higher‐level divisions that have proposed ecological or evolutionary significance to fruit ecology: conspicuous versus cryptic colors, and colors associated with bird or mammal dispersal. Conspicuous colors are identified in the literature as colors that contrast with background foliage, for example, red, yellow, orange, whereas cryptic fruits are those that do not contrast with background foliage, for example, green, brown, based on a human trichromatic phenotype  and one site in Uganda . Photographs were collected from the author's own photographic databases of fruits. For all fruits in the database, we had previously measured their reflectance in the field, relative to a Spectralon white reflectance standard , using a Jaz portable spectrometer and a PX‐2 pulsed xenon lamp  emitting a D‐65 light source. The fruit scanning angle was fixed at 45° using a probe holder, and external light was blocked using thick black fabric. Each fruit was scanned 3–5 times, and the resulting spectrograms represent mean spectral reflectance. See Valenta et al.  for detaUsing freely available Google Forms software, we generated an online survey that had participants view a photograph of a single fruit species and select one of ten colors that best described the target fruit: red, orange, yellow, green, blue, purple, pink, brown, white, and black online . BecauseWe circulated the survey online, allowing for an opportunistic, snowball sampling technique, and collected responses between April 23, 2020 and May 7, 2020. We removed all responses by individuals under the age of 18, per the requirements of the ethics review board . To reduce the potential impact of charging and brightness settings, participants were asked to ensure their viewing device was plugged in and charging and to maximize their device's screen brightness. In total, we analyzed 786 survey responses, of which 20 participants self‐reported suspected or diagnosed color vision deficiencies . We included these individuals in all analyses under the assumption that many observers contributing to published reports of fruit color, especially among field assistants, may not report or even be aware of their color vision deficiencies. Additionally, the results are qualitatively identical even if they are excluded from the analyses.—the percentage of individuals that assigned a fruit species to the most commonly assigned color. We then simulated 999 randomized datasets that assumed colors were randomly assigned to each fruit. For each simulated dataset, we calculated the percentage of randomized responses that matched the color originally attributed to these fruits by a plurality of participants in the collected data. We then compared the collected classifications to the generated distribution to obtain a p‐value. We further used descriptive statistics to estimate the degree of discrepancy between participants. We calculated the percentage of misclassifications  to determine whether any colors tended to be interrelated in their classifications . We then conducted two analyses that divided the ten colors to two major bins often used in ecological studies of fruit color: (a) conspicuous  versus cryptic  coloration, based on Onstein et al. n et al. , and Sinn et al. . We inclTo assess whether speakers of different languages classified fruits to different colors, for each fruit, we identified the color selected by a plurality of participants in each of six languages for which we had at least 20 native speakers . Other languages reported as native languages among the participants were Malay, Afrikaans, Armenian, Bahasa, Bengali, Catalan, Chinese, Czech, Danish, Doteli, Dutch, Filipino, Greek, Gujarati, Hebrew, Hindi, Italian, Japanese, Malay, Persian, Polish, Russian, Telugu, and Vietnamese.To assess whether human classifications are likely to be similarly classified by nonhuman observers, we used the reflectance data of all 67 fruit species included in the survey. We standardized the data by trimming the reflectance under and above the visual spectrum (400–700 nm), smoothed it using a running average with pavo: procspec . This indicates that colors are not assigned randomly and that the majority of participants agreed on the color of each fruit. At the same time, classifications never reached true consensus: misclassifications (compared to the majority classification) were apparent in all color groups, with high degrees of disagreement over white, pink, orange, red, and purple fruits, as opposed to near consensus in brown, blue, and green fruits , but with differing degrees of consistency Figure . Fruits Although native speakers of different languages showed a high degree of consistency, some clear discrepancies arose: In the six best‐represented languages in our sample, 22.3% of fruits were classified by a plurality of participants to at least two different colors Figure . Classif3.2F = 12.4, p < .001; F = 19.7, p < .001, respectively). Discrimination between human‐classified colors was lower in the dog visual system .Color classifications by humans showed partial agreement with the clustering patterns of chromatic distances based on the visual systems of a dichromatic mammal (dog) and a UV‐perceiving avian. In the avian visual system, some human‐classified color categories  formed coherent clusters while others  did not Figure , Table 14Our goals were to identify whether human observers consistently classify fruits to the same colors and to assess the degree to which these classifications reflect how nonhuman observers may view the same fruit. Overall, we found that there was a high degree of consistency in color categorizations across survey participants, indicating that, in the human visible spectrum, color assessments made by human observers are generally consistent. However, there was some interesting variation among color classifications. For some colors, for example, green, there was a very high level of agreement, whereas for other colors, for example, white, categorization was less consistent.Although fruits were consistently categorized to the same color, subsequent binning of those colors into ecologically relevant categories, as was done in previous studies  formed clear clusters that were statistically distinguishable from most other human‐classified colors. At the same time, some were not, and all showed substantial overlap with other colors, indicating that a high degree of consistency in human color perception. For example, fruits classified as green by humans can, in the eyes of birds, be closer to fruits classified as white, brown, or blue by humans. Nonetheless, the fact that many colors were distinguishable, and that the main functional bins were also clearly distinct, is an indication that human classification, while not noise‐less, is a reasonable proxy for chromatic variance.An additional consideration is that participants in the survey viewed fruit photographs on different devices and screens, and the resulting variation in hue, saturation, and chromaticity could have influenced our results. While we cannot exclude that this introduced some noise, we believe that it has little effect on our results for several reasons. First, this noise is expected to reduce interparticipant agreement, thus making the analysis even more conservative and strengthening our conclusion that participants show a high degree of agreement. Second, our analysis of a subset of the participants who used very similar devices reproduces the results, thereby indicating that display types did not play a major role in subjective color classification. Third, potential variation introduced by differences in viewing devices likely pales in comparison to that introduced by the myriad light and viewing conditions in the field, particularly in tropical forests where our fruit samples were taken Endler, . FurtherTaken together, our results indicate that although fruit color categorization is largely consistent, differences in language, and the binning of fruit colors into larger, ecological categories  can introduce non‐negligible variation. More critically, discrete color categories are strongly affected by either human color vision capacities or the arbitrary division of the spectrum, yielding a classification pattern that is not fully reflective of the chromatic distances perceived by nonhuman observers. This is likely to be particularly true in systems with bird dispersal‐dominated flora, for example, temperate forests, where UV reflectance is probably high. As such, our results show that studies that utilize subjective color observations are reliable to the degree that the variance between human observers is likely to be low. However, studies relying on subjective color classifications should exercise caution since human color categorizations can be affected by physiological, linguistic, and/or cultural biases and do not correspond well to the colors perceived by animals with different color vision phenotypes.KV, SLB, and ON declare that publication of this manuscript will enhance their CV and publication statistics and thus improve their academic prestige and employment status. Y‐DJ has no conflict of interest to declare.Kim Valenta: Conceptualization ; Data curation ; Investigation ; Methodology ; Project administration ; Writing‐original draft ; Writing‐review & editing . Sally Bornbusch: Conceptualization ; Data curation ; Investigation ; Methodology ; Project administration ; Resources ; Visualization ; Writing‐original draft ; Writing‐review & editing . Yan‐Daniel Jacques: Data curation ; Investigation ; Methodology ; Project administration ; Writing‐original draft ; Writing‐review & editing . Omer Nevo: Conceptualization ; Data curation ; Formal analysis ; Validation ; Visualization ; Writing‐original draft ; Writing‐review & editing .Appendix S1Click here for additional data file.


