Background: Virtual surgical planning allows surgeons to meticulously define surgical procedures by creating a digital replica of patients’ anatomy. This enables precise preoperative assessment, facilitating the selection of optimal surgical approaches and the customization of treatment plans. In neck surgery, virtual planning has been significantly underreported compared to craniofacial surgery, due to a multitude of factors, including the predominance of soft tissues, the unavailability of intraoperative navigation and the complexity of segmenting such areas. Augmented reality represents the most innovative approach to translate virtual planning for real patients, as it merges the digital world with the surgical field in real time. Surgeons can access patient-specific data directly within their field of view, through dedicated visors. In head and neck surgical oncology, augmented reality systems overlay critical anatomical information onto the surgeon’s visual field. This aids in locating and preserving vital structures, such as nerves and blood vessels, during complex procedures. In this paper, the authors examine a series of patients undergoing complex neck surgical oncology procedures with prior virtual surgical planning analysis. For each patient, the surgical plan was imported in Hololens headset to allow for intraoperative augmented reality visualization. The authors discuss the results of this preliminary investigation, tracing the conceptual framework for an increasing AR implementation in complex head and neck surgical oncology procedures. Surgery in deep neck areas has always represented a challenge, even for the most expert surgeons. The neck is a complex anatomical region, in which multiple vulnerable structures intersect each other, and dissection has to be carefully accomplished to avoid any possible injury. Disease processes occurring in such spaces require careful surgical planning, in which the most direct and harmless form of access needs to be defined .Technology can enhance the study of the case through advanced imaging modalities that can be used to perform virtual surgical planning, in which a digitalized patient anatomy is created to represent a computational replica of the tumor surrounded by critical anatomical regions. The definition of hard and soft tissue anatomy in proximity to the tumor can provide informative clues to define the most suitable surgical approach, while at the same time privileging, when possible, the preservation of noble structures.Although, nowadays, virtual surgical planning has been extensively described across the literature, its applications in soft tissue reconstruction and especially in the neck region are considerably underreported, owing to the difficulty of performing the segmentation of anatomy in such a complex anatomical region that is conventionally studied using CT scans. Thus, a multi-modality imaging technique is needed to investigate soft tissue compartments and perform an accurate segmentation to yield a reliable representation of anatomy, as described by the same authors .In addition, translating virtual surgical planning in neck surgery has always represented a major problem, with few solutions reported over the years. Navigation has been extensively described in the craniofacial region, due to stable and widespread skeletal landmarks, which lead to a less deformable anatomy, but its use in the neck region raises major issues in terms of navigator calibration, as well as a high deformability of the operative field . SimilarAugmented reality (AR) is seen as one leading technological solution that will represent a “game-changer” approach in the future for computer-aided vision. The possibility to superimpose a virtual patient replica to the real operative field without being restricted to the acquisition of physical landmarks makes it suitable for anatomical regions that cannot be approached using traditional navigation stations . AR is aThe purpose of this paper is to introduce a novel protocol for the preoperative digitalization of neck anatomy in patients with neck masses and describe an AR-based workflow to speculate on how AR will impact neck surgical oncology. Despite AR being immature and certainly unreliable at this stage, a practical demonstration of its potential may open new insights and accelerate the development of more accurate solutions in this surgical field.This is a retrospective observational study conducted from February 2022 to July 2023. Five patients were enrolled with disease processes located in the deep cervical spaces requiring surgical excision. The application of AR was not used to guide surgical excision, as it is still unreliable; however, the system was tested intraoperatively for calibration, ergonomics and correspondence with the real field. This study was conducted according to STROBE guidelines and the Helsinki declaration, and it was approved with the following number: protocol IRB_45_2020 approved by the Institutional Review Board (IRB) of the University of Udine.The protocol for digital patient reconstruction depends on strict imaging protocols that need to be acquired based on the anatomical structure that is to be segmented. Bone tissue is appropriately studied using CT scan with ultrathin slices (at least 0.625 mm) and a 512 × 512 px matrix to enhance spatial resolution.Tumors are generally well studied using gadolinium-enhanced MR in VIBE sequence with volumetric isotropic acquisition (1 mm voxel at least) and a 512 × 512 px matrix. A panoramic, volumetric neuronavigator acquisition protocol (NNV) can account for the segmentation of surrounding muscles and other soft tissue anatomy, as the VIBE sequence is generally restricted to a limited field. Arteries are acquired using a time-of-flight volumetric sequence with 0.3 mm slice thickness in the intracranial space and proximal cervical space. Similarly, 3D MR venography can define venous vessels up to a plane crossing the carotid bifurcation.Segmentation of medical images is performed using the software Materialise Mimics v. 25 . Bone anatomy is easily detected using threshold-based methods by setting the bottom limit to the bone density Hounfield Unit (HU) range. Vessels are most easily tracked using methods of dynamic region growing, in which contiguous voxels are sampled and defined by spatial proximity criteria. Tumor mass and muscles are reliably defined across their boundaries using manual artificial intelligence (AI)-guided smart brushes that enable the clinician to paint the tumor lesion of the muscle group. Once masks have been accurately created for each object of interest, they are retesselated to be converted into high-detail polymeshes, usable for virtual surgical planning.In Materialise 3-matic, a mandibular osteotomy is simulated, taking into account the position of teeth roots located in the most favorable site to allow the mandibular swing approach to optimally expose the site of disease. The full mandibular swing movement is simulated to define the optimal access portal to the cervical region in case of disease located in the upper neck region . For disFor disease in the upper cervical tract, the inferior mandibular border was exposed in correspondence with the mandibular symphysis and parasymphyseal region. Incision of the mandible fornix continuing to the lateral mouth floor was performed to enable rotation of the hemimandible on the condylar pivot. During the sectioning of the lateral oral floor, attention was carried out to preserve the lingual nerve. Prebending and predrilling of screw holes for two osteosynthesis titanium plates were performed prior to completing the mandibular splint. A paramedian osteotomy between the roots of the canine and first premolar was accomplished by means of piezosurgical cut. The mandible was extrarotated on the disease side, and the mylohyoid muscle was further sectioned to fully widen the surgical access to the deep cervical neck compartments . After tFor disease in the middle or lower cervical tract, the transmandibular approach was not generally deemed necessary. In this case, the surgical approach considered the steps for the traditional neck dissection surgery.A cervicotomy was designed, and a myocutaneous flap was raised. The anterior margin of the sterneocleidomastoid muscle was isolated, and dissection was carried out to identify and protect the spinal nerve. The posterior belly of the digastric muscle was localized to assess the plane of dissection. Depending on the location of the disease, two different approaches were used:STLs of surgical planning were previously exported and uploaded in Materialise Mimics Viewer, an online application that enables the creation of AR projects for holographic visualization of surgical planning . The samAs AR is still unreliable and not validated for precision surgery yet provides highly improved orientation and understanding capabilities, it was coupled with intraoperative navigation of surgical planning, to enhance lesion targeting and anatomical structure identification.The authors conducted a narrative literature review to assess the presence of virtual surgical planning and augmented reality in head and neck surgical oncology. For this purpose, a dedicated research query was formulated as follows:  AND (“head and neck” OR ENT OR maxillo*) AND (oncolog*) AND ). The syntax was modified to make it suitable for each of the following databases: Pubmed/Medline, Embase, ScienceDirect, Ovid. Moreover, a broad-spectrum search strategy was implemented in Pubmed/Medline using MeSH terms based on the following string:  AND “Head and Neck Neoplasms” [Mesh]. Criteria for paper selection included: publication no older than 2018; application in head and neck surgical oncology; clinical application in patients within the OR; English; reported pictures of the AR system; presence of detailed surgical planning. Exclusion criteria were as follows: applications outside head and neck region; application in fields other than surgical oncology; in silico or in vitro studies without the clinical implementation in real surgical scenarios; languages other than English; omission of pictures showing AR applied in the surgical field; no virtual surgical planning presented.Five patients were recruited in the present study. The mean age was 69 years old. In two patients, it was not possible to acquire the dedicated MR protocol, and surgical planning was performed using CT angiography, involving inferior tumor detail and the loss of separate arterial and venous vasculature reconstruction. For all patients, AR was applied. AR was applied in combination with navigation only in cases of disease localized in the upper cervical tract, due to the possibility of performing neuronavigational calibration. For disease localized exclusively in the neck, navigation was not applicable. All surgeries were successful and uneventful. We report sensitivity loss of the lateral tongue ipsilateral to the mandibular swing side due to lingual nerve sacrifice to widen the surgical corridor through mylohyoid muscle sectioning. There were no major bleeding events.In all patients, the preoperative virtual definition of an access corridor was related to the improved exposure of the tumor mass during surgery.The results of our literature review yielded 229 results overall; after applying a threshold for publication year set