Anti-Indigenous racism is a widespread social problem in health and education systems in English-speaking colonized countries. Cultural safety training (CST) is often promoted as a key strategy to address this problem, yet little evidence exists on how CST is operationalized and evaluated in health and education systems. This scoping review sought to broadly synthesize the academic literature on how CST programs are developed, implemented, and evaluated in the applied health, social work and education fields in Canada, United States, Australia, and New Zealand. MEDLINE, EMBASE, CINAHL, ERIC, and ASSIA were searched for articles published between 1996 and 2020. The Joanna Briggs Institute’s three-step search strategy and PRISMA extension for scoping reviews were adopted, with 134 articles included. CST programs have grown significantly in the health, social work, and education fields in the last three decades, and they vary significantly in their objectives, modalities, timelines, and how they are evaluated. The involvement of Indigenous peoples in CST programs is common, but their roles are rarely specified. Indigenous groups must be intentionally and meaningfully engaged throughout the entire duration of research and practice. Cultural safety and various related concepts should be careful considered and applied for the relevant context. There is substantial evidence to suggest that anti-Indigenous racism is a widespread health and social problem in Canada. While the term, Indigenous, refers to a variety of Aboriginal groups around the world , in CanaBeyond the health sector, research evidence also points to widespread anti-Indigenous racism in Canada’s social work ,19 and KIn 2015, Canada’s Truth and Reconciliation Commission (TRC) recognized the legacy and impact of residential schools on Indigenous peoples across the country  and put Initiatives such as Canada’s TRC, along with similar federal government initiatives in Australia and New Zealand, have led to the emergence of new training programs to facilitate cultural safety and competence and, ultimately, to eliminate anti-Indigenous racism and discrimination in health, social work, and education systems ,25. HoweOur team sought to synthesize the academic literature that conceptualizes and/or operationalizes Indigenous cultural safety training within the fields of health, social work, and education. The aim of this study was to answer the following three questions: (1) What is the general state of knowledge on Indigenous cultural safety training in the applied fields of health, social work, and education? (2) What methods are used to develop, implement, and evaluate Indigenous cultural safety training for students and professionals in the applied fields of health, social work, and education? (3) What content themes are included in existing Indigenous cultural safety training program for students and professionals in the fields of health, social work, and education?Social Science Protocols doi.org/10.7565/ssp.2020.2815 [This study involved a scoping review that included the PRISMA extension protocol for scoping reviews (PRISMA-Scr) proposed by Tricco et al. . A detai020.2815 , an openWe reviewed the global academic literature on Indigenous cultural safety training that included but was not limited to Indigenous peoples in Canada. Inclusion criteria: This review was restricted to articles about Indigenous cultural safety in health, social work and education in British colonial settler nation states, including Australia, New Zealand, Canada, and the United States. All peer-reviewed primary research articles on the topic of Indigenous cultural safety within the fields of health, social work, and education that were reported in the academic literature between 1996 and 2020 were included. The review dates were selected to ensure that the full history of the term “cultural safety”, first coined in 1996 , was capTo identify potentially relevant literature in health, social work, and education, the following five bibliographic databases were searched from 1996 to 2020: Medline, EMBASE, CINAHL, ERIC, and ASSIA. These databases were selected to capture the fields of health, education, and social work as aligned with the focus of this review. The search strategies were developed by an experienced librarian at the university where the authors are affiliated and further refined through team discussion.A three-step search strategy  was utilThe selection of studies for this review was performed in Covidence independently by two reviewers and involved a four-stage process. The first stage of screening involved identifying and removing duplicate studies from Covidence. The second stage of screening involved reviewing the titles and abstracts of the remaining articles and applying the inclusion and exclusion criteria. Any disagreement between the two reviewers on applying the criteria was resolved through discussion.A data-charting tool was developed for this study with input from several co-authors and a librarian at the university where the authors are affiliated. The data-charting tool was developed in Google Spreadsheet, and several decisions were made to establish the focus, nature, and scope of data to be extracted, including (1) to cut and paste entire “chunks” of text verbatim into the tool rather than paraphrasing the data; (2) to include article page numbers associated with data on cultural safety concepts and critiques; and (3) to include both the study aim, along with the research question if explicitly stated and relevant to the study. The data-charting tool was then piloted by all members of the review team based on two pre-selected articles. Several procedural decisions were made during the pilot stage to further articulate the scope of data to chart, both for existing data points and for two new data points added during this stage. These decisions included (1) whether the paper included Indigenous authors or Elders; (2) identifying whether a data collection or evaluation tool was included or referenced; (3) specifying that “training modality” referred to the format  and “training components” related to the topics covered; (4) including only “yes” or “no” on four specific data points; (5) specify that “duration of time the training program has been running” was in relation to the study publication year; (6) adding “recommendations outlined in the article”; and (7) adding “stated limitations of the evaluation”.The data-charting process involved charting each article twice, and this was undertaken between August 2020 and June 2021. The first author independently completed one round of data-charting, and the second round was completed by a team of six reviewers independently. Several questions arose among the reviewers throughout the data charting process concerning the nature and amount of data to be extracted and charted, and these issues were generally resolved through discussion as a team. Any disagreements between two reviewers were resolved through dialogue or further adjudication by a third reviewer where necessary.The items included in the data-charting tool were developed deductively and addressed four main themes. The first theme included Article Characteristic for Indigenous cultural safety training for the sources of evidence included in the review, namely, bibliographic details; country of study; whether author(s) identified as Indigenous; study aim/objective(s); target field(s)/discipline(s) ; and target population . The second theme concerned Cultural Safety Concepts, Critiques and Rationale, which included cultural safety and related concepts either articulated or cited by study authors, along with critiques of the concepts, and the rationale given for why cultural safety is necessary in the fields of health, education, and social work.The third theme involved the Characteristics of Cultural Safety Training described in the sources of evidence. Data themes included who sponsored and developed the training program, whether Indigenous scholars and practitioners or knowledge keepers were involved in the development process, and the roles of community partners who were engaged. Other themes included who delivered and received the training program, along with details of the training program itself—such as the objectives, delivery modality, component descriptions, delivery duration and timeline, details of any post-program support, and the programs’ stated limitations. The fourth and final theme addressed Evaluation Details of Cultural Safety Training. These data involved the evaluation objectives, data collection methods, type(s) of data collected , evaluation results, stated evaluation limitations, recommendations for future cultural safety training programs, and whether a data collection tool was provided see .Once the data were charted, the data synthesis process was undertaken in three stages and carried out by three reviewers. The first stage involved analyzing both extractions of data for each theme to identify and resolve any discrepancies. All inconsistencies that were discovered were resolved through discussion and/or revisiting the sources of data where needed. The second stage involved analyzing data on the general characteristics of Indigenous cultural safety within the studies selected for the review, a process which involved categorizing the data within each data theme and then counting the frequency of findings within each category. The third stage involved synthesizing data that described a cultural safety training and/or the evaluation of a cultural safety training. The last stage involved synthesizing the data within each theme to create an overview of the data characteristics of Indigenous cultural safety, then categorizing the data within each theme into distinct groups and counting the frequency of findings within each category. Finally, the process of data synthesis also involved excluding or refocusing some of the data themes that were introduced in the protocol paper and proposed as part of this study. The reasons for these changes were varied and are set out in n = 126); (b) not peer reviewed (n = 36); (c) conference summary (n = 8); (d) duplicate content (n = 2); (e) literature review (n = 2); (f) not focused on our target professional groups (n = 2); (g) full text of article not found/available (n = 1); and (h) published before 1996. While 142 remaining studies were selected for inclusion, an additional eight articles were removed during the process of data charting because either the authors and content of these articles overlapped significantly with other selected articles (n = 3), or the paper involved Indigenous peoples’ review of a cultural safety training but did not focus on the targeted professionals or students and their experiences with the training (n = 5). Data from a total of 134 included full-text articles, including quantitative and/or qualitative research studies as well as expert opinion pieces, were extracted for this study , more than two-thirds mentioned the involvement of Indigenous peoples in the training development process  . Workshops , discussions sessions , and immersive experiences/community visits  were also common, detailed by an estimated quarter to approximately a fifth of relevant articles.Of the papers that described an Indigenous cultural safety training program . Also common among training modalities were clinical placements, case-studies, tutorials, and workbooks/readings, each of which were included as part of a tenth of interventions . Finally, Indigenous Elders/mentors/community supports , course-based modules , and group work  were each described by a few papers. The least common activities mentioned were drama/role-play exercises, and a visit to a gallery/museum, each mentioned by a couple of articles . Notably, eight papers (12%) described the provision of follow up support for learners of cultural safety beyond the primary training period.Following these modalities, storytelling/yarning reflective exercise/practice online content, and video/videocasts were each described by an eighth of chosen studies . Following this, in approximately one-sixth of selected articles, the training involved part of a one-semester undergraduate course (8–25 h) . The shortest training involved a one-off lecture/workshop/cultural visit, which was mentioned in an estimated one-sixth of articles , followed by a 1–5 week immersive experience in one of ten articles . The longest training experiences involved embedded content across a four-year bachelor’s degree  followed by training of 6–10 days/sessions, with each of these approaches occurring in one of ten articles . Three training durations, namely, 3–12 months of immersion, a one-semester undergraduate course (42 h), and a partial undergraduate course over two semesters (50–52 h), each occurred in an estimated one-fifth of papers . The two least frequent training timelines were included in one