Ankle sprain is the most common injury in basketball. Chronic ankle instability develops from an acute ankle sprain may cause negative effects on quality of life, ankle functionality or on increasing risk for recurrent ankle sprains and post-traumatic osteoarthritis. To facilitate a preventative strategy of chronic ankle instability (CAI) in the basketball population, gathering epidemiological data is essential. However, the epidemiological data of CAI in basketball is limited. Therefore, this study aims to investigate the prevalence of CAI in basketball athletes and to determine whether gender, competitive level, and basketball playing position influence this prevalence.2) were analyzed. Differences in prevalence between gender, competitive level and playing position were determined using the Chi-square test.In a cross-sectional study, in total 391 Taiwanese basketball athletes from universities and sports clubs participated. Besides non-standardized questions about demographics and their history of ankle sprains, participants further filled out the standard Cumberland Ankle Instability Tool applied to determine the presence of ankle instability. Questionnaires from 255 collegiate and 133 semi-professional basketball athletes  = 0.515, p = 0.003). This gender disparity also showed from sub-analyses, that the collegiate female athletes had a higher prevalence than collegiate men athletes (X2(1) = 0.203, p = 0.001). Prevalence showed no difference between competitive levels (p > 0.05) and among playing positions (p > 0.05).In the surveyed cohort, 26% had unilateral CAI while 50% of them had bilateral CAI. Women had a higher prevalence than men in the whole surveyed cohort (XCAI is highly prevalent in the basketball population. Gender affects the prevalence of CAI. Regardless of the competitive level and playing position the prevalence of CAI is similar. The characteristic of basketball contributes to the high prevalence. Prevention of CAI should be a focus in basketball. When applying the CAI prevention measures, gender should be taken into consideration.The online version contains supplementary material available at 10.1186/s13102-022-00418-0. Ankle sprain is one of the most common injuries among active individuals . ResiduaBased on the model from Van Mechelen, the first step of sports injuries prevention is to identify the severity and the incidence . The sevRegarding the incidence of CAI, the epidemiology of ankle sprains is well documented. Yet the prevalence of CAI in basketball is not. Ankle sprain is one of the most common injuries in basketball due to repetitive jumping, cuttings, rapid stops and directional changes –14. InciReferring to the prevalence of CAI, 19–22% of all injuries in the basketball athlete population are recurrent ankle sprains , 18, 21.Gender , 21, 27,Therefore, the purposes of this study were to investigate the prevalence of CAI in elite basketball athletes at different levels  and to investigate if the prevalence of CAI is influenced by different genders, competitive levels and positions.This study presents the cross-sectional data of CAI prevalence during the pre-season of the Super Basketball League and the games of the University Basketball Association in Taiwan. The investigator contacted team staff from all semi-professional teams and college teams in Taiwan. Participants filled out a printed questionnaire inquiring demographics, history of ankle sprain/giving way/recurring ankle sprain and the Taiwan-Chinese version of the Cumberland Ankle Instability Tool Questionnaire (CAIT-TW) after a routine practice . The inv391 elite Taiwanese basketball athletes from 11 semi-professional and 17 college teams were recruited for this study. 134 athletes (99 men and 35 women) from all the Super Basketball League in Taiwan  , which do not result in an acute lateral ankle sprain and it has happened at least twice in the past six months .Do you have recurrent ankle sprains? (two or more sprains to the same ankle) .The questions stated:2.1 = 0.91, p < 0.001), good internal consistency (Cronbach’s α: 0.87), moderate to strong construct validity , and a cutoff score of 21.5  [The CAIT-TW consisting of nine items was applied to determine the presence of perceived ankle instability . CAIT-TWty 0.85) .There were three sections in the questionnaire: (1) demographics, (2) history of significant ankle sprains/giving way/recurrent ankle sprain, and (3) the CAIT-TW .The demoThe International Ankle Consortium suggested the inclusion criteria of CAI are individuals who had a history of significant ankle sprain and either (1) experience of giving way twice or more within the past six months, (2) recurrent ankle sprain or 3) perceived ankle instability (the score of CAIT-TW is lower than 22) [ perceiveAll data analysis was performed using IBM SPSS 25.0 . Descriptive statistics were performed to display the demographic data and prevalence of CAI in the population of basketball athletes (first study purpose). Differences in demographics between participants with CAI and without CAI were examined applying the Mann–Whitney U test or independent T-test depending on the distribution of the data. The Chi-square test was applied to determine the difference in the presence of CAI between genders, two competitive levels and positions on court (second study purpose). The level of significance was set at p-value ≤ 0.05.391 basketball athletes filled out the questionnaire in total, whereby three questionnaires were incomplete. Finally, 388 valid questionnaires were available for analysis . Participants’ demographics and the score of CAIT-TW are shown in Additional File 2 = 0.151, p = 0.003). When data was separated into two levels women had a higher prevalence of CAI than men at the college level (X(1)2 = 0.203, p = 0.001). No difference based on