at no older than 2018, the results were restricted to 164. MeSH tree search yielded 10 results. Combined, the initial search was conducted across 174 papers. A step-by-step selection according to the scheme implemented in PRISMA guidelines, including sequential duplicate removal, title screening, abstract screening and full-text reading, ended up with three studies being selected and carefully analyzed. Two papers deal with oncology-respective procedures, whereas one deals with fibula-free flap harvesting facilitated by AR for reconstructive purposes. The results of paper selection are reported in AR explored in terms of computer science and computation: this field mostly includes in silico studies that investigate novel strategies to improve AR usability and efficiency for clinicians ,9.AR compared to other image-guided surgery techniques: such studies compare the advantages and accuracy of novel AR devices and technologies to the current gold standard in head and neck surgery, represented by intraoperative navigation ,10,11.AR used in a real clinical setting: such studies represent the focus of this paper, and very few examples are available to denote the usability of AR for real surgeries ,12,13.The use of AR in head and neck surgical oncology has seldom been reported. In the literature, AR has been explored mostly for research purposes, and the authors identified at least three main themes:Head and neck surgical oncology requires a complete preoperative anatomical study and intraoperative guidance, owing to the inherent complexity of this anatomical district and the immediate implications that oncologic resection has in terms of compromising important functions, such as breathing, speaking and swallowing.®, that enable the simultaneous deposition of different materials within the same print, allowing the manufacture of models with different colors and consistencies to replicate the heterogeneous composition of human tissues [In malignant pathology, where surgical resections need to be tailored to individual patients trying to balance surgical radicality and subsequent comorbidities, a careful preoperative study based on virtual surgical planning is mandatory to assess resection margins, noble structure sparing and to configure the most straightforward path to the lesion. The importance of reconstructing a digital anatomical atlas of each patient, including as many segmented structures as possible, enhances the possibility of simulating surgery and foreseeing criticalities. While 3D printing has been proven by a number of studies to facilitate anatomical understanding and replicate surgical maneuvers in advance, it provides only indirect guidance during operative phases . A 3D-pr tissues .Intraoperative navigation was primarily developed for a neurosurgical setting and relies on a rigid body registration to locate a probe on the patient’s imaging while it is traced by an infrared light of a magnetic field. Subsequent studies, initially led by Schramm and Gellrich, translated this technology into craniofacial scenarios, where it was used to navigate deep spaces of the splanchnocranium, including the skull base, the orbital region, pterygopalatine and infratemporal fossa ,17,18. TIn addition, the field of virtual reality and surgical planning applied in the neck region is considerably underreported, as the segmentation of neck soft structures is more demanding in terms of skills, software equipment and time compared to traditional bone segmentation of the craniofacial region . Among tIn this paper, the authors tried to apply currently available technologies in real cases of complex tumor neck disease to identify the advantages that this technology may involve. Surgical planning described in the Materials and Methods section was exported into an STL file and imported into Materialise Mimics Viewer, where a project suitable for the Microsoft Hololens 2 headset was generated. The headset is not heavy and can be well tolerated by the surgeon during the procedure; however, it is used exclusively in phases that require AR, such as the preliminary surgical access, to enhance incision positioning, and during dissection, to facilitate intraoperative orientation and mass localization, as well as the avoidance of crucial structures, including great vessels. Current systems that lack depth accommodation tend to provoke eye fatigue, an issue that is well known in AR optics, and might be overcome by innovative lenses with multiple focal planes. This system allowed for good ergonomics during surgery, as Hololens-embedded cameras were able to capture the gesture motion of the operator wearing the headset, enabling the fine manipulation of the AR object that could be interactively repositioned, scaled and rotated according to the different spatial perception in every phase. While AR is not a mature technology and, thus, it cannot be granted any certification for medical use, such preliminary investigations are important to facilitate surgeons’ understanding of the potential benefits of this technology applied to neck surgical oncology, including the ability to locate the optimal site to perform an incision into the skin and scoping vulnerable structures before they are dissected and exposed. Conspicuous research is currently being conducted in this field to decrease the mismatch between the virtual hologram and the physical patient, including the implementation of eye-tracking technology and multiple focal planes, which is supposed to add depth to the virtual image, so that its three-dimensional superimposition is balanced with the real focal distance of the eye’s operator, reducing eye fatigue as well .Moreover, AR enables the temporary detachment of the virtual hologram from the registration with the patient and allows us to move it around the physical space to scope the virtual reconstruction separately, from multiple perspectives, enabling surgeons to dive within the patient’s anatomy as if they were manipulating a 3D-printed model.Another interesting field of research is the use of markerless registration. According to this approach, the AR software installed in the hardware device is able to track the shape of the real object and make it coincide with the virtual 3D model of the surgical planning. Recognition is still impaired by a variety of factors occurring during surgery, such as draping with coverage of broad surfaces that the algorithm might track, as well as light interference, and paucity of stable landmarks, including prominences and depressions. Battaglia et al. described an interesting tracking system based on markerless registration using an AR scene developed within Unity 3D  and empowered by Vuforia SDK (software development kit) . GsaxnerFor such a complex and movable structure as the neck, it will become essential to define an “intelligent” system, able to tailor the modifications of head position and cervical spine flexion and extension to corresponding actions translated on the virtual model. For this purpose, mesh-tracking technologies will enable the modification of imported STL, considered as rigid bodies, adapting them to the variability of the surgical scenario. At the same time, such a system will necessarily be based on artificial intelligence (AI) and deep learning (DL), requiring substantial computational power. Dynamic recalibration will become essential to adapt the intraoperative modification of the surgical fields with adaptable surgical planning, also including kinematic sequences, to simulate each procedure and phase as the surgery progresses. The advent of quantum computing will enable the enhancement of existing hardware to an unprecedented extent, enabling AI algorithms to modify the calibration second by second based on the variation in the operative field. AI will substantially improve object recognition capabilities, enabling the capture of a smaller amount of detail to perform the calibration between the real patient and the hologram, which may contribute to ensuring the correct registration when the patient is covered in sterile drapes.Despite the underreported use of AR in complex head and neck surgical oncology, this preliminary report shows that this technology has great potential to guide surgeons in the most complex scenarios. The currently available systems enable appropriate ergonomics during surgery but fail to accurately register the real patient with their holographic representation. The use of AR in the operating room is completely different from other applications due to a number of influencing factors, including light interference, patient draping and logistics. We foresee that the advent of AI and self-learning algorithms, together with the advancement of the computational power of new chips, will lead AR to the appropriate accuracy for the clinician and will radically modify intraoperative image guidance.


Additionally, the effect of the one-step SSR route on the electrical properties of the NMC is investigated. Similar to the NMC prepared using the two-step SSR route, spinel structures with dense microstructure are observed in the NMC prepared via the one-step SSR route. Based on the experimental results, the one-step SSR route can be considered as one of the effective processing techniques with less power consumption to manufacture electroceramics.Achieving carbon neutrality is important to solve environmental problems and thus requires decarbonizing manufacturing processes to reduce greenhouse gas emissions. The firing of ceramics, including calcination and sintering, is a typical fossil fuels-driven manufacturing process that requires large power consumption. Although the firing process in manufacturing ceramics cannot be eliminated, an effective firing strategy to reduce processing steps can be a choice to lower power consumption. Herein, we suggest a one-step solid solution reaction (SSR) route to manufacture O Notably, the B value represents the sensitivity to temperature change, characterized by activation energy and Boltzmann constant [ρ25 and B value for accurate temperature measurements [The semiconductor behavior of spinel  is a cost-effective and straightforward method that offers several advantages in materials synthesis and processing, including its simplicity of composition control ,11,12. EIn this work, an efficient one-step SSR route for crystalline NMC pellet, comprising calcination and sintering at a single heating profile, is proposed. The electrical properties of the NMC with temperature changes are discussed and compared to those of the NMC prepared using the one-step SSR route. Additionally, activation energies of the NMC via the two different processing routes are evaluated for their application to the temperature sensor. 