article each , namely, an intensive course over two semesters (148 h), and two years of content embedded in a health service organization. Nearly one in five articles did not include details on the duration of cultural safety training .With respect to the training timeline, the largest proportion of articles detailing a cultural safety training intervention described the training as lasting 1–5 days/sessions , and Indigenous Elders/mentors/cultural educators/community/organizations  were each mentioned in approximately one-third of relevant articles. University/college lecturers/educators delivered the training in an estimated one-fifth of articles , followed by researchers in approximately one in twenty-five articles . Allied health professionals and consultants were each mentioned in the context of training delivery in only a few articles . Two articles provided no details on who delivered the training, while one article described non-clinician health staff as responsible for training delivery. Finally, half of the articles that described cultural safety training reported that Indigenous people(s) were involved in delivering the intervention . Indigenous peoples involved in delivering cultural safety training includes both those categorized as “Indigenous Elder/Mentor/Cultural Educator/Community/Community organization” as well as those in other relevant categories listed immediately above.In terms of delivering cultural safety training interventions, university professors/administrators were mentioned in approximately twenty-five articles that described cultural safety training . Clinicians/clinical instructors  . The citations of these finding are included in n = 19; 31%) aimed broadly at understanding leaners’ general experiences, perceptions, needs, and/or preferences related to a cultural safety training in which they participated. Another paper similarly focused on understanding perceptions of a given training intervention but from the perspective of Indigenous community members rather than participants .Nearly one-third of papers selected for this review described an evaluation of an Indigenous cultural safety training intervention , and the new skills, behaviours, and/or practices that learners acquired . Similarly common, reported in nearly one-fifth of relevant papers, involved understanding learners’ new knowledge, awareness, attitudes, and confidence since the intervention . Other evaluation approaches included learners’ perceptions about Indigenous peoples and/or their health issues, as well as learners’ receptivity and/or resistance to intervention content, each mentioned in one intervention evaluation . A less common approach to evaluating cultural safety training interventions among the selected articles involved exploring processes, and specifically intervention planning and implementation processes , and leaners’ behaviour change processes . Another paper looked at the relationship between learners’ intervention participation (intervention exposure) and their perceptions of Indigenous peoples (the outcome). Finally, several papers considered the context wherein the training intervention was implemented, specifically, the organizational context as an enabling factor (n = 5), the impact of the training on organizational processes and priorities (n = 3), and new organizational policies, positions, capacity, and/or mandate related to the indigenous cultural safety training (n = 2). In terms of the methodological approaches adopted to evaluate cultural safety training interventions, just over half of relevant articles described utilizing both qualitative and quantitative methodologies . Another third of articles outlined the use of qualitative methods only , while approximately one in six papers used quantitative methods only as part of their intervention evaluations . A broad range of research methods was taken up to evaluate the influence and/or impact of cultural safety training interventions on participants. Data collection methods prior to the intervention involved pre-surveys , only four of which included open-ended, qualitative questions . Less common were pre-focus groups  and a pre-test . A small number of evaluation papers undertook observations/reflections half way through the interventions .Other common evaluation approaches involved exploring participants’ reports of learning experiences, outcomes, and/or barriers as intervention outcomes , while others also included open-ended qualitative questions  Participant interviews were also common following an intervention, also mentioned in a fifth of relevant articles . Oral or written learner feedback , and post-focus groups  were each mentioned in a tenth of papers describing a training evaluation, followed by learner reflections or case studies  and learner journal entries or digital storytelling , as described in a quarter of relevant papers. A post-test, talking circles, analysis of developed curriculum, and post-researcher observations/reflections were each mentioned in only one relevant study . Finally, a small number of relevant studies involved data collection after a period of delay following a cultural safety training intervention. These methods included a delayed post-survey undertaken at various stages between 3 and 55 months following the intervention , while a third paper described delayed learner reflections collected at 1–2 weeks following the intervention . Finally, of the papers that described a cultural safety training intervention, only approximately half of these papers presented the limitations of the methods chosen for the intervention evaluations .The greatest range of data collection methods occurred immediately following the intervention, with post-surveys being the most common approach, mentioned by two-thirds of relevant articles. A large proportion of these post-surveys focused only on quantitative data  concepts—reasons which overwhelmingly involved reducing disparities between Indigenous people and relevant settler populations on health outcomes  or education achievement (for education related papers). Data were also not presented in this paper on themes wherein the data were not described consistently across selected studies. This included themes such as description of training components, number of people who completed the training, and details of post-training supports provided. Similarly, data on who sponsored or developed the training intervention, as well as the duration of the training intervention and whether it was implemented in rural or urban settings, were largely incomplete, with a relatively small proportion of articles including fulsome descriptions for these themes. For its part, data on “the aim/objective” of the evaluation tended to be very general, including reasons such as “to evaluate a cultural safety training intervention”, which was therefore replaced with “evaluation focus”, which instead centred on the nature of data collected . Finally, the evaluation objectives and recommendation were not analyzed and included in this review because these data were rich in description, and synthesizing the findings would require undertaking content analysis, which the authors determined was beyond the scope of this review given the timeframe required to complete the study.This study sought to synthesize the state of knowledge on Indigenous cultural safety training in the applied fields of health, social work, and education. This paper sets out the broad range of approaches used to develop, implement, and evaluate these training programs, along with the substantive themes included in the trainings.This study found a significant growth in research about Indigenous cultural safety training in the three broad fields over the last few decades, and primarily within the last ten years. Half of the papers selected described cultural safety training, with the greatest share of these articles targeting the field of nursing/midwifery followed by medicine/physicians. This finding is unsurprising considering that nurses/midwives tend to comprise the largest share of the health service workforce, followed by physicians . The eduA substantial variety of training modalities was apparent in the training interventions, with teaching or lectures, workshops, and immersive experiences or community visits among the most common. Similarly, there was a huge range in the timeline or duration of cultural safety trainings. Interventions varied from several individual sessions to one or more months of immersive experience, to fully embedded content within a post-secondary course or throughout an entire undergraduate degree program. Even the actors who delivered the training ranged significantly, from university professors and health service clinicians, to lecturers, researchers, and consultants.There was little consistency in the objectives and methods to evaluate Indigenous cultural safety training interventions. Some evaluations focused on the experiences of learners and how they made sense of those experiences, while others looked at specific outcomes or processes (or the relationships between these two factors). There were also evaluations that considered the contexts within which the interventions were implemented and how these contexts influenced the interventions. Methodological approaches chosen for intervention evaluations also varied widely, including qualitative, quantitative, and mixed methods approaches. Most studies collected data after a cultural safety intervention, while fewer considered relevant data prior to, during, or following a delay after an intervention. Pre- and post-surveys were the most common method adopted (with some including open-ended questions), followed by interviews, focus-groups, and methods involving written reflections, case studies, journal entries, and/or storytelling. Notably, only half of the studies included set out the limitations of the methods chosen for intervention evaluations.Only a fifth of papers selected for this review included a named Indigenous author, while an estimated one-tenth of papers failed to specify even the broad Indigenous population relevant to the study . Moreover, while a substantial proportion of these training interventions involved Indigenous people(s) in the development processes, the specific roles they undertook were rarely mentioned. Similarly, approximately half of the training interventions involved Indigenous Elders, experts, and other community members in the training delivery process, yet how they contributed to the training vis-à-vis other actors involved was not clearly articulated. These findings highlight the need to ensure Indigenous voices are central to identifying and prioritizing the content and approaches to be included in Indigenous cultural safety trainings . MoreoveOnly half of the selected papers described and/or cited a cultural safety or similar concept. This is a somewhat surprising finding given that this review sought to understand the concept of cultural safety and how training interventions have attempted to facilitate its achievement. It is notable that many different concepts and definitions related to cultural safety emerged from the selected studies and were often used interchangeably. These concepts, in part, included cultural competence, cultural sensitivity, cultural responsiveness, cultural knowledge, cultural awareness, and cultural humility. Confusion related to these cultural concepts in selected studies was made worse by several factors, including (1) few attempts to justify why a given concept was chosen over another; (2) original sources for these concepts tended to not be clearly cited; and (3) little demonstrated understanding and contextualization of the literature wherein these concepts emerged. Similarly, and perhaps unsurprisingly given the current nascent state of this literature, less than a fifth of papers provided a critique of a cultural safety or similar concept.There is evidence to suggest there is some convergence around the geopolitical origins of two concepts, namely, cultural safety and cultural competence. Cultural safety emerged in New Zealand by a Māori nurse working within the health system at a time when the country was primarily bi-racial, comprising Indigenous peoples and Western European settlers . CulturaBoth academic research involving these cultural related concepts and training programs that seek to facilitate their development would benefit from considering, comparing, and contrasting the concepts set out by Baba . Not onlThe increased attention to cultural safety and related concepts has been fueled by national initiatives to address the historical injustices against Indigenous peoples. For example, Canada’s Truth and Reconciliation Commission’s Calls to Action (2015) set out the need for cultural safety training for healthcare professionals, and federal funding for post-secondary institutions and educators to establish