gender has been found at the semi-professional level (X(1)2 = 0.203, p = 0.47)  (Table 2(1) = 0.117, p = 0.07, women: X2 = 0.017, p = 0.84).The competitive level did not influence the presence of CAI (9) Table . When th2(2) = 0.55, p = 0.56) , 80% for forward (118/148), and 74% for center (51/69). The prevalence of CAI did not differ among positions  to investigate the prevalence of CAI in basketball athletes and (2) to assess if genders, competitive levels or positions influence this prevalence. The prevalence of CAI was high in the studied cohort. Gender affected the prevalence of CAI. Women showed a higher presence of CAI than men. The competitive level and position showed no influence on the prevalence of CAI.Regarding the first objective, the prevalence of CAI in this study cohort was high and above the prevalence of previous studies –25, 38. There is a limitation when surveying the prevalence of CAI using the exclusion criteria defined by the International Ankle Consortium. If the participants with CAI are excluded because they have the issues mentioned above, the prevalence of CAI could be underestimated –25, 38. The rate of prevalence is almost twice as high when applying the exclusion criteria when investigating the prevalence of CAI . KoshinoThe high prevalence in the current study might be caused by the factors: preexisting perceived ankle instability, the period of the investigation and recovery conditions after ankle sprains. Preexisting perceived ankle instability might be a confounder when investigating the prevalence of CAI. In the current study, 30% of the participants without a history of ankle sprain showed perceived ankle instability (left ankle: 14/53 and right ankle 21/69). Therefore, there is a possibility that athletes with preexisting perceived ankle instability and a history of ankle sprain were categorized as CAI even though they regained the baseline level of perceived ankle stability after a severe ankle sprain. The current cross-sectional study cannot clarify if the perceived ankle instability is preexisting or caused by an ankle sprain.The investigating period might be another explanation for the high prevalence of CAI. The current study was conducted one month before the start of the season. Most ankle injuries occur during the pre-season among collegiate basketball athletes . In the The inadequate recovery or lacking rehabilitation after an ankle sprain might also contribute to the high prevalence of CAI. Doherty et al. showed that after an acute ankle sprain, 40% of the participants who did not seek rehabilitation developed CAI, and 60% who did became ankle sprain copers . NeverthThe current study found that gender influences the prevalence of CAI. Female athletes had a higher prevalence of CAI than men at the collegiate level. This is consistent with previous work . In contThe factors causing the differences in ankle injury rates between genders could be different anatomical structural, joint laxity and menstrual cycles , 45–47. The current study found that the athlete’s competitive level did not relate to the prevalence of CAI. The relation between competitive level and ankle injury rate is not clear . Two preThe potential explanation for the inconsistent findings might be that athletes attend highly specialized training from a young age in Taiwan which is a risk factor for serious overuse injury . Access The current study found that the different positions showed no difference in the prevalence of CAI. To the best of the authors’ knowledge, no study has investigated the prevalence of CAI in different positions within basketball athletes. Regarding the relation of ankle injuries and positions, the outcome is inconsistent with previous works , 32, 34.There were some limitations to the study. Firstly, the current study is a cross-sectional design that portrays the prevalence of CAI among Taiwanese basketball athletes in pre-season. The prevalence is not representative for the whole season. Factors that affect the prevalence of CAI cannot be determined from the current data. In addition, the mechanical instability has not been examined so the participants with solely ankle pathological laxity may not be shown in the results. Finally, due to limited study resources no physician was present to differentiate between CAI and ankle instability caused by other issues. This may lead to an overestimation of the prevalence of CAI in the current study.An acute ankle sprain can cause the development of CAI, which can impact athletes negatively. In the current study, elite Taiwanese basketball athletes showed a higher prevalence of CAI than in previous studies. Female collegiate athletes have a higher prevalence of CAI than men. Competitive level and positions showed no difference in the prevalence of CAI. Prevention of chronic ankle instability should be a focus in basketball. Gender should be taken into consideration when applying the CAI prevention measures.The recommendations for further studies investigating the prevalence of chronic ankle instability are: (1) prospective longitudinal study is recommended so the fluctuation of prevalence can be clearly depicted and the preexist perceived ankle instability will not confound the prevalence, (2) standard criteria for survey the prevalence of CAI should be developed, that can increase the precision of the prevalence, and (3) implementation of rehabilitation followed by ankle sprains should be reported.Additional file 1. Demographic characteristics of participants.Additional file 2. Demographical differences between genders in collegiate athletes (n=255).Additional file 3. Demographical differences between genders in the groups with and without chronic ankle instability (N=388).Additional file 4. Demographical differences between genders in semi-professional athletes (n=133).