3O4  Co3O4 , and NiO  powders as raw materials were weighed with stoichiometric amounts needed to obtain the Ni0.3Mn1.5Co1.2O4 (NMC). The oxide powders were mixed with 5% polyvinyl alcohol (PVA) in deionized water (D.I. water) via ball-milling and then dried using a spray drying process. The prepared powders were further dried at 60 °C for 12 h in the air. For applying the one-step heat treatment, the oxide powders were uniaxially pressed into pellets of 1.2 cm2 × 0.5 cm under a pressure of 8.3 ton/cm2. After drying the green body in the air for 24 h, pellets were fired in the air with a heating profile, as described in 2 × 0.5 cm under a pressure of 8.3 ton/cm2, followed by further drying for 24 h. The pellets were sintered in the air, as described in MnCrystallographic information and microstructure of the pellets prepared via the two different processing routes were observed using the X-Ray diffractometer  with Cu Kα radiation (λ = 1.5404 Å) and scanning electron microscopy , respectively. Additionally, the element distribution of the samples was analyzed using energy dispersive X-ray spectroscopy . The oxidation states of the elements in the samples were measured using an X-ray Photoelectron spectrometer . Thermal analysis was also performed using thermogravimetric-differential thermal analysis . To evaluate the semiconductive behavior for potential application as a temperature sensor, electrical resistance was measured in the temperature range between −15 °C and 85 °C using an LCR meter  after applying the silver paste on the surface of the pellets.The effect of calcination temperature on the crystal structure of the NMC is depicted in xMnyCo3-x-y)O4 are determined by the ratios of Ni, Co, and Mn in the spinel structure. Hence, the Ni0.3Mn1.5Co1.2O4 in this study is identified as a mixture of cubic and tetragonal spinel structures [Previous reports indicate that the crystallographic phases of . This suggests that the one-step SSR route effectively provides sufficient energy not only for the formation of the desired crystalline NMC with a spinel structure but also for the densification of the NMC compact. The microstructure of the NMC prepared via the two-step SSR route with different calcination temperatures is presented in Additionally, the volume density of the NMC prepared via the two-step SSR is increased up to 4.7799 g/cm3+ cations on octahedral sites [To understand the chemical reaction and sintering behavior during the one-step SSR route, thermo-gravimetric analysis was performed, and the result is shown in al sites . AdditioNegligible weight loss was observed when the temperature was increased to 1100 °C, which indicates that chemical reaction for the formation of the spinel NMC does not occur. However, gradual weight loss from 1200 °C was observed, similar to the one observed in the NMC prepared via the one-step SSR route. Based on the TG-DTA results, it is evident that the chemical reaction for the formation of spinel NMC and following sintering occurs during the one-step SSR route, which implies that power consumption and the processing time are significantly reduced by the one-step SSR route for the fabrication of the crystalline spinel NMC pellet.Applying different thermal energy during heat treatment can influence the arrangement of constituent ions at the A and B sites of the spinel NMC, and thus the varying valence states of the ions . To inve3/2 and Co 2p1/2, respectively. Main peaks can be decomposed into two characteristic curves, indicating the presence of Co2+ and Co3+. The Co 2p3/2 of Co2+ and Co3+ appear at 781.5 eV and 779.8 eV, respectively. Additionally, the Co 2p3/2 and Co 2p1/2 satellite peaks appear at 786.7 eV and 802.2 eV, respectively [3/2 and Ni 2p1/2 energy levels are centered at 855.7 eV and 873 eV, respectively. Additionally, the satellite peaks of Ni 2p3/2 and Ni 2p1/2 are located at 879.1 eV and 860.6 eV, respectively, indicating Ni2+ [1/2 spectra show the binding energies of 654.8 eV, 653.3 eV, and 652.6 eV, while Mn 2p3/2 spectra show the binding energies of 640.9 eV, 642.7 eV, and 645.6 eV, which indicates the Mn2+, Mn3+, and Mn4+, respectively [2+, Co3+, Ni2+, Mn2+, Mn3+, and Mn4+ as presented in 2+, and more Mn3+ and Mn4+ in the NMC, compared to the NMC prepared via the two-step SSR route, as summarized in 3+/Mn4+ pairs at octahedral sites in spinel structures that lower the electrical resistivity of the NMC [L) at 530 eV, chemisorbed oxygen (OC) at 531.4 eV, and oxygen vacancies (OV) at 533.6 eV in the spinel structure [As shown in ectively . Ni 2p sing Ni2+ . Mn 2p1/ectively . Althoug the NMC ,23. Additructure . The peaThe electrical resistivity of the NMC prepared via different processing routes as a function of temperature is shown in 3+/Mn4+ pairs and a higher ratio of tetragonal to cubic spinel phase. Although the resistivity of the NMC prepared via the one-step SSR route is different from that of the NMC prepared via the two-step SSR route, the design of the sensor module modulating the form factor can easily tune the electrical resistance required from industrials. The logarithm of the resistivity is linearly related to the inverse temperature in a). Additionally, ρ, k, and T are resistivity, the Boltzmann constant, and absolute temperature, respectively. B value, resistivity, and temperature coefficient of the NMC depending on different processing routes are summarized in Both NMCs prepared via the different processing routes show the electrical properties with negative temperature coefficient (NTC), as shown in ature in R=R0exp(ExCoyMn3-x-y)O4 (NMC) depending on different processing routes including one-step solid solution reaction (SSR) and two-step SSR was investigated: one-step SSR route consists of calcination and sintering at single heating profile, while two-step SSR route includes individual calcination and sintering process. Both processing routes show a dense microstructure of the NMC. Additionally, the crystallographic phase of the NMC prepared via one-step and two-step SSR routes shows a mixed spinel structure with cubic and tetragonal phases. Additionally, Ni, Co, and Mn ions of the NMC show similar valence states: Ni2+, Co2+/3+, and Mn2+/3+/4+ are observed in the NMC prepared via the two different processing routes. However, more Mn3+/Mn4+ pairs were observed in the spinel NMC prepared using the one-step SSR route, which can lower the electrical resistivity. The NMC prepared via the two different processing routes shows an exponential decrease in resistivity with an increase in temperature, and the logarithm of resistivity is linearly related to the inverse temperature, which indicates that NMC is applicable in the temperature sensor. Electrical resistivity at 25 °C of the NMC prepared via one-step and two-step SSR route is 12.05 Ω and 442.35 Ω, respectively. The difference in electrical resistivity can be attributed to the ratio of tetragonal to cubic spinel structure and the number of Mn3+/Mn4+ pairs induced by different processing routes. Additionally, B values of the NMC prepared using the one-step and two-step SSR routes are 3549 K and 3551 K, respectively. Based on the results, we suggest that the one-step solid solution reaction (SSR) route is an efficient processing method to prepare spinel NMC pellet as NTC-based temperature sensor. Simplified processing steps for the fabrication of electroceramics can significantly reduce power consumption and processing time, thereby not only reducing carbon emissions but also saving manufacturing costs. Additionally, it is expected that the efficient processing methodology suggested in this study can be a starting point to develop more efficient and green processing technology for the ceramic industry.Semiconductor behavior of the spinel (Ni


Head-mounted displays (HMDs) have the potential to greatly impact the surgical field by maintaining sterile conditions in healthcare environments. Google Glass (GG) and Microsoft HoloLens (MH) are examples of optical HMDs. In this comparative survey related to wearable augmented reality (AR) technology in the medical field, we examine the current developments in wearable AR technology, as well as the medical aspects, with a specific emphasis on smart glasses and HoloLens. The authors searched recent articles (between 2017 and 2022) in the PubMed, Web of Science, Scopus, and ScienceDirect databases and a total of 37 relevant studies were considered for this analysis. The selected studies were divided into two main groups; 15 of the studies (around 41%) focused on smart glasses  and 22 (59%) focused on Microsoft HoloLens. Google Glass was used in various surgical specialities and preoperative settings, namely dermatology visits and nursing skill training. Moreover, Microsoft HoloLens was used in telepresence applications and holographic navigation of shoulder and gait impairment rehabilitation, among others. However, some limitations were associated with their use, such as low battery life, limited memory size, and possible ocular pain. Promising results were obtained by different studies regarding the feasibility, usability, and acceptability of using both Google Glass and Microsoft HoloLens in patient-centric settings as well as medical education and training. Further work and development of rigorous research designs are required to evaluate the efficacy and cost-effectiveness of wearable AR devices in the future. Artificial intelligence (AI), particularly deep learning (DL), has facilitated the advancement of virtual reality (VR) and AR technologies. DL’s ability to perform object tracking and segmentation, as well as improve video resolutions, can reduce the computing power and costs needed for AR and VR systems and improve device performance. In the healthcare field, AR and VR technologies have been applied in a variety of areas, including laparoscopic surgery, robotic surgery, oral and maxillofacial surgery, guided biopsy, tumour resection, rehabilitation, cancer management, psychology, and neurosurgery. AR technology has been used to help surgeons inside the operating room (OR), as well as outside the OR for remote mentoring, patient education, resident training, and preoperative planning. It has also been used in orthopaedic procedures to assist surgeons in improving their speed and accuracy and has been applied in the treatment of spinal disorders. HMDs provide a hands-free display of information within the user’s visual field and have the potential to greatly impact the surgical field by maintaining sterile conditions in healthcare environments . AccordiDue to increasing demands for health sciences, new and effective options are required in this field. According to Moro et al. , VR and AR technology allows for three-dimensional knowledge of human organ systems and structures . Google Although there are numerous advantages of using Google Glass in clinical settings, possible limitations are connected with its use among patients and healthcare professionals. More studies are required to better understand Google Glass’s data security, as well as its suitability in specialized medical applications. Another limitation of Google Glass is the lack of triage accuracy, which is necessary to identify and prioritize patients with the most urgent medical needs ,8. MoreoAR technology is widely used in healthcare settings to treat and help patients. Many studies have been reported in this field; however, they focus on a specific AR technology, for example, a focus on Google Glass in clinical and non-clinical settings ,2,4. In In this systematic review related to the application of AR technology in the medical field, we will examine the current developments in wearable AR technology, as well as its medical aspects, with a specific emphasis on smart glasses and HoloLens. In line with this, we aim to identify the research gaps and problems regarding wearable AR technology in healthcare, as well as categorize the current research on wearable AR technology in this field. Furthermore, we would like to provide