national research programs in collaboration with Indigenous peoples to advance Reconciliation . A similThe main limitation of this study is that the data presented is somewhat dated. The article searches were undertaken in mid-2020, in the early stages of the COVID-19 pandemic, and with no dedicated research funding. New priorities to understand and address Indigenous peoples’ experiences with the COVID-19 became competing priorities with this study, and at a time when there was increased demand for Indigenous CST. As a result, our team used the preliminary findings from this review to prioritize the development of Oshki M’naadendimowin, a 36 h Indigenous cultural safety training program for faculty members, staff, and students at the Faculties of Medicine, Nursing, Social Work, and Public Health at the University of Toronto. For these reasons, combined with the large number of articles and data categories included in this review, we were not able to update the article searches to 2023. There is also the possibility that some relevant studies may have been missed due to the selection of databases or the exclusion of grey literature. The language skills of the researchers on the team also limited the searches to English publications, where French, Spanish, or Indigenous languages may have been used within the selected geographic regions. Furthermore, search terms for populations did not include Indigenous nation-specific names , and thus publications that did not use overarching terms such as Indigenous or First Nations may have been missed.This review presents the substantial work undertaken over the last three decades in Canada, Australia, New Zealand, and the United States to deliver Indigenous cultural safety training interventions to address anti-Indigenous racism and its historical legacy in national, publicly funded health and education systems. While the research findings from this review set out the substantive progress toward developing training interventions, this field of research remains in its infancy. Future research on cultural safety and related training interventions requires greater clarity in conceptualization of cultural related concepts, and more robust approaches to evaluate such interventions and identify which training strategies are most effective. Moreover, future work is required to identify how and when cultural safety and related concepts should be applied, and this is likely to vary across countries, regions, and relevant Indigenous groups.Finally, to advance future research and practice on Indigenous cultural safety, relevant Indigenous groups must be intentionally and meaningfully engaged throughout the entire duration of research and practice. A 2021 report published by the Yellowhead Institute on Canada’s progress toward reconciliation concluded that symbolic actions were being prioritized by the Canadian government over lasting permanent and structural changes necessary to transform the country’s relationship with Indigenous peoples . It is i


Am J Epidemiol. 2023;XXX(XX):XXX–XXX) document striking inaccuracies in pulse oximeter readings among Black patients, with significant clinical implications. Their findings suggest that this resulted in racial differences in delivery of evidence-based care during the coronavirus disease 2019 (COVID-19) pandemic, affecting admissions and treatment protocols. Despite the medical community’s growing awareness of the pulse oximeter’s significant design flaw, the device is still in use. In this article, I contextualize Sudat et al.’s study results within the larger history of racial bias in medical devices by highlighting the consequences of the continued underrepresentation of diverse populations in clinical trials. I probe the implications of racially biased assessments within clinical practice and research and illustrate the disproportionate impact on patients of color by examining 2 medical tools, the pulse oximeter and pulmonary function tests. Both cases result in the undertreatment and underdiagnosis of Black patients. I also demonstrate how the social underpinnings of racial bias in medical technology contribute to poor health outcomes and reproduce health disparities, and propose several recommendations for the field to rectify the harms of racial bias in medical technology.While medical technology is typically considered neutral, many devices rely upon racially biased algorithms that prioritize care for White patients over Black patients, who may require more urgent medical attention. In their accompanying article, Sudat et al. ( As a result, the use of medical technology increased significantly at home and in hospital settings. Medical staff relied on information provided by patients  and medical tools  to determine hospital and intensive care unit admissions and the distribution of supplemental oxygen therapies, including mechanical ventilation. While medical technology is typically considered neutral, many devices rely upon racially biased algorithms that prioritize care for White patients over care for Black patients, who may require more urgent medical attention.Journal documents striking inaccuracies in pulse oximeter readings among Black patients. The authors conducted retrospective cohort analyses using electronic health records and investigated pulse oximetry measurements of oxygen saturation in self-identified non-Hispanic Black and non-Hispanic White patients. They found that differences in oxygen saturation measurements influenced hospital admissions, treatment delays, health-care delivery, and hospital readmission rates in both patient groups. They found that oximeters overestimated oxygen saturation measurements for Black patients, influencing care, and adding to the literature documenting admission and treatment delays, inequitable health-care delivery, and disparate hospital readmission rates.The article by Sudat et al.  in this It is critical to examine the totality of how technology is used in clinical encounters to produce and reproduce health inequities. Our reliance on biased instruments and measurements has led to errors, including our ability to detect hypoxia effectively. This has several implications for patients, including treatment delays and unnecessary intubation . OximeteIn this commentary, I contextualize Sudat et al.’s study results within the larger history of racial bias in medical devices. Specifically, I describe pulse oximeter devices and then provide historical and social context by highlighting the roles of the Food and Drug Administration (FDA), the National Institutes of Health (NIH), and the continued underrepresentation of diverse populations in clinical trials. I probe the implications of racially biased assessments within clinical practice and research and illustrate the disproportionate impact on patients of color by examining 2 medical tools, the pulse oximeter and pulmonary function tests. Both cases result in the undertreatment and underdiagnosis of Black patients. I also demonstrate how the social underpinnings of racial bias in medical technology contribute to poor health outcomes and reproduce health disparities, and I propose several recommendations for the field to rectify the harms of racial bias in medical technology.As of September 2022, over 1 million patients had died from COVID-19 in the United States . ResearcThe concepts of race, genetics, and skin tone are not synonymous. “Race” is a social and political construct with no inherent biological or genetic basis. Furthermore, it does not accurately reflect skin hue, pigmentation, or human biological diversity . Racial emanated from American chattel slavery, where individuals such as Cartwright endorsed ideas that “lung capacity” deficiencies existed in Black bodies and that race was an essential biological factor  whether a patient should receive supplemental oxygen and 2) the amount of oxygen a patient should receive. These devices are used to evaluate many conditions, including asthma, pneumonia, anemia, congenital heart disease, and lung cancer , and thePulse oximeter inaccuracy is a global concern. Oximeter measurement errors harm Black patients and all patients with darker skin tones. While Sudat et al. exclusively considered non-Hispanic White and non-Hispanic Black patients , other sInaccuracies in the measurement of fingertip oxygen saturation have been made apparent since the 1970s  Figure . In 1987Two significant responsibilities of the FDA include “protecting the public health by assuring the safety, efficacy, and security of human and veterinary drugs, biological products, [and] medical devices”  and “helThe NIH and FDA work in concert to “[advance] public health by promoting the translation of basic and clinical research findings into medical products and therapies” . The NIHStill, in 2023, most medical devices in the United States are tailored for White bodies. For example, other devices, including forehead thermometers and tools for identifying veins, may also be inaccurate for patients with more melanin, documenting inaccuracies in output measurements . Both weRecently, the FDA announced plans to change pulse oximeter standards, and it launched several initiatives to improve strategies for better calibrating the device to perform equally across all skin tones and to promote diversity within clinical trials on the device . HoweverEpidemiologists are well positioned to investigate the processes that create and sustain racial bias within our larger societal systems, interpersonal interactions, and the tools used within medicine. The work to eliminate bias from the clinical encounter requires assistance at all levels. On a large scale, researchers have explored how bias influences health outcomes, such as the influence of residential segregation and discriminatory housing policies . On an iConsidering the large-scale impact on patients with darker skin tones, we must assess regulations and policies concerning the manufacturing, testing, marketing, and distribution of pulse oximeters. The FDA must require sufficient skin tone representation in their new guidelines to allow for sufficiently powered statistical tests. We must continue to evaluate the impact on patients and the potential impact on various clinical outcomes, including morbidity, mortality, and overuse or underuse of procedures  for different patients. Designing inclusive tools improves health-care quality for all. A commitment to diversity and inclusion will support novel strategies to remove and avoid bias within future medical tools and practices.Measurement inaccuracy is not only a clinical issue but a public health crisis; precision is vital in all research designs. Misclassification error and measurement error compromise reliability and validity; this raises concern about pulse oximeter measurements overall. Given the limited representation and testing, the medical community, researchers, and consumers should be cautious about these measurements. Leading scholars like Dr. Ellis Monk are investigating new ways to expand technology’s color palette. The Monk Skin Tone Scale expands the Fitzpatrick Scale and includes a more inclusive index of scales . AdditioEpidemiologists and the public health community can contribute to rectifying racial bias in medicine by considering essential questions: Consider the social and historical context of data collection practices .Assess your definition and measure of “race” and “ethnicity.”Investigate the original use of race in secondary data .Examine the impact of flawed data in real-world applications .Incorporate an equity lens in research design .Diversify research design at all stages .As a society, we often believe that technology is benign and neutral; as health practitioners, that our tools are benevolent. On the contrary, many medical devices are racially biased and carry a strong legacy of racism. Historically marginalized groups suffer disproportionality from the remnants of racist policies and structural forms of racism . Sudat et al.’s novel approach to assessing oxygen saturation emphasizes the critical need to redesign medical devices. Biased tools can misrepresent disease severity and threaten overall health-care quality. As the COVID-19 pandemic continues, scientists, clinicians, epidemiologists, medical practitioners, the NIH, the FDA, and other members of the medical device community must address their role in creating a healthier world, and explicitly improving the accuracy of pulse oximeters is an essential first step. This includes an intentional evaluation of the multidimensional components of bias in health care and clinical practices and investigation of the intersections between race, structural racism , and health outcomes. Racially biased tools and inaccuracies within pulse oximeters and pulmonary function tests are not random but are products of racialized historical policies, statistical errors, and research design flaws.