CD276 is an immune checkpoint molecule. Elevated CD276 expression by urothelial carcinoma is associated with poor prognosis, but little is known about its expression across different tumor stages. We therefore investigated CD276 expression in bladder cancer (BC) cells and in tissue samples of BC stages from pT2 to pT4.CD276 expression was explored in 4 urothelial cancer cell lines and 4 primary normal urothelial cell populations by quantitative RT-PCR, Western blot and flow cytometry. CD276 was investigated in bladder tumors from 98 patients by immunohistochemistry using a score (0–300) incorporating both, staining intensity and area of CD276 staining. Normal appearing urothelium in the bladder of the same patients served as controls.p < 0.006), total protein levels (p < 0.005), and on the cell surface (p < 0.02) when compared to normal urothelial cells. In pT2–T4 tumor tissue samples, CD276 was overexpressed (median score 185) when compared to corresponding healthy tissues from the same patients . No significant differences in CD276 expression were recorded in late, locally advanced ≥ pT3a tumors (median score 185) versus organ-confined < pT3a tumors (median score 190), but it was significantly lower in the normal urothelial tissue associated with ≥ pT3a tumors (median score 40) versus < pT3a tumors .The urothelial carcinoma cell lines expressed significantly higher levels of CD276 on transcript (CD276 expression is significantly elevated in urothelial carcinoma cells in all stages but varies between individuals considerably. Reduced CD276 expression in normal urothelial cells may imply that these cells would be protected from CD276-mediated immuno therapies. Bladder cancer ranks among the most common malignancies. Despite efforts in cancer research, the 5-year survival rates between 1996–2004 (80%) compared to 2008–2014 (77%) have not improved . Pr. Pr18]. To quantify CD276 expression on UCCLs and NUCs, cells were grown to confluence, detached by mild proteolysis and washed twice by PBS. 5E05 cells were resuspended in PFEA buffer, incubated with anti-CD276 mAB and measured by flow cytometry (FC) as described  . StaininTissue microarrays (TMA) were assembled from 0.6 mm bladder tissue punches after radical cystectomy of 98 BC patients after informed and written consent as described . 98 tissExperimental results were processed by spreadsheet  and statistics software . P values less than 0.05 were considered significant and marked in the figures accordingly.p < 0.006, Fig. p < 0.005, Fig. p < 0.012; Fig. Transcript amounts encoding CD276 were enumerated in UCCLs and NUCs by quantitative RT-PCR. CD276 mRNA was detected in both populations but the mean expression in the 4 UCCLs was significantly higher than in the 4 NUCs  were assembled from samples of 28 stage pT2, 46 stage pT3, 23 stage pT4 tumors and one additional BC tumor sample with unknown stage. The clinical and pathologic characteristics of the patient cohort are summarized in Table However, the range of the CD276 score of benign samples surpassed the lowest quartile of the range of CD276 scores of the tumor samples  in only 3 of 47 cases . In 12 of 47 benign samples (25%) CD276 expression was not observed at all . In contrast, in benign urothelium from samples of patients with later stage tumors (≥ T3a) mean CD276 was significantly reduced when compared to benign sites in sample from patients with early-stage tumors (< T3a).Expression of CD276 in bladder tissue samples from cancerous and adjacent healthy areas was determined by immunohistochemistry but not, for instance, by transcriptomics or other molecular analyses. Therefore, the mechanisms contributing to the significant changes in CD276 expression in situ in the normal tissue remained obscure. Total protein expression is often regulated on the transcript level and tumor grade-depended elevation of CD276 transcripts and CD276 total protein were found in BC . HoweverWe noted considerable variations of CD276 expression in individual samples from all stages of bladder tumors. This may be in part associated with changes in cell surface versus cytoplasmic expression of CD276. Such a conversion of CD276 expression has been observed in clear cell renal cell carcinoma . Tumors A technical challenge is of course the fact that histology yields in many cases the sum of protein expression in the cytoplasm and on the cell surface. For the interaction with T lymphocytes as well as the direct binding of anti-CD276 antibodies or alike, the presentation of CD276 on the cells surface is critical. Therefore, additional studies need to determine the correlation between total protein expression in bladder tumor tissue in comparison to the CD276 density on tumor cell surfaces , 24, 25.Median expression of CD276 is significantly elevated in bladder carcinoma tissue but presents with a high inter-individual variability among patient samples. Diagnosis or therapy utilizing CD276 as target molecule should therefore be considered and evaluated with care, especially in late-stage patients.


Bone morphogenetic proteins (BMPs) are potent signaling molecules initially described as osteopromoting proteins. BMPs represent one of the members of the larger TGFβ family and today are recognized for their important role in numerous processes. Among the wide array of functions recently attributed to them, BMPs were also described to be involved in the regulation of components of the innate and adaptive immune response. This review focuses on the signaling pathway of BMPs and highlights the effects of BMP signaling on the differentiation, activation, and function of the main cell types of the immune system. These receptors are divided into two types, type-I receptors, which are also called activin receptor-like kinases (ALKs), and type-II receptors. Seven type-I and five type-II receptors have been identified so far. TGFβ family members first bind to type-II receptors, which in turn phosphorylate the type-I receptors leading to the activation of intracellular SMAD proteins and consequently to gene transcription in the nucleus (Bone morphogenetic proteins (BMPs) are a subfamily of signaling molecules that belong to the larger transforming growth factor-beta (TGFβ) family. The TGFβ family comprises more than 30 members which are structurally similar and share a similar signaling pathway. All the components of the TGFβ family signal  nucleus .As their name implies, BMPs were first described for their ability to induce bone formation. Following this observation and thanks to advances in molecular biology, it was observed that BMPs do not only participate in bone formation but are endowed with numerous different functions . These iIn this review, we discuss the current knowledge regarding the BMP signaling pathway and BMP-mediated immune regulation focusing on its effect on the various components of the immune system.BMPs are released by cells in an inactive precursor form. Once secreted, they are cleaved by protein convertases into their mature form that can bind to its receptor . To dateThe canonical BMP signaling pathway involves the participation of type-I and type-II receptors and SMAD complexes . The recThe affinity of the different BMP subgroups to the different type-I and type-II receptors varies. BMP2 and BMP4 were described to preferentially bind BMPR1a and BMPR1b. BMP6 and BMP7 were described to bind BMPR1a, BMPR1b (weakly), and ACVR1(strongly). BMP9 and BMP10 instead were described to bind to ACVRL1 and ACVR1. Lastly, the BMP12/13/14 group preferentially interacts with BMPR1b , type-II receptors (BMPRII), and the BMP downstream signaling components SMAD1, SMAD5, SMAD8, and SMAD4 . Numerou+DC differentiation and inhibit plasmacytoid DC (pDC) development in a process that is mediated through ACVRL1  cells inhibited the differentiation of moDCs from monocytes. Furthermore, moDCs treated with BMP4 displayed increased immunosuppressive functionality by expressing higher levels of IL-10 and TGFβ . In miceh ACVRL1 .in vitro and in vivo. LCs can be differentiated in vitro by culturing CD34+ hematopoietic progenitor cells (HPCs) in the presence of GM-CSF, SCF, FLT3L, TNFα, and TGF-β1  differentiation. Before this observation, TGF-β1 was believed to be the key cytokine promoting LC differentiation d TGF-β1 , and BMPd TGF-β1 . Similar1  revealed no significant differences in LC counts in the epidermis between knockout and wild-type mice in steady-state and during inflammation  . FunctioBMPs were also described to influence macrophage polarization. In murine models of prediabetic cardiomyopathy and atherosclerosis, BMP7 was observed to skew macrophage differentiation into the anti-inflammatory M2 phenotype with higher detectable levels of IL-10 and lower levels of IL-6, and TNFα , 23. BMP-CD8- double-negative (DN) thymocytes (+CD8+ double-positive (DP)  revealed that BMP signaling is required for thymocyte development and that the effects are dose-dependent. Physiological levels of BMPR1a signaling are necessary for the correct differentiation however, elevated levels of BMPR1a signaling, obtained through the addition of exogenous BMP4, produced an opposite effect characterized by inhibition of the DN to DP stage  . In vivoDP stage .+ T cells. Naïve CD4+CD45RA+ T cells express mRNA for BMPR1a, ACVR1a, and the BMP intracellular components SMAD1, SMAD5, SMAD8, and SMAD4  further confirmed the role of BMP signaling in Treg differentiation. These mice displayed lower Treg numbers and in addition, CD4+ T cells isolated from these knock-out mice did not efficiently convert into Tregs  production. BMPs inhibited the production of IgM, IgA, and IgG by both naïve and memory B cells and also inhibited the differentiation of B cells into CD27+CD38+ plasmablasts  and cell surface markers  which are associated with NK cells , whereas their reconstitution with CD34+BMPR1a- counterparts failed to reach 10% CD3-CD161+CD56+. Moreover, in vitro differentiation experiments with the BMP inhibitor DM clarified that during their differentiation process NK cells produce BMP4 and that autocrine BMP signaling is involved in their differentiation : Investigator Grant (IG) 2020-24440, the National Operational Program (PON), “TITAN”, Ministry of the University and Research (MUR)-EU, and Rome Foundation project “Diabetes Mellitus, Regenerative and Reparative Processes, and Improvement of Pancreatic Beta Cell Function”. TS was trained within the Ph.D. program Molecular Fundamentals of Inflammation (DK-MOLIN) of the Medical University of Graz.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.


Saccharomyces cerevisiae for the utilization of d-xylose, a five-carbon sugar found in high abundance in lignocellulosic biomass and a key substrate to achieve good process economy in chemical production from renewable and non-edible plant feedstocks. Despite many excellent engineering strategies that have allowed recombinant S. cerevisiae to ferment d-xylose to ethanol at high yields, the consumption rate of d-xylose is still significantly lower than that of its preferred sugar d-glucose. In mixed d-glucose/d-xylose cultivations, d-xylose is only utilized after d-glucose depletion, which leads to prolonged process times and added costs. Due to this limitation, the response on d-xylose in the native sugar signaling pathways has emerged as a promising next-level engineering target. Here we review the current status of the knowledge of the response of S. cerevisiae signaling pathways to d-xylose. To do this, we first summarize the response of the native sensing and signaling pathways in S. cerevisiae to d-glucose (the preferred sugar of the yeast). Using the d-glucose case as a point of reference, we then proceed to discuss the known signaling response to d-xylose in S. cerevisiae and current attempts of improving the response by signaling engineering using native targets and synthetic (non-native) regulatory circuits.Extension of the substrate range is among one of the metabolic engineering goals for microorganisms used in biotechnological processes because it enables the use of a wide range of raw materials as substrates. One of the most prominent examples is the engineering of baker’s yeast  Metabolic engineering has enabled various microorganisms to grow on and convert non-native carbon sources into useful bulk and fine chemicals through recombinant expression of heterologous pathways identified in other species. A remarkable amount of successful engineering strategies that enable yeast and bacteria to grow on substrates they cannot naturally assimilate have been published in the last decades and have broadened the possibilities of applied biotechnology  sugar d-xylose , a flagellulose . The fir in 1990  and it hS. cerevisiae  copy numbers, or the implementation of an alternative dehydrogenase in the Weimberg pathway ,151d-gluP pulses . The imm absence . In addi-glucose ,155,156.The function of the cAMP pulse is to convert the inactive PKA complex to its active form . InactivS. cerevisiae laboratory strains due to a mutation in CYR1 . I. Id-xylod-xylose  77]. A . A d-xylse sugar . Severald-xylose .d-xylose for these two genes was distributed over two populations (one repressed and one induced). This was seen both for strains that had not been engineered with a d-xylose-utilization pathway . . S. cered-xylose sensing in S. cerevisiae emerge: (i) increased efforts to elucidate the effects on d-xylose on the native signaling pathways and their subsequent engineering; (ii) development of synthetic signaling pathways that can operate orthogonally to the native systems; and (iii) computational modeling of signaling networks.There are more and more indications that achieving well-performing microbial cell factories engineered to utilize non-native substrates requires not only functional expression of the heterologous metabolic pathway, but also engineering of the sensing and signaling networks. The major challenge of engineering non-native sensing is, however, that it requires an advanced understanding of the signaling of the native metabolites before any non-native signals can be understood. Based on the current status of the field reviewed above, three synergistic future directions for the research on d-xylose utilization in S. cerevisiae has reached a point where several hypotheses regarding metabolic issues