a road map of wearable AR-technology-related research in healthcare worldwide.This manuscript partially followed the checklist and explanation for preferred reporting for systematic reviews and meta-analyses for scoping reviews (PRISMA-ScR) . This maIn October 2022, we searched for recent articles published between 2017 and 2022 using the keywords “Head-Mounted Display”, “Head-mounted Device,” “Smart glasses”, “Google Glass”, and/or “Microsoft HoloLens” that were associated with applications in healthcare in the PubMed, Web of Science, Scopus, and ScienceDirect databases.A total of 1175 articles were gathered from the various databases. The authors screened around 300 original articles after removing duplicates. Upon analysis of the titles and abstracts, 60 full texts were considered relevant and underwent a detailed review, resulting in 37 manuscripts being included in the final analysis see . ArticleThe authors screened all articles individually, including a review of all full texts, and specific data were collected, namely authors’ names, publication year, country, sample size, study design/ study settings, AR technology used, medical speciality application, and categorization/classification of the literature. It is important to note that all data were analyzed quantitatively and qualitatively. The following were the inclusion criteria for this review: (1) original research, (2) involved the use of a head-mounted display (HMD) for a surgical task, (3) published in English, and (4) conducted in a clinical setting, either in real time or in a simulated environment.Out of the 1175 studies that were reviewed, 37 relevant review manuscripts were selected for further analysis and exploration. These 37 articles were divided into two main groups: 15 (approximately 41%) were conducted on smart glasses  and 22 (approximately 59%) were conducted on HoloLens . A summary of the 37 included studies is illustrated in both As discussed previously, Google Glass is a wearable technology in the form of eyeglasses and is associated with a high-definition camera that allows the user to interact using voice commands. Considering the studies based on Google Glass (or similar types of smart glasses), we selected 15 studies for extended analysis and incorporation into this review. It is important to note that all 15 studies were conducted in hospital settings . Most ofIt is important to note that the vast majority of the studies examined the potential use of Google Glass as an intraoperative intervention 9/15, 60%) [, 60% 15,19,20,21The authors selected international studies related to medical applications of Google Glass Regarding operative settings, Google Glass was used in various surgical specialities, including urological surgery ,21, spinBased on our review of the literature, it is evident that Google Glass is a valuable tool for medical and educational applications ,18,20,22The Microsoft HoloLens is based on AR technology and uses multiple sensors, advanced optics, and holograms that allow for the simulation of a VR world. It is considered a novel AR tool with multiple clinical and non-clinical applications in pathology. According to Hanna et al. , this deA total of 22 studies that focused on Microsoft HoloLens matched our criteria and were selected for inclusion in this review. The data from these studies were analyzed and are discussed in this section. Similar to Google Glass, the studies based on Microsoft HoloLens were conducted in medical settings . The vast majority of the selected studies were associated with the potential use of Microsoft HoloLens as an intraoperative intervention  ,33,34,35The authors selected international studies focusing on medical applications of Microsoft HoloLens. Regarding operative settings, Microsoft HoloLens was used in various surgical specialities, including anatomy pathology , otolaryAccording to recent reports, Microsoft HoloLens is a useful tool for basic life support and defibrillation training , as wellThe use of AR technology for clinical and non-clinical applications is promising and has attracted the attention of consumers and corporations. In the beginning, these technologies were commonly used in gaming, personal entertainment, and various business applications. In practice, the use of advanced technology and AR has increased in medical applications . To the best of our knowledge, only a few international literature reviews have been reported to date ,2,4,23. Medical education, health training, different surgical fields, pathology, and autopsy are considered some of the main applications associated with Google Glass and Microsoft HoloLens. Among the main advantages, they can virtualize online information without interruption while saving time. Moreover, video capture can be used in the education of medical students, as well as for the publication of articles . AR techHanna et al.  reportedIn contrast with Microsoft HoloLens, Google Glass is small and has an unobtrusive design; it can be used throughout the day while still being considered a fashion object. Google Glass has the potential to address communication and educational challenges in a telemedicine context . RecentlFurthermore, in metaverse education and training, augmented reality can be used in medical education to create holographic museums and virtual rooms for ophthalmic teaching, anatomy instruction, and surgical simulations . The useHowever, these technologies are associated with some limitations. In contrast with Microsoft HoloLens, Google Glass is associated with an information-only display that appears on one side. Moreover, a study showed that Google Glass was unable to capture all relevant anatomy during a specific surgery, and it also has short battery life, video recording time limits, display overexposure, and small screen size. Google Glass is considered an expensive device, starting at around USD 1500. Moreover, no increase in disaster telemedicine triage accuracy was found . AnotherAnother study that aimed to compare the precision and user preferences of different AR methods for HMDs, including Google Glass , confirmTheoretically, Google Glass is voice-operated; however, many repetitions (3–5 times) are required in order to recognize and analyze a voice. In line with this, some changes must be considered before its integration into the surgical field. Although it can be considered a useful supplement to traditional monitors, it is not recommended to be used as an independent monitor . AccordiOn the other hand, Microsoft HoloLens’s memory size and battery life are not among its advantages (approximately 100 minutes when running an application before having to be charged again) . In contTo the best of our knowledge, this is one of the most comprehensive SRs that covers and evaluates a vast majority of the wearable AR technology used in the medical field, whereas most previous SRs focused on one specific aspect. Moreover, this work provides a road map for researchers and policy makers for the use of AR technology in healthcare. The authors aimed to categorize all the literary works and synthesize their outcomes. The initial strategy guidelines and recommendations for the established systematic review methodology were followed as expected by the authors. Despite the overall promising data regarding the feasibility and the acceptability of using AR technology (mainly Google Glass and Microsoft HoloLens) in different surgical settings, there are some possible limitations associated with their use ,2. So, tAlthough the authors extensively search for studies on AR applications in the medical field, there is a possibility that a few articles were missed during the literature review search. The authors of this review did not have full access to some of the articles, which may be another limitation. It is important to note that the exclusion of conference proceedings may have affected the quality of this review. Further investigations with rigorous research designs are required to evaluate the efficacy and cost-effectiveness of AR devices in the future. The implementation of and investment in numerous new healthcare technologies are required. Furthermore, clinicians may be better able to understand the best devices to use with their patients. However, in general, the use of both Microsoft HoloLens and Google Glass devices can be considered of great benefit to the use of wearable devices in medicine.This article discusses the potential impact of head-mounted displays, specifically Google Glass and Microsoft HoloLens, on the healthcare industry as wearable augmented reality devices. The authors conducted a comparative survey of 37 recent studies that examined the use of these devices in various medical applications, such as surgical procedures, pre-operative care, medical training, and rehabilitation. The results of these studies suggest that both Google Glass and Microsoft HoloLens have potential uses in healthcare settings and they have received positive feedback in terms of their feasibility, usability, and acceptability. Several studies have yielded promising results regarding the feasibility, usability, and acceptability of using Google Glass or Microsoft HoloLens in patient-centred or student training settings. Regarding the articles analyzed, we can consider these devices as interesting tools that could help to improve the quality of patient care. Even with their technical limitations, the use of these technologies is widely reported due to their potential for use in surgical settings, as well as non-clinical fields.For users to select a suitable device, both Google Glass and Microsoft HoloLens have strengths and limitations as wearable augmented reality devices in the healthcare sector. Google Glass offers a compact design, low cost, and the ability to respond to voice commands, making it ideal for telemedicine communication and education. However, it has limitations such as short battery life, limited video recording time, a small display, and the need for a good Internet connection. On the other hand, Microsoft HoloLens offers high-quality 3D images and a comfortable user experience without VR nausea or headaches. It is useful for autopsies, telemedicine, and surgery, but it is complex, heavy, and expensive, and has a narrow field of view, making it less suitable for outdoor use.Based on a comparison of the two devices, the best device depends on the intended application and the specific needs of the user. If the user is looking for a more cost-effective device for telemedicine communication and education, Google Glass might be the better choice. However, if the user needs a device for surgery or autopsies, Microsoft HoloLens might be more suitable due to its 3D imaging capabilities and comfortable wearability. In any case, it is important to consider the limitations and trade-offs associated with each device before making a final decision.However, the authors also note some general limitations, such as low battery life and limited memory size, and recommend further research and development to fully evaluate the efficacy and cost-effectiveness of these wearable augmented reality devices. Further studies with rigorous research designs are required to evaluate the efficacy and cost-effectiveness of AR devices. The use of both Microsoft HoloLens and mobile-based AR devices in medical settings can be considered beneficial.