To conduct a systematic review of nanoparticles’ use in the treatment of prostate cancer in animals.A systematic review was conducted in the databases PubMed, Scientific Electronic Library Online (SciELO), Latin American and Caribbean Health Sciences Literature (LILACS), Cochrane Library, and EMBASE, and the descriptors were chosen based on terms indexed in Health Sciences Descriptors (DeCS)/Medical Subject Headings (MESH), which are: nanoparticles, nanomedicine, and prostate cancer. The systematic review protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO) with ID CRD42021271008.A total of 3,897 articles was chosen; after reading the inclusion and exclusion criteria, six scientific articles with themes involving nanoparticles carrying medications were reached. Among the nanoparticles found, there were carboxymethylcellulose polymer, micellar casein nanoparticles, liquid crystal nanoparticles, serum albumin nanoparticles, and poly(ethylene glycol)-block-polylactide (mPEG-PLA) conjugated nanoparticles encapsulating cabazitaxel, docetaxel, and flutamide, which were nanoparticles used to treat prostate cancer in animals.Through using nanoparticles to encapsulate medications for treating prostate cancer in animals, studies show a decrease in weight and tumor reduction, with nanoparticles resulting in greater survival time than free medications. The improved permeability and retention effect of nanoparticles in the bloodstream contribute to their effectiveness. Cancer is a major public health issue; in 2018, approximately 18 million new cases of cancer were registered worldwidePCa is a solid tumor that has permeable tumor vessels due to irregular neovascularization, which facilitates the treatment and targeting of drugs with nanoparticles (NPs) due to the permeability and retention effect (PRE). NPs with sizes of 100–200 nm are ideal for reaching solid tumors by PRE without being eliminated, and they also exhibit fewer adverse effects and better therapeutic responses when compared to conventional chemotherapeuticsTaking into account technological advancement and tumor treatment alternatives, nanoparticle-based targeting and delivery systems have demonstrated beneficial effects in cancer treatmentThe use of NPs in the development of effective actives for biological targets with controlled release increases bioavailability without changing distribution or absorption. Efficiently developed formulations can reduce toxicity risks, and treatments can be administered via a variety of routes, including oral consumption, inhalation, intravenous, and subcutaneous injectionThe proposal was to conduct a systematic review based on in-vivo animal studies on the use of medications and NPs in the treatment of PCa in order to improve existing studies and provide new insights for clinical studies.The systematic review protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO) with ID CRD42021271008, and the research design was carried out according to Review of Data from Experimental Studies in Animals (CAMARADES)This review was created and carried out to answer the following question: what are the advantages of using NPs and drugs in the treatment of animal prostate cancer? The PICO strategy was used to formulate the question, as follows:P: animals (rats and mice) inoculated and induced for prostate cancer;I: treatment with NPs and medication;C: animals given free medicine and saline solution;O: Primary outcome: efficacy of treatment using NPs and secondary outcomes–tumor regression, animal weight loss, underlying organ toxicity.Based on the question and the PICO strategy, the inclusion and exclusion criteria were developed. The criteria for inclusion was: scientific papers published in any language that described the use of drugs and NPs to treat PCa in animals . The criteria for exclusion were:Pre-2010 publications;Literature reviews, letters, case reports, theses, book chapters, abstracts, in-vitro studies, and human studies;Herbal medicine studies;PCa diagnosis studies.The databases used for the research were Medical Literature Analysis and Retrieval System (MEDLINE), Scientific Electronic Library Online (ScieLO), Latin American and Caribbean Literature in Health Sciences (LILACS), and Virtual Health Library (BVS Brasil). Nanoparticles, nanomedicine, and prostate cancer were used as descriptors.The initial search strategy included the following different terms: “Nanoparticle”, “Nanomedicine”, “Prostate cancer”, “Cancer”, “Prostatic Neoplasms”, “Nanoparticles AND Prostatic Neoplasms”, “Nanoparticle OR Nanomedicine AND Prostatic neoplasms”, “Nanomedicine OR Nanoparticle AND Prostate Cancer”, “Nanotherapy OR Nanoparticle AND Prostate Cancer”, “Nanoparticle OR Nanotherapy AND Prostate Cancer”, “Nanoparticle OR Nanomedicine AND Prostate Cancer”, “Nanoparticle OR Nanotherapy AND Prostate AND CANCER”, “Nanoparticle OR Nanotherapy AND Prostate CANCER”, “Nanoparticle AND Prostate AND Cancer” e “Nanoparticle AND Prostate Cancer”.The Intelligent Systematic Review (RAYYAN) tool was used to assist researchers in screening and selecting articles for study selection. Based on the inclusion and exclusion criteria, two researchers independently analyzed the selected articles. Duplicate articles were excluded in the first phase, and titles and abstracts were read individually and blindly. The articles were read in full in the second phase, and the differences in study selection were discussed between both.To assess the risk of bias in each study, the Systematic Review Center for Laboratory Animal Experimentation (SYRCLE) tool was used. This tool was adapted from the Cochrane Collaboration RoB Tool, which evaluates randomized controlled trials. The SYRCLE tool was modified to accommodate randomized controlled trials and interventions in animal studies. The tool includes 10 entries on selection bias, performance bias, detection bias, and attrition bias. Answers to judgments are “yes” for low risk of bias, “no” for high risk of bias, and “unclear” for insufficient data. Two researchers answered the questions independently, and there were no disagreements.The methodology used in the studies was heterogeneous, and it was not possible to determine the relative data of each study; thus, no data meta-analysis was performed.There were 3,897 articles chosen, including 51 from the Cochrane Library, 246 from Lilacs, two from SciELO, 772 from PubMed, and 2,826 from EMBASE. Before screening, duplicate articles (n = 525), systematic review articles (n = 10), literature review articles (n = 12), meta-analyses (n = 3), and other articles that researched animals other than the focus of the systematic review, such as dogs (n = 11), swine (n = 7), fish (n = 6), and rabbits (n = 4), were excluded. There were 3,319 articles in the screening selection. Following the inclusion and exclusion criteria, 21 articles were read in full after reading the titles and abstracts. The NPs and medications used in these studies were actively directed, linked to receptors, or even natural treatments unrelated to the proposed theme, so 15 articles were excluded, leaving six articles for the study .The selected studies’ characteristics were consistent with the chemotherapeutics utilized; three trials used cabazitaxel (Cbz), two used docetaxel (DTX), and one used flutamide (FLT). All medications were nanoparticle-coated with the goal of treating rats and mice generated with PCa or those with drug resistance. All the developed NPs had diameters larger than 5 nm and less than 200 nm. The size limit of the NPs allows them to target tumors through permeability and retention effects, and they were given intravenously in most of the included studies, except for one, which compared the use of taxotere and liquid crystal nanoparticle (LCNP)/DTX intraperitoneally and intravenously. In terms of experimental design, the animal model studies were heterogeneous due to the medication employed, the administered dose, the duration of the investigation, and the induction of PCa in the animals. Four of the six selected studies observed tumor growth after injecting PC-3 PCa cells subcutaneously into the flanks of animals. To assess drug resistance, one study inoculated Du-145 human PCa cells subcutaneously into the flanks of healthy ICR mice, and two studies inoculated PC-3 cells and C4-2BRES cells directly into the bone marrow. In another study, the hormone androgen was used to induce PCa in animals, and prostate-specific antigen (PSA) levels were measured to substantiate the presence of the protein in the animals’ blood.The studies showed that the drugs carried by the NPs released more slowly and had a greater capacity for accumulation in tumors. During the treatment period, the average tumor size and weight of the animals were monitored, and reduction in tumor size was observed with the use of NPS and medications. Among the six articles selected, four examined the antitumor activity and the risks of adjacent organ toxicity, with the liver being the most reported. It was also observed that the animals in the control group lost less weight than those receiving free medication.DTX was used in combination with two different NPs (carboxymethylcellulose–Cellax and LCNP) in two models of PCa (mice inoculated with PC-3 resistant and another model inoculated with PC-3), only one dose of Cellax/DTX completely regressed a castration-resistant PCa in 120 days, demonstrating low adverse effects and drug resistance in addition to increasing survival in cases of metastasis. Both native DTX-treated mice and control mice exhibited bone stasis. Similarly, when analyzing the mean tumor volumes, LCNP/DTX demonstrated a superior effect on tumor regression compared to the free drug.Taxotere was administered intraperitoneally and intravenously in conjunction with LCNP. When administered intraperitoneally, LCNP/taxotera demonstrated less antitumor activity than when administered intravenously, which effectively decreased tumor volume. In contrast, FLT associated with casein (CAS) micelles demonstrated superior antitumor activity in an androgen-dependent model of PCa induced with cyproterone acetate and testosterone, reducing tumor proliferation, controlling tumor angiogenesis, and increasing tumor apoptosis with decreased hepatotoxicity compared to free medication.4k-PLA4k-Cbz, Cbz-NPs, and Cellax-Cbz) and tested in three different xenographic models , demonstrating an increase in tumor development inhibition and toxicity reduction. When combined with Cellax (Cellax-Cbz), it demonstrated a remarkable ability to direct drug release directly into the tumor with minimal accumulation in normal tissues, thereby increasing the survival of mice with PCa and bone metastases, even in chemotherapy-resistant tumors.Cbz was combined with three different NPs (mPEGPolylactic acid (PLA) and poly(ethylene glycol) (PEG) are the most commonly used synthetic polymers. Both are used together (MPEG-PLA), and, when combined with other polymers, they produce remarkable molecular carriers that can be administered in aqueous or lipid mediaThe studies that used NPs conjugated to PEG obtained promising results in directing the NPs into target cells without exposing other tissues or going through the endothelial reticulum system’s opsonization mechanismThe same NPs of MPEG-PLA encapsulating cisplatin were evaluated in a study for the treatment of ovarian cancer, observing the toxicity presented by the animals due to the use of different doses. The mortality rate of the animals treated with NPs and cisplatin at 100 mg/kg was 40%, and, when compared to the use of free cisplatin at 10 mg/kg, it was 62.5%. As a result, using NPs loaded with cisplatin at higher doses is safer for clinical useAlbumin has the highest concentration of plasma proteins in the body and, due to its high solubility, it is an excellent drug carrier for tumor cells. DTX-NPs constructed by using human serum albumin (HSA) demonstrated that these NPs can offer promising anti-tumor activity with low systemic toxicityIn most preclinical studies, the intravenous route is the preferred method of chemotherapy administration. Bioavailability is measured by the percentage of the drug that is absorbed in the body, and this information can be used to determine the appropriate doses for treatments and characterize the benefits and side effects that the drug has on the bodyOur results showed one preclinical study in which effective encapsulation LCNP with stable drug release were developed. Two separate studies were conducted, with study 2 correlating the findings of study 1. Both studies investigated the use of LCNP/DTX, as well as free taxotere. Taxotere, on the other hand, was administered intraperitoneally in study 1, as opposed to intravenously in study 2. Even when administered differently, free taxotere