have been addressed and to some extent resolved. Examples include the expression of various catabolic pathways from different hosts, the balancing of redox equivalents, the adjustments to the native pathways including the pentose phosphate pathway, the release of inhibition by xylitol and the expression of D-xylose transporters. As a consequence, the signaling and regulatory effects imposed by the d-xylose molecule on the cell increasingly appears as the final frontier that needs to be explored to solve this engineering challenge. This calls for more studies on the effect of d-xylose on the signaling networks of both wild-type and engineered S. cerevisiae. Excellent first steps have been taken  d-glucose specific sensors can respond non-specifically to d-xylose due to the structural similarity of d-xylose and d-glucose; (iii) the different levels of the shared glycolysis and gluconeogenesis metabolites formed by the catabolism of d-glucose or d-xylose can be sensed by the signaling pathways; and iv) the different redox and energy carrier levels created during cultivation on the different sugars can be sensed as a signal of cellular homeostasis or well-being. We believe that the complexity of a microbial cell calls for holistic views of the molecular events of the cellular system and that the interactions between signaling networks and metabolic pathways need to be considered together, and not as two isolated parts. With that in mind, increased investigation of hypotheses three and four will be imperative to reach improved d-xylose utilizing and sensing strains.The four hypothetical mechanisms for S. cerevisiae MAPK signaling pathways, Furukawa and Hohmann identified five different approaches for signaling network engineering: assembly of regulatory elements, forced protein compartmentalization, systematic pathway modifications, heterologous expression of signaling cascades and rewiring of signaling transduction [d-xylose signaling engineering, as has been discussed in d-xylose. Up to now, most attention has been given to target elements of the cAMP/PKA pathway, which has led to strains with improved d-xylose utilization, but also industrially undesirable side traits such as decreased stress tolerance and biomass formation  is an aXYL regulon. Whereas the bacterial XylRs theoretically only affects the synthetic hybrid promoters containing xylO motifs, the d-xylose-sensitized Gal3p can still affect the native GAL regulon. This results in the expression of the GAL regulon’s many targets in addition to the recombinant material, such as the d-xylose-utilization pathway. This was indeed confirmed by a differential expression analysis of the constitutive and XYL regulon-controlled xylose pathway strains in which many expression differences related to the native targets of the GAL regulon were also found on d-xylose [XYL regulon. This orthogonality will likely lead to a lower level of background expression and a lower metabolic burden caused by expression of unrelated and/or undesired genes, ultimately giving the metabolic engineer more control over the circuit. Using non-native genetic material in a synthetic signaling circuit is not guaranteed to achieve orthogonality. However, as has recently been shown in E. coli, orthogonal synthetic signaling is achievable if testing of potential cross-talk between the heterologous material with the native pathways is part of the design [The high degree of interconnectivity and cross-talk in native signaling networks complicate their engineering, thereby synthetic (non-native) signaling circuits can provide a higher degree of pathway orthogonality, i.e., the ability to function independently of and in parallel to the native signaling and metabolic pathways . This isd-xylose . While te design .d-xylose signaling in S. cerevisiae is still at its infancy with a level of complexity many factors lower than the multi-element cascades of the native sugar signaling networks. The XylR circuits, for instance, which could be considered the only fully synthetic d-xylose signaling circuit in S. cerevisiae to date since all its regulatory elements (XylR and xylO) are of exogenous origin, only cover the final step of a gene regulating signaling cascade:TF-controlled gene expression [d-xylose utilization, it is currently not known if a circuit containing a single signaling element (the XylR) is enough to improve d-xylose utilization in S. cerevisiae, which is the case in e.g., E. coli [B. subtilis, for instance, a multi-step XylR-based circuit using two regulators that each control a promoter has been successfully implemented [d-xylose signaling circuits H imbalance in the first generations of the XR/XDH pathway [d-xylose utilization, it becomes clear that a mathematical model that can combine metabolism, signaling and gene regulation would be needed to better simulate systemic effects of the non-native sugar d-xylose.Mathematical modeling of the cellular metabolism is extensively used to drive strain design in metabolic engineering and systems biology and can be used to simulate and predict systemic effects of changes to the metabolic pathways such as adding new reactions and deleting existing ones . In sili pathway ,322,323.S. cerevisiae signaling reconstructions have been made, including the Snf3p/Rgt2p pathway [So called hybrid models that integrate reconstructions of both the metabolic and the signaling networks and are able to take metabolic flux and signal transduction into account have indeed been in the works for some time and are increasing in complexity ,326,327. pathway , the SNF pathway ,329, the pathway  and the  pathway . The ubi pathway .S. cerevisiae sugar signaling-metabolism hybrid models could be expanded to include the reactions of the recombinant d-xylose pathways and their interactions with the native signaling pathways The resulting S. cerevisiae d-xylose hybrid model could then become a highly useful systems biology tool to identify targets for signaling engineering.Optimally the d-Xylose sensing by engineered S. cerevisiae has a good potential to become a golden standard in the field of non-natural substrate sensing and signaling because substantial metabolic engineering achievements are already in place owing to many decades of research progress; also, the native d-glucose sensing is already a well-studied topic in this yeast. While a lot remains to be understood of the signaling responses to different sugars before rational signaling engineering can be attempted at a larger scale, the first steps towards that end have already been taken as has been illustrated by this review.To achieve industrially and societally relevant bioprocesses, microbial cell factories often need to be engineered with expanded substrate ranges. However, once functional expression of novel catabolic pathways has been achieved, substantial molecular optimization is typically required to reach economically feasible yields, titers and productivities. To be able to achieve these levels of optimization, we foresee that engineering of the sensing of non-native substrates shall be an essential component of the metabolic engineering and systems biology strategies.