Prostate cancer is the most common type of cancer in men, and its treatment options include surgery, radiation therapy, and chemotherapy. Prostate surgery can often result in erectile dysfunction (ED), significantly impacting patients' quality of life. Penile rehabilitation techniques have been developed to restore erectile function following prostate surgery. This review discusses the different penile rehabilitation techniques available, their effectiveness, and the factors affecting their success. This paper also addresses the importance of addressing the psychological aspects of ED in these patients and the need for personalized and tailored rehabilitation plans. By providing a comprehensive understanding of penile rehabilitation techniques, this paper can assist clinicians in restoring the quality of life of patients who have undergone prostate surgery. Prostate cancer is the most diagnosed cancer in men worldwide, with over 1.4 million new cases reported annually . While RPenile rehabilitation is an essential aspect of postoperative care for men who have undergone RP. Penile rehabilitation involves the use of various techniques to improve erectile function following surgery. The primary goals of penile rehabilitation are to enhance the quality of erections, restore sexual function, and improve the patient's quality of life . The impThe objective of this paper is to provide a comprehensive overview of the current state of knowledge regarding penile rehabilitation techniques following prostate surgery. This review will focus on the most used penile rehabilitation techniques, including oral medications, penile injections, and vacuum devices. We will examine the timing of penile rehabilitation interventions and the outcomes measured, including erectile function, quality of life, and patient satisfaction. This review aims to provide an updated and comprehensive overview of the current evidence on penile rehabilitation techniques following RP.MethodologyThe search was conducted using electronic databases, including PubMed, MEDLINE, and Cochrane Library, using medical subject headings (MeSH) with keywords, "radical prostatectomy", "quality of life", "erectile dysfunction", "prostate surgery", and "penile rehabilitation." Inclusion criteria included studies written in English, peer-reviewed papers published between 2000 and 2022, and in vivo human studies reporting on penile rehabilitation techniques following prostate surgery. Exclusion criteria were animal studies, case reports, and studies reporting on nonsurgical interventions for ED. Figure Description of prostate surgery and its impact on erectile functionProstate cancer is a prevalent malignancy, and radical prostatectomy is one of the most common surgical interventions used to treat it. While this procedure has shown efficacy in eradicating the cancerous tissue, it can potentially engender deleterious consequences on sexual function, chiefly erectile function. The prostate gland is proximal to nerves and blood vessels that innervate and perfuse the penis, respectively, and its excision or damage during surgery can culminate in ED . It is iOverview of the existing literature on penile rehabilitation techniques following prostate surgeryProstate surgery is known to have a negative impact on erectile function, leading to significant interest in developing penile rehabilitation techniques to aid men in recovering their erectile function postsurgery. Penile rehabilitation encompasses a variety of therapies, including oral medications, penile injections, vacuum devices, and other interventions aimed at increasing blood flow and stimulating nerve growth in the penis. Innumerable studies have investigated the efficacy of such techniques following prostate surgery ,11.The success of penile rehabilitation is influenced by various factors, including the timing of the intervention, the type of rehabilitation technique utilized, and the degree of ED experienced by the patient. Some studies have indicated that early penile rehabilitation, conducted within a few weeks of surgery, proves to be more effective than delayed rehabilitation ,13.Penile rehabilitation techniquesOral MedicationsPhosphodiesterase type 5 inhibitors (PDE5i), namely, sildenafil, tadalafil, and vardenafil, are orally administered medications employed for penile rehabilitation following prostate surgery. These compounds impede the degradation of cyclic guanosine monophosphate (cGMP), a crucial mediator that facilitates the relaxation of the smooth muscles and escalation of blood flow to the penile tissue. The aforementioned mechanisms of action of PDE5i render them a potentially effective treatment for the enhancement of erectile function and preservation of penile health after prostate surgery. Nonetheless, it is worth noting that the efficacy of PDE5i is not universal, and some individuals may suffer from side effects such as headaches, flushing, or gastrointestinal disturbances. Furthermore, using PDE5i concurrently with certain medications, such as nitrates, is contraindicated, as this could result in an alarming reduction in blood pressure .Penile InjectionsPenile injections refer to administering medications such as alprostadil or papaverine via direct injection into the penis, which aims to induce enhanced blood flow and promote erectile function. This technique is often resorted to when conventional oral medications fail to yield the desired results or are not tolerated by the patient. While penile injections have demonstrated efficacy in improving erectile function, they can also potentially result in adverse effects such as pain, bruising, or scarring at the injection site. Hence, patients must receive adequate training on the appropriate injection techniques and adhere to strict guidelines to minimize the risk of infection or other complications .Vacuum DevicesVacuum devices, specifically penile pumps, establish a negative pressure environment around the penis, which causes blood to flow into the erectile tissue. Afterward, the device is removed, and a constrictive band is positioned at the penis base to uphold the erection. These vacuum devices can be implemented as a monotherapy or combined with other treatments. While vacuum devices are generally perceived as safe and efficacious, they may be accompanied by adverse effects such as bruising or numbness. Additionally, it is crucial to handle the constriction band with caution to prevent tissue injury or other associated complications .Other Penile Rehabilitation TechniquesAdditional penile rehabilitation techniques that have been the subject of research include low-intensity shockwave therapy, penile vibratory stimulation, and penile traction therapy. Low-intensity shockwave therapy entails utilizing low-energy shockwaves to stimulate blood flow and encourage tissue repair in the penis. Penile vibratory stimulation involves a device that vibrates the penis to boost blood flow and promote nerve regeneration. Penile traction therapy requires a device that gently applies traction to the penis to enhance tissue growth and increase penile length ,17.Although these techniques have displayed promise in initial studies, further investigation is necessary to establish their efficacy and optimal employment in penile rehabilitation after prostate surgery. Table Outcomes of penile rehabilitationErectile FunctionThe primary outcome measure in most studies on penile rehabilitation following prostate surgery is erectile function. Several studies have reported significant improvements in erectile function with penile rehabilitation techniques, including PDE5i, vacuum erection devices, and penile injections. One randomized controlled trial found that patients who received PDE5i therapy beginning four weeks after surgery had significantly higher rates of erectile function recovery than those who received a placebo . AnotherQuality of LifeProstate surgery is a widely utilized treatment for prostate cancer. However, it can significantly impact patients' quality of life, as it often leads to ED. Penile rehabilitation techniques, such as PDE5i, have emerged as promising therapies to mitigate this complication and enhance patients' overall quality of life following prostate surgery. The benefits of penile rehabilitation extend beyond sexual function. For instance, a study reported that patients who underwent rehabilitation had significantly improved urinary function and overall satisfaction with their sexual and urinary health compared to those who did not -9.Incorporating penile rehabilitation into the postoperative care of patients undergoing prostate surgery could potentially enhance their quality of life and overall recovery. These findings underscore the importance of addressing the sexual and urinary health of patients undergoing prostate surgery and highlight the potential benefits of penile rehabilitation techniques in achieving this goal ,22.Patient SatisfactionPatient satisfaction is a critical outcome measure for evaluating the success of penile rehabilitation following prostate surgery. After prostate surgery, many men may experience ED, which can significantly affect their quality of life. Measuring patient satisfaction following penile rehabilitation involves assessing various aspects of the patient's experience, including their level of satisfaction with the treatment, the degree of improvement in their erectile function, and the impact on their overall sexual function and quality of life -16.Patient satisfaction surveys can gather information about these aspects of the patient experience. These surveys may include questions about the patient's level of satisfaction with the treatment they received, the degree of improvement in their erectile function, and any adverse effects or complications they experienced. By measuring patient satisfaction, healthcare providers can better understand the effectiveness of their penile rehabilitation programs and make necessary adjustments to improve patient outcomes. In addition, patient satisfaction can be a valuable tool for guiding treatment decisions and improving patient education and support ,21-23.Clinical implicationsRecommendations for Clinical PracticesBased on the existing literature, it is recommended that men undergoing prostate surgery receive penile rehabilitation to help preserve and potentially restore erectile function. PDE5i are one of the most commonly used penile rehabilitation techniques and be effective in improving erectile function following prostate surgery ,24.In addition to PDE5i, other penile rehabilitation techniques, such as penile injections, vacuum devices, and penile vibratory stimulation, may also be effective. The exact timing and duration of penile rehabilitation are still being studied, but early intervention (within a few weeks of surgery) proves to be more effective than delayed intervention ,25. HealPotential Barriers to ImplementationDespite the potential benefits of penile rehabilitation, several barriers exist to implementation in clinical practice. One barrier is healthcare providers' lack of awareness and education about the importance of penile rehabilitation and the available techniques. This can lead to underutilizing penile rehabilitation and a missed opportunity to improve a patient's quality of life. Another barrier is the cost of penile rehabilitation techniques, particularly for patients without insurance coverage or limited resources. Some patients may be reluctant to use certain techniques due to perceived invasiveness or inconvenience .Future Research DirectionsWhile the existing literature suggests that penile rehabilitation can effectively improve erectile function following prostate surgery, there is still much to learn about the optimal timing, duration, and type of penile rehabilitation. Future research should focus on addressing these questions to improve outcomes for patients. There is also a need for more studies on the long-term effects of penile rehabilitation, including its impact on quality of life and overall sexual function. Additionally, research is needed on the potential benefits of combining different penile rehabilitation techniques for optimal outcomes.In conclusion, prostate surgery is a common treatment for prostate cancer but can have a significant impact on erectile function. Penile rehabilitation techniques, such as PDE5i, penile injections, vacuum devices, and penile vibratory stimulation, can be effective in improving erectile function following surgery. Early intervention may be more effective than delayed intervention, and healthcare providers should educate patients about the importance of penile rehabilitation. While there are potential barriers to implementation, such as the lack of awareness and education among healthcare providers and cost considerations, it is important to prioritize penile rehabilitation in clinical practice to improve patients' quality of life. Future research should focus on addressing questions about the optimal timing, duration, and type of penile rehabilitation, as well as the long-term effects of these interventions. Overall, penile rehabilitation is a promising approach to preserving and restoring erectile function following prostate surgery and should be considered an important aspect of patient care.