had a lower antitumor effectA nanoparticle prepared from CAS, a milk protein that facilitates drug release due to its amphiphilic property, can involve different drug properties, such as hydrophobic or hydrophilic drugs, in addition to being cheap and easily accessible, biodegradable, and non-toxic to the bodyThe use of drugs for long periods can cause high toxicity and resistance to treatment. With that in mind, two selected studies in this systematic review, with the intention of inhibiting tumor activity in mice resistant to castration, tested Cellax, a conjugate of polymer-DTXIn general, when compared to free drugs, all studies that passively directed drug-bound NPs to tumor tissue via the PRE demonstrated significant therapeutic efficacy. This is possible because chemotherapy drugs with low molecular weight are rapidly eliminated by renal glomerular filtration. The use of nanocarriers in combination with chemotherapeutics extends the pharmacokinetics and, as a result, increases bioavailability. When incorporated drugs are used, animal survival and tumor reduction are higher than when free drugs are used,,We can observe the effectiveness of NPs in different treatments, as seen in three studies selected for this systematic review, in which the polydispersity index (PDI) was used to evaluate particle uniformity, required due to the results of cell uptake by endocytosis. The PDI results were favorable for all the researchers’ NPs developed for the treatment of PCa, with an index close to 0,Numerous doses of chemotherapy are used to treat cancer, as long as there is no toxicity due to the maximum tolerated dose. Pre-clinical studies can confirm the link between drug doses and tumor reduction and weight loss in animals. Determining the maximum tolerated dose in preclinical studies aids in the evaluation of the initial doses of treatment used in humans while taking side effects into accountCarboxymethylcellulose-based NPs loaded with DTX were employed in in-vivo models for the treatment of breast cancer, yielding promising outcomes. The administration of free DTX was conducted at the maximum acceptable dose, but Cellax-DTX was delivered at a dosage three times greater, resulting in notable efficacy in the treatment. Specifically, Cellax-DTX exhibited a 90% suppression of tumor development. The researchers reached the conclusion that, like the treatment of PCa, the administration of higher doses of chemotherapy medications can be employed in a safe manner for the treatment of mice afflicted with breast cancer,,Notably, the most favorable outcomes in terms of tumor disappearance were observed when utilizing NPs in conjunction with chemotherapy,The efficacy of a combination of cisplatin and DTX encapsulated with LCNP linked to folate in targeting cancer was evaluated in a study for the treatment of breast cancer with bone metastasesDifferent formulations of NPs encapsulating hydroxycamptothecin modified with menthol were used in the treatment of mice with glioma and compared to the use of free medication. The results were also promising when encapsulated medications were used, with animals surviving 1.5 times longer when treated with CAS and menthol NPs. The organs  were removed and stained with hematoxylin and eosin for histological analysis, and no significant damage was found. According to the researchers, the menthol-linked nanocarriers have excellent tumor penetration capacity and low systemic toxicity, extending the average survival of the mice in the study,,,When female mice with metastatic breast carcinoma were treated with Cellax (170 mg/kg DTX) versus abraxane (170 mg/kg paclitaxel), 85% of mice treated with abraxane developed pulmonary metastasis, while 40% of mice treated with Cellax had some pulmonary nodules. Furthermore, abraxane treatment resulted in severe toxicity with metastasis , whereas Cellax treatment resulted in no metastasisDuring conducting this systematic review, some limitations were discovered. There are few clinical trials involving the use of NPs and chemotherapy for PCa treatment; additionally, there was heterogeneity in the studies used; the NPs had different properties; the dose concentrations and administration times were not the same; and these variations hampered the performance of a meta-analysis.By considering the 3Rs in the context of this systematic review, researchers can promote ethical practices and foster a more responsible and compassionate approach to animal studies in the field of PCa treatment using NPs. In addition to assessing the efficacy of nanoparticle treatments and identifying the elements that lead to good outcomes using fewer animals in research without sacrificing the validity of the results, researchers can improve their experimental techniques to increase animal welfare and minimize any potential harmful effects on animals.This systematic review highlights the advantages of using NPs to encapsulate medications for treating PCa in animals. Studies show a decrease in weight and tumor reduction, with NPs resulting in greater survival time than free medications. The improved permeability and retention effect of NPs in the bloodstream contribute to their effectiveness.


Virtual and augmented reality (VAR) represents a combination of current state-of-the-art computer and imaging technologies and has the potential to be a revolutionary technology in many surgical fields. An increasing number of investigators have developed and applied VAR in hip-related surgery with the aim of using this technology to reduce hip surgery–related complications, improve surgical success rates, and reduce surgical risks. These technologies are beginning to be widely used in hip-related preoperative operation simulation and training, intraoperative navigation tools in the operating room, and postoperative rehabilitation.With the aim of reviewing the current status of virtual reality (VR) and augmented reality (AR) in hip-related surgery and summarizing its benefits, we discussed and briefly described the applicability, advantages, limitations, and future perspectives of VR and AR techniques in hip-related surgery, such as preoperative operation simulation and training; explored the possible future applications of AR in the operating room; and discussed the bright prospects of VR and AR technologies in postoperative rehabilitation after hip surgery.We searched the PubMed and Web of Science databases using the following key search terms:  AND (“pelvis” OR “hip”). The literature on basic and clinical research related to the aforementioned key search terms, that is, studies evaluating the key factors, challenges, or problems of using of VAR technology in hip-related surgery, was collected.A total of 40 studies and reports were included and classified into the following categories: total hip arthroplasty, hip resurfacing, femoral neck fracture, pelvic fracture, acetabular fracture, tumor, arthroscopy, and postoperative rehabilitation. Quality assessment could be performed in 30 studies. Among the clinical studies, there were 16 case series with an average score of 89 out of 100 points (89%) and 1 case report that scored 81 (SD 10.11) out of 100 points (81%) according to the Joanna Briggs Institute Critical Appraisal Checklist. Two cadaveric studies scored 85 of 100 points (85%) and 92 of 100 points (92%) according to the Quality Appraisal for Cadaveric Studies scale.VR and AR technologies hold great promise for hip-related surgeries, especially for preoperative operation simulation and training, feasibility applications in the operating room, and postoperative rehabilitation, and have the potential to assist orthopedic surgeons in operating more accurately and safely. More comparative studies are necessary, including studies focusing on clinical outcomes and cost-effectiveness. Currently, there is consensus on the precise definitions of virtual reality (VR) or augmented reality (AR). Milgram et al  created Virtual and augmented reality (VAR) technology is an emerging surgical technique that can enhance orthopedic surgeons’ competence by intuitively reinforcing medical information . In thisThe average age at the time of hip fracture is 80 years, and the lifetime prevalence of hip fractures is 20% in women and 10% in men . OsteoarHence, the aim of this review was to determine the use of VR and AR techniques in hip-related preoperative operation simulator and training, postoperative rehabilitation, and feasibility applications in the operating room.The PRISMA  guidelines (refer to Two independent reviewers (PS and YZ) systematically searched the PubMed and Web of Science databases using the following key search terms:  AND (“pelvis” OR “hip”). We believed that these databases would be appropriate because of the number of indexed journals and the coverage of related disciplines, such as bone and joint, clinical medicine, and computer science. When selecting academic databases, we also considered the flexibility of their search engines (for combining search terms) and the ability to export the results to a format accepted by the reference management software. Two investigators (PS and YZ) independently conducted literature screening based on the titles and abstracts of the studies. When the information in the titles and abstracts was not sufficient, we reviewed the full text to decide whether to include or exclude the studies. The reference lists of the included studies and existing reviews on the topic were screened to identify additional eligible studies. Any disagreement in the study selection process was resolved by a full discussion, and a third reviewer (JM) was consulted if a consensus could not be reached.A review of the use of VAR technology in hip surgery is presented, with an emphasis on the evaluation of the necessity, advantages, and limitations of trials investigating the application of VAR technology in hip-related surgery. We also discuss the advantages of and potential barriers to VAR simulation training as compared with conventional training simulations and its future development and specifications.The literature inclusion criteria were as follows:Basic and clinical research related to the aforementioned key search terms, that is, studies evaluating the key factors, challenges, or problems of VAR technology in hip-related surgeryThe study type was a monograph, paper, guide, or reviewThe exclusion criteria were as follows:Studies that did not focus on hip or pelvic surgeryStudies that did not have human participantsStudies that did not focus on VR or ARStudies with low-quality or low-level evidenceStudies that did not resolve any of the aforementioned issuesA predesigned extraction form was used to extract the data. The extracted data included the name of the first author, type classification, visualization, preoperative simulation and training or intraoperative applications and postoperative rehabilitation, nature of the study, patients or diseases, intervention procedures, comparison measures, and outcomes. Disagreements in data extraction were resolved through discussions between the 2 investigators (PS and YZ), and a third reviewer (ZRM) was consulted if necessary. The quality of all the studies including real patients was then assessed using the Joanna Briggs Institute Critical Appraisal Checklist . A scoriUsing the aforementioned search strategies, we retrieved >630 potentially relevant papers published between 1992 and 2022. We identified a total of 22 studies on the application of VR in hip surgery ; 13 studies on the application of AR in hip surgery ; and 5 studies on emerging devices using VR and AR technologies. A schematic stepwise algorithm for the search strategy is shown in The first screening step was to eliminate duplicate studies using a software, which resulted in the exclusion of 364 papers. The second step was to exclude studies according to the exclusion criteria (n=211). We then assessed the eligibility of the studies based on their quality and excluded substandard studies (n=15). Finally, we included 40 studies.The included articles were published between 1992 and 2022. Each of these articles covered the implementation of VAR in a different procedure. The classification of VAR devices, visualization, nature of the study, patients or diseases, intervention, comparison, and outcome characteristics are presented in The quality assessment process could be performed in only 73% 30/40) of the studies, in which either human study populations or cadavers were evaluated. As such, of 40 studies, 5 (12%) studies included patients, and 2 (5%) described cadaveric results. Among the clinical studies, there were 2% (1/40) of case series with an average score of 85 out of 100 points (85%) and 16 (16%) case series with an average score of 89 (SD 10.11) out of 100 points (89%) according