Antiviral innate immune response triggered by nucleic acid recognition plays an extremely important role in controlling viral infections. The initiation of antiviral immune response against RNA viruses through ligand recognition of retinoic acid-inducible gene I (RIG-I)-like receptors (RLRs) was extensively studied. RLR’s role in DNA virus infection, which is less known, is increasing attention. Here, we review the research progress of the ligand recognition of RLRs during the DNA virus infection process and the viral evasion mechanism from host immune responses. The innate immune response is the first line of host defense against microbial infection . PatternThree members of the RLR family, RIG-I , MDA5 (melanoma-differentiation-associated gene 5), and LGP2 (laboratory of genetics and physiology 2), have been identified to be expressed in most types of cells and tissues .RIG-I was originally identified as a retinoic acid-treated cell induction gene from acute promyelocytic leukemia . SubsequMDA5 is the closest relative of RIG-I, exhibiting 23 and 35% sequence similarities in the N-terminal and C-terminal domains, respectively . MDA5 wai for a common interaction site on MAVS, inhibiting NF-κB-dependent signaling pathway activation. Thus, LGP2 is proposed as a regulatory element of intracellular antiviral signaling  and share two structure similarities, a central helicase domain (responsible for intrinsic dsRNA binding and ATP hydrolysis functions) and a carboxy-terminal domain  which are involved in the detection of immunostimulatory RNAs , 2013. OSince host RNAs are present together with pathogen RNAs in the cytosol of infected cells, RLRs need to discriminate immunostimulatory pathogen RNAs from physiologically normal RNAs. Cellular mRNAs, often single-stranded and 5′-triphosphorylated, acquire a cap structure involving 2′-O- methylation (cap 1 or cap 2) in the cell nucleus following transcription . TypicalThe sensing and activation of RIG-I like receptors are not well understood, although much work has been done to elucidate RNA-triggered MDA5 activation. MDA5 forms filaments with a ring-like conformation around dsRNA in a sequence-non-specific manner . In addiIn vitro studies showed that LGP2 could affect dsRNA recognition and MAVS interaction of RIG-I and MDA5 and compete with IKK-i for recruitment to MAVS (–/– mice and mice harboring a point mutation in the LGP2 helicase domain (K30A) showed that LGP2 functions as a positive regulatory factor and enhances RIG-I- and MDA5-mediated antiviral activity  play an important role during this process, including phosphorylation, ubiquitination, ISGylation, acetylation, and other less well-studied modifications . Among tTRIM25 is the first E3 ligase identified for CARD-mediated signaling activation of RLG-I. Subsequent studies also showed that modification of RIG-I by TRIM25 is also influenced by several other host factors . The mitSeveral deubiquitinating enzymes have been demonstrated to function in the RLRs activation process. If the K48-linked ubiquitin chains are eliminated, it will promote signaling activation, such as the function of ubiquitin specific peptidase 4 (USP4) and ovarian tumor domain-containing ubiquitin aldehyde binding protein 1 (OTUB1) . ConversPhosphorylation of RLRs (extensively investigated in RIG-I and MDA5) mainly shows inhibitory effects on their activation. Phosphorylation on CARDs (at S8 and T170) and the CTD (at T770 and S854/855) of RIG-I and on MAD5 (at S88 and S828) suppresses the activation of these sensors, if not all, most of which are removed during their activation . DynamicFunctions of the cytoplasmic DNA sensor, cyclic GMP-AMP synthase (cGAS) during the infection of several DNA viruses have been exclusively investigated . InteresIn physiological conditions, cytoplasm DNA existence should be avoided. Nevertheless, under some circumstances, such as autoimmune responses or virus infection, host DNA and/or foreign DNA would be inappropriately delivered into the cytosol, and this DNA could be transcribed by cytoplasmically localized Type III RNA polymerase (RNAPIII) . Though In addition to being present and functioning in the cytosol, RNAPIII is also a nucleus resident who transcribes RNAs to activate RLR/MAVS signaling, as illustrated during Epstein-Barr virus (EBV) infection . After iThe importance of RNAPIII in controlling varicella-zoster virus (VZV) infection is revealed in a study showing that mutation in the RNAPIII machinery results in severe illness . FurtherAside from the immunostimulatory RNAs transcribed in the cytoplasm, transcripts of retrotransposons and pseudogenes from the host genome that can activate RLR/MAVS have also been identified in DNA virus infection. During murine gammaherpesvirus 68 (MHV-68) infection, SINE (short interspersed nuclear element) RNAs are rapidly transcribed by RNAPIII in the nucleus and activate the antiviral NF-κB signaling pathway through MAVS-dependent and independent mechanisms . HSV-1 iVault RNAs (vtRNAs) are another type of host small RNAs. They initially contain a 5′-triphosphate after being transcribed by RNAPIII, and the 5′-triphosphate moieties are removed by the cellular triphosphatase, dual-specificity phosphatase 11 (DUSP11), in uninfected cells resulting in the conversion of these RNAs to be non-immunostimulatory . During Although RLR-mediated innate immune response could elicit a robust immune response against incoming DNA viruses, these viruses have adopted multiple evasion mechanisms for counteracting and escaping such immune responses. RLR recognition of PAMPs, responsible for initiating antiviral signaling, is a target for these viruses. Damping of RLRs and host factors participating in RLR activation regulation in the signaling pathway is one of the key mechanisms for these viruses’ evasion. For example, EBV can promote RIG-I degradation through the proteasomal pathway by recruiting an E3 ubiquitin ligase, the carboxyl-terminus of Hsp70 interacting protein (CHIP) to the RIG-I through EBV-encoded LMP1 . Our preManipulation of post-translational modification of RLRs is another key strategy for immune evasion. As described above, reversed ubiquitination is an important step in regulating RLR signaling cascade. Many DNA viruses attenuate IFN response by altering the ubiquitination of RLRs and/or RLR-regulatory proteins through various mechanisms. Since the E3 ligase TRIM25 is a key activator of the RIG-I-mediated signaling pathway , many viIn recent years, the roles of activating the RLR/MAVS signaling pathway during DNA virus infection has been identified. However, the genome features of these DNA viruses are not readily for RLR recognition. Some of the viral transcripts and the unusual cellular RNAs (mislocated or unmarked) can be recognized and bound by RLRs, which