The increase in the economic value of soccer occurred in parallel with an increase in competing demands. Therefore, clubs and federations evolved to greater specialization  to support players’ performance and health. Currently, player preparation is far from exclusively club or national team centered, and the lack of control in each player’s environment can be more prevalent than expected. For example, an elite group of professional players faces disruptions in the season club-oriented planification due to involvement in national teams. Moreover, as elite players’ financial resources grow, it is common for them to employ specialized personal staff  to assist in their preparation, resulting in complex three-fold relationships . Although efforts have been made to improve communication with and transition from the club to the national team supervision, this new reality (club-players’ staff) may generate serious compound role-related problems and difficulties in monitoring load and training adaptation and having a unified message. Therefore, efforts must be implemented to ensure a more informed management of the players’ performance environment, where the existence and impact of these various personal staff are considered to avoid a long-term non-zero sum for all intervening parties. If left unchecked, current professional thinking may collide or overlap, potentially triggering conflict escalation and impairing athletic performance or health, especially if effective communication routes are not adequately established. Moreover, diluted personal responsibility regarding performance may ensue, resulting in decreased productivity from all involved, which may cause more harm than benefits for the player’s overall health and performance. This emerging reality calls for developing a joint working framework  and better managing of a player-centered process. Soccer has considerably evolved in its multifaceted forms  over the last decades . The expThe increase in the economic value of soccer occurred in parallel with an increase in competitive demands, such as the number of national and international competitions , 11 and However, player preparation is currently far from exclusively club centered, and the lack of coordination in each player’s environment can be more prevalent than expected. For example, an elite group of national team players may have their performance preparation and health supervision under the umbrella of two different entities throughout the season . However, this scenario quickly changes  , 21. As These realities challenge the organization and management of the player’s preparation, as effective performance- and health-related concerns depend strongly on the quality of the intrateam communication  , 25 and The above-described complexity in player preparation highlights the importance of Situational Awareness in modern soccer. According to Stanton et al.  SituatioThis current opinion explores why and how to implement such communication and articulation to ensure win–win relationships for the player’s benefit and decrease the somewhat apparent lack of Distributed Situational Awareness among players, clubs (staff), national teams, and individual staff. With this manuscript, we hope to spark discussion and foster the development of systematic or evidence-driven approaches and frameworks to address this growing problem.”  [Initially, there was the coach and the players. The coach conducted the warm-up and the central part of the training session, analyzing the opponents and negotiating with the players. As soccer evolved, so did the challenges, and athlete-centered structures with state-of-the-art sports facilities and materials for performance optimization have been created . Consequionists) , 21, 29.ionists)  (and wheionists) .To increase performance and reduce injury incidence, elite clubs implement training programs, monitoring strategies, and complementary strategies to aid player recovery , 20, 32.This complex dynamic can generate compound role-related problems. Current professional thinking may collide, professional overlap may exist, and ineffective communication may arise and trigger conflict escalation if some structural risk factors are not considered and effective strategies are implemented , 37. ComUnsurprisingly, the first order of communication and organization challenge is related to the multidisciplinary team, i.e., within the club . In fact, given the complexity of working in high-performance environments with multiple people in the same team with different philosophies and egos, we first need to control what we can control . This caHowever, other communicational and organizational challenges currently exist that make monitoring load and training adaptations considerably more demanding and dependent on the quality of the external communication process.Although the club “owns” the player for the duration of the contract, the FIFA regulations of the status and transfer of players state: “Clubs are obliged to release their registered players to the representative teams of the country for which the player is eligible to play on the basis of his nationality if they are called up by the association concerned. Any agreement between a player and a club to the contrary is prohibited” . As so, Coaches may fear that this interruption in players’ monitoring and training will negatively impact players’ performance when returning to the club, as they may arrive over- or under-loaded  . MoreoveCommunication is the transaction that allows awareness to be developed within a distributed team, and as a two-way exchange, it can be affected by team dynamics . Since cBuchheit and Dupont  discusseAccording to the specific competitive calendars (Europe versus South America), there are international periods  where players may have a window of time between the terminus of the club obligations (release from the club) and the start of concentration with the national team. During this period, players may be under the umbrella of the personal staff. However, the most frequent international windows are typically 9 days, often during the club’s competitive period, wherein most scenarios have two matches . PlayersUsually, national team concentrations occur away from the player’s residence (most players play in leagues other than one of their countries) and operate in a close environment . The time outside these training centers is just for traveling to the country where the away game will occur. During these short-term national team periods, no opportunities exist to interact physically with the players’ staff, so the exposure will be zero .As will be discussed afterward (5.2 Why build bridges?), the degree of commonality between the club, national team, and players’ staff will depend on each of their characteristics and qualities. There may be cases where the best solution would be to centralize the information exchange in the club, i.e., when communicating with the national team, the data already includes exposure with the personal staff . Otherwise, it would be best for the player’s staff to communicate directly with the national team. We acknowledge that this process is not as simple as it may seem, especially if rules and what is valued vary between national teams/federations. In fact, some national teams/federations may only recognize player contracts with clubs and likely assume they owe no explanation to players’ staff . IndepenWhile the articulation between the clubs and the national team may still be challenging, there is a potential additional issue. Indeed, players’ staff (third layer) are a relevant puzzle piece.Players follow the same evolutionary pathway as observed at industry and institutional levels: modern players deal from an early age with professionals with backgrounds in psychology, physiology, strength and conditioning, biomechanics, and performance , 19. ThiAs modern elite players’ financial resources grow exponentially , 7, it iAdopting a personal staff can be motivated by several factors of varying complexity. Considering player preferences, the player may wish for more personalized support , 23. AthConsidering the interindividual variability in response to training , 68 and Even when there is a perfect alignment between the player’s needs and preferences and the coaching philosophy and methods, the unstable reality of soccer may break this process apart. Dismissal of the head coach and corresponding supporting staff is a frequently occurring phenomenon in soccer , 71. SomHiring personal staff may also happen because it is fashionable. As so, players may dedicate their time outside training obligations to improve, among other things, psychological aspects, specific physical characteristics , or performing extra activities  that they judge relevant to their health and performance, thus impacting their careers. This occurs not only during specific season moments , but may occur more or less daily throughout the season. The drivers that motivate having an individual staff can be multiple and very diverse and discussing their merits or lack thereof may be pointless. What is important is that this new reality is upon us and must be acknowledged and dealt with appropriately.Clubs and players may benefit more from building bridges  than building walls that may hinder internal and external efficiency. If we do not establish a proper communication channel with the players’ staff, this unintentionally works both ways . MoreoveCommunication may “make or break” an organization’s effectiveness . FosteriIn this line of thought, Brito and colleagues  raised aIn this regard, if left unchecked, it may impact, not exclusively: (i) training load management and (ii) training programs optimization, and thus result, not solely, in: (i) excessive testing, (ii) early return to sports, and (iii) disruptions in nutrition and sleep education, habits, and shared meaning. Until an agreement on the context of players being concurrent under club and players’ staff supervision, the guidelines for improving the transition from elite clubs to national teams can support this initial process , 21, 25,We acknowledge that different types of bridges may be needed and have different drawbacks. Notably, the differences between the groups one is trying to bridge may imply distinct forms of communication, interaction , and information to share, customized to each club’s reality and each player’s personal staff qualities. How can someone build a bridge if he does not have access to the other side? Ideally, this should be a two-way process. With great power comes great responsibility .The importance of quantifying training load is extensively considered in the detailed frameworks of the majority of the performance, stress, strain, overuse-related, and injury prevention conceptual models in the scientific literature –78, and Another scenario where the absence of communication may strongly impact a player's training load management is during the competitive microcycle. The player’s chronic and acute exposure drives the planification at the club’s level. The latter, in particular, is one of the most robust individual variables that influence and modify short-term training prescription (48 h after the game) at the club , 82–84. In this regard, although there is the documented protective and performance enhancement effect of eccentric exercise and exposure to high-speed running in soccer players, more is not always better , 87, 88.Independently of the season moment, if we fail to consider the stimulus outside the club settings, this may result in incorrect training load data-driven decision-making , and well-informed decisions will be at risk , 35. ForSeveral testing approaches are applied in the club that may be replicated in the national team environment  and by tThe return-to-play decisions after injuries are one of the most sensitive aspects of managing players’ performance and health. Coaches and players possess sufficient theoretical knowledge about soccer medicine . SurveysIt is possible to observe performance enhancement  and injury prevention technologies and paradigms being promoted and acclaimed in the media and digital channels, with or without proper scientific support. Although modern players are more aware of the different dimensions of performance support, they are also more vulnerable to “noise”  around performance optimization, with greater susceptibility in young and adult players –102. ThiFurthermore, we should not exclude the possibility of someone from the players’ staff acting outside his scope of practice  . SignifiWe understand that it is impossible to quantify and control everything that may influence players’ performance and health, and this process is not as simple as it may seem. However, efforts must be implemented to clarify and certify complete management of the players’ performance and health environment, where the existence and impact of this personal staff are considered. Although the positive aspects of possessing a personalized support team can be easily named, if a proper communication channel is not established, this may unintentionally work both ways; just letting the processes into the hand of chance will not be the best way to proceed. This emerging reality calls for enhanced communication and data sharing across all the elements that provide players performance support; in other words, connecting the teams inside the “team”, the player’s personalized support team, with the club’s team. The final goal would be to put personal agendas aside and try to get the balance right and better manage a player-centered process.