to the Joanna Briggs Institute Critical Appraisal Checklist (refer to /40 of thThe ROBODOC  is a robThe combination of advanced VR simulation technology and 3D visualization allows users to quickly and intuitively understand the results of implant placement in hip arthroplasty. Interactive feedback and intuitive control mechanisms help identify the optimal implant location for a given patient’s anatomy. The HipNav system developed by Digioia et al  remains Game-based surgical training is emerging as an educational tool for hip replacement and resurfacing because of the complexity of the spatial angulation involved and the lack of clinical theoretical studies on the location of the acetabular cup during acetabular cup placement. Edheads , a compaAcetabular subluxation often occurs after femoral neck impingement. Other potential adverse effects of early impingement include accelerated polyethylene wear, acetabular component loosening, and linear dislocation. Owing to the numerous potential adverse effects of early component impingement, it is advantageous to clarify the range of component motion before the components come into contact with each other. Kummer et al  designedThe purpose of the surgical treatment of pelvic fracture is to maintain the anatomical shape of the pelvis and restore its biomechanical characteristics. When reconstructing acetabular fractures, the basic principles of anatomical reconstruction, stable fixation of the articular surface, and immediate postoperative exercises should be observed. Cimerman et al  introducIliosacral screw placement is a useful technique for the fixation of posterior pelvic ring injuries. If the pelvic ring is broken, percutaneous iliosacral screw fixation can be performed in the supine position using computer imaging techniques -54. Thisthreat-free and unhurried environment. The system may be used in other orthopedic operations to learn technical skills and ensure the smooth upgrading of task complexity so as to improve the trainees’ performance of the actual operation in the operating room.The objective structured assessment of surgical skills provides a method for assessing the technical skills of students . AlthougFrom low-cost task trainers to complex VR solutions, the development of simulators in various surgical specialties has increased substantially. Recent technological advances have enabled the creation of realistic VR environments with tactile feedback. Synthetic bone simulators are the most commonly used simulators in orthopedic training but have considerable limitations: they usually do not simulate soft tissue or use real patient positioning . Racy etThe central step of the planning procedure for hip tumor surgery is to place the cutting plane in the hip bone, which largely depends on the location of the tumor. Segmentation of the tumor and bone in magnetic resonance and CT data and fusion of magnetic resonance and CT image sequences are necessary to visualize the location of the tumor in the hip. Handels et al  introducWith increasing applications in diagnosis and treatment, hip arthroscopy is one of the most rapidly evolving areas in modern surgery ,60. The The increase in the working time of orthopedic trainees and the priority given by the global modern medical system to patient safety have led to a decline in the surgical autonomy of surgical trainees. Therefore, training courses that emphasize the simulation of surgical skills outside the operating room have steadily developed. Bishop et al  assessedEarly rehabilitation after total hip arthroplasty is very important for proper functional recovery . HoweverPostoperative physical therapy for patients who underwent total hip arthroplasty is generally considered to be effective in reducing pain and disability. However, after hip replacement, the muscle strength, postural stability, balance, and gait speed of patients will affect the function and performance of activities of daily living. In addition, it has been reported that the weight load between the lower limbs changes, which increases the strength capacity of the hip joint–stabilizing muscle tissue and adversely affects the function of these patients. Zavala-González et al  exploredGiven the anticipated increase in the longevity and activity level of patients after total hip arthroplasty, the longevity of the prosthetic components used is critical. Accurate acetabular component positioning is essential to ensure good outcomes. Inaccurate placement may result in impingement, malposition, accelerated wear, loosening of components, and the need for modification. Alexander et al  used a rFor joint replacement, simulation training is typically performed on dry bones or cadavers. The former has low fidelity, whereas the latter has a high cost and requires an internal structure. Neither can objectively measure technology or 3D orientation skills . A MicroComputer-assisted orthopedic surgery offers obvious advantages for patients, with higher positioning accuracy and fewer outliers; however, its invasiveness, cost, and complexity limit its wide application. To provide seamless computer-aided, improved real-time imaging and a more natural surgical process, Liu et al  developePercutaneous screw osteosynthesis of pelvic fractures performed under conventional imaging guidance represents a challenge for even experienced surgeons . Befrui Percutaneous sacroiliac screw fixation is a widely accepted method for the treatment of posterior pelvic ring instability . CompareIn the past decades, the application of computer-aided navigation systems in preoperative planning has greatly reduced surgical risks and improved surgical accuracy . CurrentAcetabular fractures remain to be one of the most challenging fractures to treat because of the complex anatomy, difficulty in gaining surgical access to the fracture site, and the relatively low incidence of these lesions, resulting in a long learning curve ,69 OwingThe conventional surgical treatment method for pelvic and acetabular fractures requires complete exposure of the fractures and intraoperative implant contouring after intraoperative fracture reduction so that the reconstruction plate can adapt to the reduced pelvis. This invasive approach often leads to prolonged operation time and considerable injury and bleeding . Shen etExtracapsular fractures account for a substantial proportion of femoral neck fractures. Extracapsular femoral neck fractures can be treated using a fixed-angle sliding screw device, which is commonly referred to as a sliding compression or dynamic hip screw. However, the mechanical failure rate is as high as 20% -73. To oThe treatment of pelvic malignancies is a complex scenario for surgeons because in many cases, extensive resection is required, and there is a risk of damage to important structures. During these interventions, accuracy is crucial to minimize local recurrence and maximize limb function. However, when tumors are resected using conventional methods, the probability of obtaining a sufficient resection margin is only 52% . In compThe main findings of this study are as follows. First, VAR technology can perform these hip-related surgery steps very well, and the resulting surgery–related complications problems and the probability of poor prognosis of patients are greatly reduced. Second, the application of VR and AR technologies in hip-related preoperative operation simulation and training is perfect for determining the dimensions and the individualization of acetabular and femoral implants so that the most appropriate implants are used for each patient. Moreover, interactive and immersive experience can save time, decrease surgical risk and intraoperative radiation exposure, and reduce the chance of poor outcomes in total hip replacement surgery. Finally, the application of VR and AR technologies in the operating room and during postoperative rehabilitation will become a rapidly developing field in the future.VAR technology enables orthopedic surgeons to simulate operations outside the operating room, thereby allowing them to perform repetitive hand movement training in a safe environment. Several simulator models have been developed and studied, including high- and low-fidelity simulators, synthetic bench simulators, animal or human cadaver simulators, and VR simulators. The results of relevant studies ,80-82 haA paradigm shift is occurring in the teaching of surgical techniques. The conventional learning mode of apprenticeship training is not efficient and cannot achieve the integration of surgical techniques under varying circumstances. Total hip replacement is critically dependent on the surgeon’s skill and experience, and VR and AR techniques have great potential for rapidly improving the surgical skills required for total hip replacement. Cadaveric training has been the gold standard for surgical training for many years ,61. The However, a potential barrier to the use of VAR technology is the lack of interest in computers among surgeons, who still prefer to use textbooks and journal papers to correct or improve surgical techniques . TherefoSimulators are being increasingly used for evaluation and training in clinical learning, and VR and AR techniques are being widely used for procedures such as hip trauma and hip tumor surgeries. Nevertheless, training simulators for total hip replacement have lagged behind those for other surgical procedures. Therefore, creating simulators for procedures related to total hip replacement is warranted.The goal of hip surgery simulation is to improve the operator’s understanding of the anatomy and develop a good touch sensation. Training simulators allow for the repeated practice of surgical techniques before actual surgery, which helps surgeons deepen their visuospatial skills, that is, their visual perception of anatomical structures. Further studies are required to verify whether simulators reduce the odds of poor outcomes and improve the technical ability of trainees to perform actual operations. In addition, more research trials are required to develop simulators for total hip replacement surgery that will shorten the learning curve and increase trainee acceptance. Ideally, the technical skills derived from simulators should be easily transferable to the operating room, thus improving patient satisfaction and helping trainee surgeons accumulate more clinical experience. We believe that the ideal simulator for total hip replacement surgery should be multimodal and provide an immersive environment combining tactile, visual, and auditory cues.AR technology has successfully provided surgeons with a wide range of visual information about anatomical structures and assisted them throughout the operation. AR technology allows surgeons to view the surgical field through a superimposed 3D virtual model of anatomical details. Dennler et al  conducteAfter hip trauma or surgery, postoperative rehabilitation is essential to restore damaged functions . SuccessWe fully believe that VR has made great progress. With AR technology, simulations of alternative environments have been incorporated into rehabilitation therapy. Remote rehabilitation via virtual technology allows high-quality care to be provided at a low cost. In view of the growing demand for orthopedic rehabilitation and the increasing related costs, VAR technology will be increasingly applied in the physical rehabilitation of patients after hip surgery.Our systematic review has a few limitations. First, the review lacks a meta-analysis. It was not possible to conduct a meta-analysis because each article involved a different surgical intervention, making the group too heterogeneous. Second, we aimed to cover the use of VR and AR techniques in total hip replacement and reconstruction, hip trauma and fracture, and revision total hip replacement surgery. However, few of the included articles discussed hip tumor surgery simulators.We expect that in the future, more researchers will apply VR and AR technologies to hip tumor simulators for surgical training and preoperative simulation. The new generation of surgeons should be prepared and willing to adopt these new technologies. Through collaboration among experts in the fields of medicine, engineering, and gaming, we will be able to combine all these areas in the future to fundamentally improve the components of hip surgery.This systematic review suggests that VAR technologies have the potential to assist surgeons in performing surgeries faster and more accurately. Although VAR are promising modern technologies, more comparative studies on technical accuracy, operative time, clinical outcomes, and cost-effectiveness are necessary. Moreover, we expect future studies to demonstrate whether augmented technology is beneficial in the field of postoperative rehabilitation.