could subsequently trigger an antiviral innate immune response that is proven to play an important role in controlling viral infections. Meanwhile, almost all these viruses have also developed individual strategies to escape RLR/MAVS-mediated antiviral response, which needs to be elucidated in the contexts of each virus infection (summarized in A large amount of studies in this field has been focused on elucidating mechanisms of immunostimulatory RNA ligands for RLR recognition, modification of key components of the RLR/MAVS pathway, and the evasion strategies usurped by the viruses. Additional studies for most DNA viruses have to be conducted to investigate whether RLR/MAVS signaling activation is a general phenomenon and the physiological roles of the signaling in the disease contexts. Furthermore, it is worth to clarifying whether and how RLR/MAVS signaling cooperates with other innate immune signaling.All authors listed have made a substantial, direct, and intellectual contribution to the work, and approved it for publication.JF is employed by Genor Biopharma Co., Ltd. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. 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Myelin oligodendrocyte glycoprotein (MOG) antibody disease has been recognised as a distinct demyelinating disorder. Optic neuritis has been reported as the most common presentation and manifestation of this spectrum disorder. This is a case series of three MOG optic neuritis patients. Patients involved are female with disease onset ranging between 7- and 37-year-old. Most of these patients experienced symptoms of profound reduced visual acuity with eye pain. All three patients had optic disc swelling upon first presentation and they experienced at least one episode of bilateral simultaneous optic neuritis. Only one patient had demonstrable optic nerve enhancement on magnetic resonance imaging (MRI). Disease was confirmed through positive MOG antibody. Patients typically responded well to intravenous methylprednisolone (IVMP) during acute attack of optic neuritis. However, one patient had suboptimal response to IVMP after multiple relapses. We noted multiple relapses of optic neuritis are common in MOG patients. MOG optic neuritis is a devastating, but treatable condition. Aggressive treatment during acute optic neuritis attack and relapse prevention may favour a good visual prognosis in MOG antibody disease. Myelin oligodendrocyte glycoprotein optic neuritis (MOG-ON) has a distinct clinical characteristic . TypicalCase 1A 7-year-old girl presented with reduced vision for three days with low-grade fever. There was pain on eye movement bilaterally with no symptoms of raised intracranial pressure. Visual acuity (VA) was 6/60 on the right eye (RE) and counting finger (CF) on the left eye (LE). Funduscopy showed a swollen and hyperaemic optic disc bilaterally. Systemic examination was unremarkable. MRI brain and orbit suggestive of bilateral optic neuritis with absence of associated brain parenchymal lesions Figure . A diagnCase 2A 37-year-old lady presented with three episodes of optic neuritis. The first episode was bilateral, and subsequently the left eye was affected. During the attacks, optic neuritis was associated with severe headache and pain on eye movement. The patient also had low grade fever and generalised fatigue. VA was CF on the RE and 2/60 on the LE on the first episode of optic neuritis. Funduscopy revealed bilateral hyperaemic and swollen optic disc. The patient was given a course of IVMP and her VA improved to 6/9 bilaterally. Subsequently, during another two optic neuritis episodes, her VA profoundly decreased. However, patient’s VA improved after being given IVMP. MRI of the brain and orbit showed normal optic nerves with no associated brain parenchymal lesion. Serology analysis showed positive anti-MOG antibody. Corticosteroids treatment was tapered down slowly and the patient subsequently started on oral azathioprine. During the follow-up after six months of the latest relapse, bilateral VA was 6/9 and optic disc appears pink and normal. She remains stable with no other neurological complain.Case 3A 19-year-old girl had a total seven episodes of optic neuritis. She was initially diagnosed with acute disseminated encephalomyelitis (ADEM) at the age of 10. After one year, she developed LE optic neuritis with symptoms of reduced vision and pain on eye movement with low grade fever. VA was hand movement (HM) on the LE, and 6/6 on the RE. There was marked LE optic disc swelling and hyperaemia. She was given a course of IVMP and her LE VA returned to 6/6. She was in remission for four years before developing another six episodes of optic neuritis within a period of three years. The initial four episodes of right eye optic neuritis responded well to IVMP treatment. She was put on Azathioprine after the third optic neuritis attack. Subsequently, she had bilateral optic neuritis and another one episode of RE optic neuritis. In those two episodes of optic neuritis, VA remains poor despite being given IVMP. MRI brain and orbit were normal, while anti-MOG antibody was noted to be positive. The patient was started on intravenous immunoglobulin (IVIG) and her VA dramatically improved. She was then put on maintenance oral Prednisolone and Azathioprine. She is currently in remission for two years. Her VA was 6/12 on the RE and 6/9 on the LE. Fundus examination showed pale optic disc bilaterally with cup disc ratio of 0.3. She remains stable with no other neurological complication.Table Incidence of MS and NMOSD has been widely reported world-wide -6. HowevMOG-AD is caused by damage of myelin oligodendrocyte glycoprotein, a membrane protein expressed on oligodendrocyte cell surfaces and on the outermost surface of myelin sheaths . All of Pain on eye movement and optic disc swelling on the first presentation are the striking features of MOG-ON in our patients. This corresponds to the previous report highlighting these two features as typical findings of MOG-ON -12. BilaIn MOG-ON, optic nerve enhancement in MRI tends to be longitudinally extensive with perineural enhancement, usually sparing the chiasm and optic tract ,11-12. OThe main principle of acute treatment in MOG-ON is to eliminate the systemic MOG antibodies . Prompt Poor VA was reported to be 16% (defined as VA of 6/36 or worse) to 36% (VA worse than 0.5) in at least one eye from previous studies of MOG-AD ,16. ThisMOG-ON affects young patients in our series, with high incidence of relapses. IVMP is generally effective in acute attacks, but multiple relapses may lead to treatment resistant and other treatment modalities such as IVIG or PLEX may be required. Long-term follow-up is important for MOG-ON patients, with prompt and adequate treatment as the key to attain a good outcome.