Polymeric excipients play an important role in a cocrystal formulation to act as precipitation inhibitors to maximize the potential. Otherwise, a stable form of the parent drug will be recrystallized on the dissolving cocrystal surface and/or in the bulk solution during the cocrystal dissolution process, negating the solubility advantage. The objectives of this work were to investigate the potential of using combined polymers to maximise the dissolution performance of surface precipitation pharmaceutical cocrystals.The dissolution performance of a highly soluble flufenamic acid and nicotinamide (FFA-NIC) cocrystal has been systematically studied with predissolved or powder mixed with a single polymer, including a surface precipitation inhibitor  and two bulk precipitation inhibitors , or binary polymers combinations.A single polymer of PVP-VA prevented the FFA surface precipitation for an enhanced dissolution performance of FFA-NIC cocrystal. Unfortunately, it cannot sustain the supersaturated FFA concentration in the bulk solution. A combination of two polymers of PVP-VA and SLP has shown a synergistic inhibition effect to enhance the dissolution advantage of FFA-NIC cocrystal.The dissolution of a cocrystal with surface precipitation of the parent drug can be described as: i) the cocrystal surface contacting the dissolution medium; ii) the cocrystal surface dissolving; iii) the parent drug precipitation on the dissolving surface; and iv) the parent drug particles redissolving. A combination of two types of polymers can be used to maximise the cocrystal performance in solution.The online version contains supplementary material available at 10.1007/s11095-023-03532-x. Solid crystalline forms of active pharmaceutical ingredients (APIs) are preferred in the drug product development because they can be easily formulated into tablets and capsules. However, many APIs exhibit poor solubility and low dissolution rates in the aqueous environments of the gastrointestinal tract, leading to erratic dissolution performances and low oral bioavailability. Pharmaceutical cocrystallisation has become an attractive strategy for the discovery of new solid forms of an API with improved physicochemical properties, such as solubility, dissolution rate, stability and mechanical properties, through non-covalent interactions with a pharmaceutical cocrystal former molecule  . SuccessAlthough the promising benefits, developing pharmaceutical cocrystal formulations is challenging because of the instability of pharmaceutical cocrystals in both solid and solution states. In the solid state, cocrystals could be susceptible to phase conversion at high humidity or in the presence of excipients in the formulation , 4. In tGenerally, cocrystals, which cause surface precipitation of parent drugs, are of significantly improved solubility and dissolution rates , 14. TheThe specific objectives of this work were to investigate the potential of using combined polymers to maximise the dissolution performance of surface precipitation pharmaceutical cocrystals across different dissolution environments. This study firstly examined the dissolution performances of a cocrystal with surface precipitation of the parent drug FFA-NIC) as the model cocrystal in double distilled water (DDW) in the absence and presence of an individual polymer, including a polymeric surface precipitation inhibitor, i.e., PVP-VA, and two different bulk precipitation inhibitors of PEG and Soluplus (SLP) , 6. PVP-C as the In practice, polymers used in the formulation cannot be predissolved in the solution. Thus, in this work, the FFA release performances were examined in the powder mixtures of FFA-NIC cocrystal with an individual or combined polymeric excipients under non-sink (i.e. PBS pH 4.5) and sink  environments. Finally, insights into the dissolution and recrystallisation mechanisms of a cocrystal system were discussed.2PO4), and sodium hydroxide (NaOH) were purchased from Sigma- Aldrich . Copolymer of vinylpyrrolidone (60%) /vinyl acetate (40%)  was kindly donated by Ashland Inc. . Poly(ethylene glycol) (PEG) 4000 was purchased from Sigma-Aldrich . Soluplus® (SLP) was donated by BASF . Methanol (HPLC grade) and acetonitrile (HPLC grade) were purchased from Fisher Scientific  and used as received. Double distilled water (DDW) was generated from a bi-distiller  and used throughout the study.Flufenamic acid form I (FFA I), nicotinamide (NIC) (≥ 99.5% purity), theophylline (TP) (≥ 99.5% purity), potassium dihydrogen phosphate (KHPBS pH 6.8 (0.01 M) and PBS pH 4.5 (0.01 M) as dissolution media were prepared according to British Pharmacopoeia 2018. For PBS pH 6.8, 50 mL of 0.2 M potassium dihydrogen phosphate and 22.4 mL of 0.2 M sodium hydroxide were mixed and diluted to 1000 mL with DDW. For PBS pH 4.5, 1.361 g of potassium phosphate monobasic dissolved in 1000 mL DDW. pH value of the solution was adjusted using sodium hydroxide solution if necessary.The FFA-NIC and FFA-TP cocrystal powders were generated by cooling crystallisation using Polar Bear Plus Crystal . A 1:1 molar ratio mixture of FFA and NIC or TP powders was added into the cosolvent (70% v/v acetonitrile: 30% v/v water) in a 20 mL vial and held at 45°C until all solids were dissolved. The temperature was then reduced to 0°C at a cooling rate of 0.3°C/min. The powders formed were isolated by paper filtration and air-dried. Prior to further usage, the obtained powders were analysed by PXRD for confirmation of the cocrystal formation by comparing the predicted PXRD pattern retrieved from the Cambridge Structural Database (CSD), i.e., CSD reference: ZIQDUA for FFA-TP or EXAQAW for FFA-NIC.The FFA solubility was determined by suspending an excess amount of crystalline materials of FFA I in small vials with 20 mL of a selected dissolution medium  in the absence and presence of a predissolved single polymer and a combination. The detailed polymers and their corresponding concentrations were 0.2 mg/mL of PVP-VA, 1 mg/mL of PEG and 0.2 mg/mL of SLP, which were based on the previous study [Additionally, the FFA solubility in PBS pH 6.8 at 37 ± 0.5°C was also measured in triplicate.For a 1:1 AB cocrystal without consideration of ionization of each component, its molar solubility lated as 1\documenIn order to determine the FFA-NIC cocrystal solubility, the physical mixtures of the FFA I and NIC solids and a constant 10 mL of the medium , representing 10% w/w and 90% w/w of the total weight of a sample, were used. More than eight different ratios of the FFA I and NIC solids in the physical mixtures  of the solid particles were compared. The data were analysed by the Microtrac FLEX software (12.0.0.1).All samples  used in the dissolution tests were slightly ground by a mortar and pestle and sieved by a 60-mesh sieve (below 250 μm) to reduce the influence of particle size on the dissolution rates. The particle size distributions of the test samples were measured using a SYNC Analyzer . The particle size distributions  at 37 ± 0.5°C with a paddle speed of 50 rpm in 400 mL of DDW in the absence and presence of a predissolved polymer  or a combination of two polymers .71.7 mg of FFA-NIC cocrystal powders with the equivalent of 50 mg FFA I powders were used in each of the dissolution tests. Samples of 1 ± 0.1 mL were withdrawn from the dissolution vessel at the predefined time points of 5, 10, 15, 30, 60, 120, 180 and 240 min. The supernatant of each of the samples was separated from the excess solids by centrifugation at 13,000 RPM for 1 min in an MSE Micro Centaur. HPLC was used to determine the concentrations of FFA and NIC in solution. Solid residues obtained from the experiments were dried at room temperature and analysed by PXRD. All experiments were repeated in triplicate.For comparison, the above dissolution tests were also repeated using 50 mg of pure FFA I powders and 82.0 mg of FFA-TP cocrystal powders.in vitro dissolution tests of the powder mixtures of 71.7 mg of the FFA-NIC cocrystals with an individual polymer or a combination in PBS pH 4.5 or PBS pH 6.8 were conducted in triplicate. The amount of a polymer used in the powder mixture was 80 mg of PVP-VA, 400 mg of PEG, or 80 mg of SLP, corresponding to their predissolved concentrations used in Section "Similarly, The solid residues obtained from the experiments in PBS pH 4.5 were dried at room temperature and analysed by PXRD. t, and DPP was used to evaluate the dissolution profile of the test powders in comparison to a reference system, which is defined as ,4\documeIn comparison with the reference dissolution profile, a positive DPP value indicates an increased ability of the dissolved drug to be maintained in a dissolution medium, while a negative DPP value shows a lesser amount of the drug to be maintained in solution.The sample concentration of FFA, NIC or TP in solution was determined by a Hewlett Packard series 1100 automatic HPLC system . A Roc C18 5 μm column, 150 × 4.6 mm  was used at ambient temperature. FFA was detected by UV absorbance detection at a wavelength of 286 nm. The mobile phase used consisted of 15% water (including 0.5% formic acid) and 85% methanol, and the mobile phase flow rate was maintained at 0.5 mL/min. NIC and TP were detected by UV absorbance detection at a wavelength of 265 nm and 271 nm respectively, the mobile phase was composed of 15% water (including 0.5% formic acid) and 85% methanol, and the mobile phase flow rate was kept at 0.5 mL/min. The injection volume was 20 μL.The solids were scanned by D2 phaser diffractometer  with Cu-Kβ radiation operating at voltage of 30 kV and current of 10 mA. The scanning angle ranged from 2°-40° of 2θ. The scanning time per step was 0.4 s. The scan step size was 0.02° of 2θ.The differences in the FFA solubility in DDW and PBS pH 4.5 at 37°C in the absence and presence of a predissolved polymer or a combination were analysed by two-way Student's t-test with a significance level of 5%.10 and D50 values. The D90 and mean values of FFA-NIC cocrystal distribution are the smallest, indicating a narrow size distribution . In contrast, in the presence of a predissolved PEG or SLP in DDW, it shows different behaviour (P < 0.05). The FFA solubility was increased significantly to 110.54 ± 16.22 μg/mL with predissolved 0.2 mg/mL SLP whilst a small increase was observed in the presence of 1 mg/mL PEG, indicating that SLP is a stronger solubilizing agent. The FFA solubility in the presence of a combination of two predissolved polymers of 1 mg/mL PEG with 0.2 mg/mL PVP-VA also remained the same as that in the presence of PEG (P > 0.05), indicating there is no synergistic interaction between PEG and PVP-VA to solubilize the FFA molecules in DDW. A similar observation (P > 0.05) was applied to the combined predissolved polymers of 0.2 mg/mL SLP and 0.2 mg/mL PVP-VA when compared with that in 