Pregnancy and postpartum-related mental health problems pose serious public health threat to the society, but worryingly, neglected in sub-Saharan Africa (SSA). This review will assess the burden and distribution of maternal mental health (MMH) problems in SSA, with the aim to inform the implementation of context sensitive interventions and policies.African Journals Online and IMSEAR will be searched from inception to 31 May 2023, without language restriction. The reference lists of articles will be reviewed, and experts contacted for additional studies missed by our searches. Study selection, data extraction and risk of bias assessment will be done independently by at least two reviewers and any discrepancies will be resolved through discussion between the reviewers. Binary outcomes  of MMH problems will be assessed using pooled proportions, OR or risk ratio and mean difference for continuous outcomes; all will be presented with their 95% CIs. Heterogeneity will be investigated graphically for overlapping CIs and statistically using the I2 statistic and where necessary subgroup analyses will be performed. Random-effects model meta-analysis will be conducted when heterogeneity is appreciable, otherwise fixed-effect model will be used. The overall level of evidence will be assessed using Grading of Recommendations Assessment, Development and Evaluation.All relevant databases, grey literature and non-database sources will be searched. PubMed, LILAC, CINAHL, SCOPUS and PsycINFO, Google Scholar, African Index Medicus, HINARI, Although no ethical clearance or exemption is needed for a systematic review, this review is part of a larger study on maternal mental health which has received ethical clearance from the Ethics Review Committee of the Ghana Health Service (GHS-ERC 012/03/20). Findings of this study will be disseminated through stakeholder forums, conferences and peer review publications.CRD42021269528. This study uses robust methods, best practices and reporting guidelines to attempt to synthesise evidence on the burden of maternal mental health problems in sub-Saharan Africa to provide country and regional-specific estimates.Screening of articles, data extraction and quality assessment will be done using validated tools by at least two independent reviewers to minimise bias.The study uses comprehensive search terms and strategy, and involves relevant electronic databases and non-database sources to attempt to retrieve all potentially relevant studies.A possible limitation is, there were no previous data to compare our systematic review to.Maternal mental health (MMH) problems, occurring during pregnancy and postpartum constitute a serious public health problem globally, affecting about 10% of pregnant women and 13% of postpartum mothers.The common mental health problems experienced by pregnant and postpartum women are depression and anxiety.25 26Mothers with mental health problems may not be able to realise their abilities, work productively or cope with the normal stresses of life.This review will assess the burden of MMH problems among pregnant and postpartum women in SSA and attempts to provide robust country and regional estimates of the burden of disease across countries in SSA. Specifically, it will determine the prevalence and incidence and describe the sociodemographic characteristics, general obstetric histories and characteristics of women with MMH problems; assess effects of MMH problems on birth outcomes and analyse for differences in the burden of mental health problems among pregnant and postpartum women between rural and urban settings. The review will answer the following specific questions: (1) What is the magnitude of MMH problems among pregnant and postpartum women living in SSA? (2) What are the sociodemographic characteristics of pregnant and postpartum women with mental health problems in SSA? (3) What are the general obstetric histories and characteristics of pregnant and postpartum women in SSA with mental health problems? (4) Is there any difference in the burden of pregnant and postpartum women with mental health problems between rural and urban settings? and (5) Are there any documented effects of birth outcomes of pregnant women with mental health problems?This review protocol has been prepared following the Preferred Reporting Items for Systematic Review and Meta-Analysis extension for protocols (PRISMA-P)10.1136/bmjopen-2022-069545.supp1Supplementary data10.1136/bmjopen-2022-069545.supp2Supplementary dataThe review questions and outcome measures have been developed collaboratively with the relevant patient and consumer involvement and informed by their priorities, experience and preferences in line with GRIPP2 reporting checklists. The review findings will be shared with relevant wider patient communities who will also be involved in the results dissemination.Any study  conducted in SSA that assessed burden of MMH problems among pregnant and postpartum women will be eligible for inclusion. This review is not an intervention effectiveness review and randomised controlled trials (RCTs) are not the focus but if a RCT reported baseline number of cases and used a well-defined sample to serve as the denominator to allow the calculation of proportion/prevalence/incidence in pregnant or postpartum women, such an RCT will be eligible for inclusion. Reviews will not be eligible for inclusion. However, we will go through the reviews to identify potentially eligible studies missed by our searches. If the study is a global review having, for example, SSA or subregional subset, we will extract the studies conducted in SSA for inclusion in this review. If the study reported a country or regional estimate without a well-defined sample (representative sample or subsample of the source population), it will not be eligible for inclusion. In cases where the results of a multicountry study have been lumped together and there is no way of disaggregating the data, such studies will not be included. Case studies and case series , commentaries or opinions, will not be eligible for inclusion.Pregnant and postpartum (postpartum is defined as up to 12 months after delivery) women living in SSA, diagnosed of any mental health disorder  will be eligible for inclusion. The tool or criteria for diagnosis should be stated, for example, standard operational diagnostic criteria such as Research Diagnostic Criteria (RDC),This systematic review is not intervention review.This is non-comparative review but where outcomes or variables permit comparison, we will attempt to compare.Burden of MMH problems measured as prevalence, incidence, etc.Birth outcomes  up to 12 months postpartumType of MMH conditions (for diagnosed cases)Proportion of MMH conditions captured in the communityPredisposition socio-demographic characteristics of pregnant and postpartum women with mental health problemsPredisposition obstetric histories and characteristics of pregnant and postpartum women in SSA with mental health problemsPsychiatric predisposition .Burden of mental health problems among pregnant and post-partum women between rural and urban settingsAfrican Journals Online, IMSEAR and relevant preprint repositories. Grey literature including dissertations and conference proceedings will be searched. Reference list of retrieved articles will be reviewed, and experts in the field of MMH will be contacted for studies not captured by our searches  independently using the appropriate ROB assessment tools. Since this review is not focusing on randomised controlled trials (RCTs), the domains on the Cochrane ROB tool10.1136/bmjopen-2022-069545.supp4Supplementary dataBinary outcomes will be assessed using OR or risk ratio (RR), and for continuous data, we will use mean difference (MD) or standardised mean difference (SMD) for means that used different scales. Meta-analysis, the statistical component of systematic review, will be used to combine study outcomes. OR, RR and MD of the individual studies will be pooled and presented with their 95% CI. Random-effects model will be used in the meta-analysis when heterogeneity is high, otherwise fixed-effect model will be used. Descriptive statistics will be used to describe proportions .2 statistic which describes the percentage of variability that is due to heterogeneity rather than chance will be estimated. The I2 is classified into four levels: 0%, 1%–29%, 30%–59% and 60%–100%2>50% indicates significant heterogeneity.Heterogeneity arises because of variation in the study design, characteristics of participants or outcomes between or within studies.guidelinedevelopment.org/handbook). The GRADE system assesses the following domains: ROB, imprecision, inconsistency, indirectness and publication bias, and classifies the quality of evidence as high, moderate, low and very low. If evidence from a study is graded high quality, it implies further research is very unlikely to change the confidence in the estimate of effect while a grading of very low quality implies an estimate of effect is very doubtful.The overall evidence of the systematic review will be graded using Grading of Recommendations Assessment, Development and Evaluation (GRADE)Although no ethical clearance or exemption is needed for a systematic review, this review is part of a larger study on MMH that involves primary data collection and which has received ethical clearance from the ethics review committee of the Ghana Health Service (GHS-ERC 012/03/20). The results of the review will be presented to stakeholders (policymakers and practitioners). It will also be disseminated through conferences and peer review publications.


Glioblastoma (GBM), a highly malignant glioma of the central nervous system, is the most dread and common brain tumor with a high rate of therapeutic resistance and recurrence. Currently, the clinical treatment methods are surgery, radiotherapy, and chemotherapy. However, owning to the highly invasive nature of GBM, it is difficult to completely resect them due to the unclear boundary between the edges of GBM and normal brain tissue. Traditional radiotherapy and the combination of alkylating agents and radiotherapy have significant side effects, therapeutic drugs are difficult to penetrate the blood brain barrier. Patients receiving treatment have a high postoperative recurrence rate and a median survival of less than 2 years, Less than 5% of patients live longer than 5 years. Therefore, it is urgent to achieve precise treatment through the blood brain barrier and reduce toxic and side effects. Nanotechnology exhibit great potential in this area. This article summarizes the current treatment methods and shortcomings of GBM, and summarizes the research progress in the diagnosis and treatment of GBM using nanotechnology. High grWith the rapid development of nanotechnology, a growing number of studies have used nanotechnology to provide new options for the diagnosis and treatment of GBM . NanoparIn this review, we will introduce and discuss the research progress related to nanomaterials as developed for precise diagnosis and precise treatment of GBM.2.in vitro, but it will be restricted by the blood brain barrier during systemic administration. PTX-PLGA nanoparticles coated with polyethylene glycol (PEG) can well stay in the blood circulation and increase their bioavailability.With the continuous development of nanotechnology, researchers continue to research and develop new nanoscale diagnosis and treatment strategies for GBM. In the diagnosis and imaging of GBM, compared to conventional enhancer imaging, nanoparticles can enhance contrast sensitivity, binding affinity, and targeting specificity. When combined with nanoparticles, drugs can cross the blood brain barrier, enabling the detection of lesions that are difficult to detect, and achieving precise diagnosis. During the treatment of GBM, the nanocarrier platform can not only transport small molecule drugs, but also transport macromolecular drugs such as proteins, polypeptides, and genes to actively or passively target GBM cells, achieving better tissue penetration through the blood brain barrier, better drug release, lower toxicity, and more precise treatment. Nanoparticles are made into drug carriers such as shells or cages to encapsulate chemotherapy drugs and specifically present them to GBM, greatly improving the therapeutic effect. For example, paclitaxel (PTX) has a good inhibitory effect on GBM 3.Precise diagnosis is an essential component to successful cancer treatment, and diagnosis is particularly challenging in the context of GBM due to its location deep in brain tissue. To achieve high sensitivity, high specificity, high resolution and deep tissue penetration, researchers are actively developing a variety of imaging techniques and contrast agents . The smaThe most commonly used medical imaging methods for GBM are magnetic resonance imaging (MRI), computer tomography (CT), and optical imaging. In order to improve the accuracy and sensitivity of imaging, contrast agents are usually needed. Nanomaterials are well suited for this role because they tend to have high loading capacities and low toxicity. They are also amenable to simple surface modifications that allow the preparation of multifunctional materials to create long-lasting and low toxicity contrast agents for multimodal imaging or simultaneous treatment and diagnosis . Accordi3.1.Magnetic resonance imaging (MRI) allows the imaging of biological tissues by measuring the interactions of radio frequency pulses with magnetic fields to generate images of internal organs . Its higin vitro, and mediated precise aggregation of nanoprobes at glioma sites in both in vivo MRI and ex vivo NIR fluorescence imaging. This strategy promises to improve preoperative precision imaging of GBM and to provide precise intraoperative display of GBM for real-time imaging.Any simple imaging method will have limitations, so it is necessary to find and develop multi-mode imaging with nanoparticles that can combine multiple imaging methods to diagnose GBM more accurately. For example, MnO NPs (nanoparticles) with excitation dependent fluorescence have been synthesized by thermal decomposition of manganese-based compounds to be used as nanoprobes for MRI imaging ; this ap3.2.Electronic computed tomography (CT) is relatively inexpensive, yet it has a high resolution and wide application range. Related applications include single electron emission computed tomography SPECT; , positroin vivo, more obvious contrast effect, and a stronger imaging ability (in vitro and in vivo targeted SPECT/CT imaging and radionuclide therapy of glioma cells in subcutaneous tumor models (X-ray (CT) involves irradiation of the body with X-ray, and it images the differential resistance of different tissues to X-rays . Since t ability . These p ability . These pr models . This na3.3.Photothermal therapy (PTT) uses photothermal converters accumulated in a tumor to absorb light energy and generate heat that ablates tumor cells. Photothermal nanoprobes can realize fluorescence, photoacoustic and infrared thermal therapy as well as thermal imaging with high detection depth, high imaging contrast and high spatial resolution. It can distinguish tumor tissue from normal tissue and achieve precise diagnosis of glioma . The comNanomaterials with strong absorption in the near-infrared region  includi, and melThe introduction of fluorescent nanomaterials as probes for tumor imaging  and the 4.The treatment of brain tumors is challenging due to the difficulty of surgical resection, low drug efficacy and high recurrence rate . CurrentThere are many receptors on the surface of the BBB, these receptors tend to be highly specific for cognate target molecules. The application of nanoparticles as drug carriers , combineThe strategies used by researchers to move nanoparticles across the BBB are proliferating. Nanoparticles can carry drugs through the BBB and enrich in the area of GBM, improving the bioavailability and reducing toxic side effects. Macrophages entering the central nervous system is closely related to the destruction of the BBB . Using nNanomaterials include organic nanomaterials (such as liposomes and polymer nanoparticles) and inorganic nanomaterials . Nanodrugs that have been explored in clinical research and even brought to include liposomes, polymer nanoparticles and other organic nanomaterials. The following section introduces the organic nanomaterials with the highest biocompatibility and biodegradability: liposomes, polymer nanoparticles, and extracellular vesicles.4.1.Liposomes are small spherical vesicles  with sinNanoparticles can form tight interactions with plasma proteins, which then generate a protein corona (PC) that mediate their interaction with cellular and biological barriers . Apolipovia receptor-mediated endocytosis. LF has been added via passive drug loading into a lipid bilayer of magnolol, which is extracted from magnolia root and has a strong antiangiogenic effect. LF has been added via passive drug loading into a lipid bilayer of magnolol, which is extracted from magnolia root and has a strong antiangiogenic effect. These LF-modified nanocarriers then were induced to entrap daunorubicin via an active drug loading method. These nanocarriers were shown to inhibit angiogenesis mimicking channels (VM) and block the source of nutrients that fuel tumor cell invasion, and thus blocked tumor cell invasion (Lactoferrin (LF) is an iron binding protein  that caninvasion .via receptor-mediated endocytosis and adsorption-mediated endocytosis to deliver daunorubicin and the VM channel inhibitor rofecoxib . This improved carrier used 4-aminophenyl β-D-glucopyranoside (Glu), a glucose derivative that binds to overexpressed glucose transporters (GLUTs) on the BBB  Another ofecoxib .Cancer stem cells (CSCs) promote drug resistance by preferentially upregulating DNA damage checkpoint proteins . PreviouLiposome radiation therapy  can magn4.2.Polymer nanoparticles are promising materials for drug delivery. They can be classified according to their shapes, including polymer micelles, dendritic macromolecules, and polymer conjugates. Polymeric nanoparticles are stable and have good biocompatibility. They also have a high drug loading capacity and low production costs and are readily scalable and modifiable . Polymervia junctions of damaged endothelial cells and are then internalized. This is now considered as a potential force for the precision treatment of GBM  is typically chosen as a hydrophilic block to combine with different hydrophobic blocks to form conjugated polymers. Combination therapies of targeting GBM with peptide-modified polymer micelles are better able to access the target GBM by moving through the BBB . The intibit GBM .Dendrimers are highly branched and structurally precise molecules synthesized by repeated growth reactions . Dendrim4.3.Extracellular vesicles (EV) are a group of heterogeneous cell-derived membrane structures that provide a mechanism for intercellular communication and allow cells to exchange proteins, lipids, RNA, and other genetic material . The two2) which were then loaded with indocyanine green (ICG) as a sonosensitizer. Inspired by the ability of macrophages to cross the BBB, CSI was further encapsulated with AS1411 aptamer-modified macrophage exosomes to form CSI@Ex-A nanoparticles. High levels of reduced glutathione triggered the biodegradation of CSI@Ex-A, and the released CAT catalyzed the production of O2 from H2O2 to alleviate the intracellular hypoxia. The nanoparticles exhibited efficient BBB penetration and a good cancer cell-targeting ability. In addition, depletion of glutathione and the supply of O2 improved the efficiency of SDT, and the nanoformulation showed low toxicity to normal cells and tissues. Thus, this nanoplatform may offer great promise for clinical applications  the limited penetration of drugs through the BBB to the brain parenchyma; (2) High postoperative recurrence rate due to chemical resistance caused by stem cell like characteristics; (3) The toxic and side effects of low selectivity of drugs on normal nerve cells. Although there are currently various strategies and schemes for enriching nanoparticles through the BBB into lesions, approved clinical drugs for the treatment of solid tumors mainly rely on passive targeted therapy, while dense brain matrix in GBM can hinder diffusion, so passive targeted therapy is likely to be ineffective. Direct injection of drugs into the brain using stereotactic therapy or passive targeting therapy cannot effectively penetrate GBM infiltrating tumor cells. Therefore, future treatment of GBM should focus on active targeted therapy.Overall, nanotechnology has opened up a new path for the diagnosis and treatment of GBM. The field is still new, and this road can be broadened. However, the application of nanotechnology remains limited throughout the treatment process. The toxicity, stability, biocompatibility, biodegradability of nanomaterials and the ethical issues of the application of nanotechnology to the human body still need to be further studied and clarified.DW, JL, and NZ designed this study. DW, NZ, SQ, and HW drafted this manuscript. All authors contributed to the article and approved the submitted version.This study was supported by grants from National Key R&D Program of China (2022YFC2009906 and 2022YFC2009900), 1.3.5 Project of West China Hospital, Sichuan University (ZYJC21029), Post-Doctoral Research Project, West China Hospital, Sichuan University (20HXBH040), and Project funded by the China Post-Doctoral Science Foundation (2021M692293).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.