0.2 mg/mL SLP.The FFA solubility in DDW and PBS pH 4.5 at 37°C in the absence and presence of a predissolved polymer or a combination are shown in Fig. P > 0.05) in SLP predissolved PBS pH 4.5 in the absence and presence of PVP-VA. Overall, there is no synergistic interaction between PVP-VA with PEG or SLP to solubilize the FFA molecules in PBS pH 4.5.The FFA solubility in PBS pH 4.5 at 37°C was 18.27 ± 2.39 μg/mL in Fig. It is worth noting that the PXRD results of the solid residues after the solubility tests  within 60 min and then stayed constantly at 10.78 μg/mL during the FFA-NIC cocrystal powder dissolution in DDW [Fig. As shown in Fig. A further enhancement of the dissolution performance of FFA-NIC cocrystal was observed in a combined PVP-VA with SLP predissolved DDW, i.e., the DPP value of 160% was observed in Fig. There was no obvious change of the DPP value under the dissolution conditions of the predissolved PVP-VA solution in the absence and presence of PEG in Fig. As shown in Fig. According to the PXRD results [Fig. At a fixed concentration of 0.2 mg/mL PVP-VA predissolved in DDW, the FFA release rate from FFA-NIC cocrystal was not affected significantly by varying the predissolved SLP concentration  [Fig. The PXRD results [Fig. In order to compare the dissolution behaviours of FFA-NIC cocrystal in different environments under non-sink conditions, PBS pH 4.5 was selected as the dissolution medium due to the low FFA solubility [i.e., 18.27 ± 2.39 μg/mL in Fig. A combination of PVP-VA and SLP with the FFA-NIC cocrystals showed a further enhanced dissolution performance in PBS pH 4.5 [Fig. Surprisingly, FFA-NIC cocrystal mixed with the combination of PEG and PVP-VA led to a reduced dissolution performance (36%) in comparison with PVP-VA alone (92%).The PXRD results [Fig. As the equilibrium solubility of FFA in PBS pH 6.8 at 37°C was 741.15 ± 6.27 μg/mL, the 400 mL dissolution medium used in the test can dissolve around 300 mg of FFA. Thus, the dissolution tests of the FFA-NIC cocrystal powders with an equivalent of 50 mg FFA used in PBS pH 6.8 at 37°C were conducted under sink conditions. The dissolution tests of the FFA-NIC cocrystal powders mixed with PVP-VA, SLP or their combination were examined. The physical mixtures of FFA-NIC cocrystal with SLP cannot improve its dissolution performance, shown in Figs. Due to the high solubility of both FFA and NIC in PBS pH 6.8 at 37°C, no solid residue can be collected after the dissolution after 4 h.Cocrystallisation of a poorly water-soluble API with soluble coformers has been extensively exploited as a strategy for improving its dissolution performance over the last two decades . As a coIt has been frequently mentioned that the advantage of pharmaceutical cocrystals is to increase the solubility of poorly water-soluble drug compounds. A definition of pharmaceutical cocrystal solubility without consideration of ionization of each component is given in Eq. , which iA cocrystal PSD in Fig. n system , 28, 29.solution , 31. ThiWithout excess coformer in solution, any dose, which is greater than In our previous studies, we have demonstrated that the API precipitation occurred once the surface of a cocrystal contacts the dissolution medium , 6, 32. solution , it is eAs the surface precipitation of the parent API is induced by the local supersaturation, recrystallisation of API is expected to occur during a cocrystal dissolution under sink conditions as well, in which the cocrystal dose is less than The predissolved PVP-VA in solution can be adsorbed on the dissolving cocrystal particles to reduce the cocrystal surface area directly contacting the dissolution medium, leading to a reduced cocrystal dissolution rate and the local drug supersaturation . Hence, PEG or SLP alone cannot reduce or prevent the surface precipitation of FFA during FFA-NIC cocrystal dissolution [Fig. In the above experiments, PVP-VA played an important role to avoid surface precipitation for an enhanced FFA DPP value from the dissolution of FFA-NIC cocrystal. However, once the built-up FFA concentration in the bulk solution was higher than its equilibrium solubility, the bulk recrystallisation took place because at this point the FFA molecules cannot be sustained in solution by the coformer of NIC due to its low concentration shown in Fig. In this study, PVP-VA was used as a precipitation inhibitor to prevent the surface precipitation of FFA whilst the other polymer PEG or SLP functioned as an effective bulk solution precipitation inhibitor to maintain the FFA molecules in solution shown in Fig. In contrast, a combination of PVP-VA and SLP resulted in a synergistic effect. In DDW with a combination of the predissolved PVP-VA (0.2 mg/mL) and SLP (0.2 mg/mL), a 160% increase in DPP was observed compared with the individual polymers, i.e., 19% for PVP-VA and 67% for SLP [Fig. Finally, it was worth noting that the dissolution behaviour of a cocrystal with bulk precipitation of the parent drug, (FFA-TP) was similar to its parent drug of FFA I in Figure in vitro kinetic solubility profile has been used to correlate the corresponding potential bioavailability enhancement. The insights into the cocrystal dissolution mechanisms have been revealed. It is shown that the dissolution of a cocrystal with surface precipitation of the parent drug can be described by four consecutive steps as: i) the cocrystal surface contacting the dissolution medium; ii) the cocrystal surface dissolving; iii) the parent drug precipitation on the dissolving surface; and iv) the parent drug particles redissolving. A single polymer of PVP-VA as a surface precipitation inhibitor prevented the FFA surface precipitation for an enhanced dissolution performance of FFA-NIC cocrystal. Unfortunately, it cannot sustain the supersaturated FFA concentration in the bulk solution. Thus, a single polymer of PVP-VA could not fulfil all requirements, for example, a higher AUC or a “spring” effect. A combination of two polymers of PVP-VA and SLP has shown a synergistic inhibition effect to maximise the dissolution advantage of the surface cocrystal of FFA-NIC, in particular by reducing the amount of polymer used in the formulation. Our results also highlight that the type of polymers and their concentration combinations either in pre-dissolved solution or in physical mixtures need to be optimised to maximise the kinetic solubility curve of cocrystal in solution.In this study, the dissolution performance of a highly soluble FFA-NIC cocrystal has been systematically studied under both non-sink and sink dissolution environments with predissolved or powder mixed a single polymer  or binary polymers combinations . The impact of the polymers on the drug release rates from the FFA-NIC cocrystal formulations has been examined. To quantitatively evaluate the performance of different cocrystal formulations, the FFA DPP value based on the AUC of the Supplementary file1 (DOCX 2797 KB)Below is the link to the electronic supplementary material.


Osteoporosis is a prevalent complication of diabetes, characterized by systemic metabolic impairment of bone mass and microarchitecture, particularly in the spine. Anemarrhenae Rhizoma/Phellodendri Chinensis Cortex (AR/PCC) herb pair has been extensively employed in Traditional Chinese Medicine to manage diabetes; however, its potential to ameliorate diabetic osteoporosis (DOP) has remained obscure. Herein, we explored the protective efficacy of AR/PCC herb pair against DOP using a streptozotocin (STZ)‐induced rat diabetic model. Our data showed that AR/PCC could effectively reduce the elevated fasting blood glucose and reverse the osteoporotic phenotype of diabetic rats, resulting in significant improvements in vertebral trabecular area percentage, trabecular thickness and trabecular number, while reducing trabecular separation. Specifically, AR/PCC herb pair improved impaired osteogenesis, nerve ingrowth and angiogenesis. More importantly, it could mitigate the aberrant activation of osteoblast pyroptosis in the vertebral bodies of diabetic rats by reducing increased expressions of Nlrp3, Asc, Caspase1, Gsdmd and IL‐1β. Mechanistically, AR/PCC activated antioxidant pathway through the upregulation of the antioxidant response protein Nrf2, while concurrently decreasing its negative feedback regulator Keap1. Collectively, our in vivo findings demonstrate that AR/PCC can inhibit osteoblast pyroptosis and alleviate STZ‐induced rat DOP, suggesting its potential as a therapeutic agent for mitigating DOP. It is characterized by activation of Caspase1 and Gasdermin D (Gsdmd)‐mediated membrane rupture, resulting in the excessive release of pro‐inflammatory mediators, particularly interleukin‐1β (IL‐1β).As a pivotal modulator of oxidant–antioxidant equilibrium, the nuclear factor erythroid 2‐related factor 2 (Nrf2) plays a crucial role in upholding cellular redox homeostasis by impeding the binding of Kelch‐Like ECH‐Associated Protein 1 (Keap1) and governing the expression of antioxidant genes.In this study, to investigate the therapeutic effect of AR/PCC herb pair in the progression of DOP, we constructed an STZ‐induced DOP model in rats and found that STZ‐treated DM rats exhibited elevated fasting blood glucose (FBG) levels along with a striking DOP phenotype, and administration of AR/PCC herb pair effectively reversed these manifestations. Subsequent analyses showed that AR/PCC exerts inhibitory effects on Nlrp3‐mediated pyroptosis in osteoblasts by activating the Nrf2/Keap1 signalling pathway. Our in vivo findings provide further insights into the pharmacological properties of AR/PCC concerning the progression of DOP, highlighting the potential of AR/PCC as a promising therapeutic agent for DOP treatment.22.1Crude drugs of AR and PCC were provided by Zhejiang Jingyuetang Pharmaceutical Co. Ltd. Voucher specimens of AR no. RA2019090821) and PCC (no. PA2019052101) were deposited at the Department of Medicine, Zhejiang Academy of Traditional Chinese Medicine. The primary antibodies used in this study are summarized in Table 9090821 a2.2AR/PCC pair was prepared in a 1:1 (w/w) ratio, as we previously described.2.3Eight‐week‐old male Wistar rats, weighing 200–220 g, were procured from Beijing Vita River Laboratory Animal Technology . All rats were housed in a temperature‐controlled room at 23 ± 2°C within a 12‐h light/dark cycle, and they had ad libitum access to water and lab chow. All experiments were approved by The Ethics Committee of Zhejiang Traditional Chinese Medicine Institution and performed in accordance with the ethical guidelines for using and caring of laboratory animals with the permission of Zhejiang Traditional Chinese Medicine Institution principles for laboratory animal use and care (no. [2019]018).n = 6 per group): Control group, Model group, Low AR/PCC group and High AR/PCC group. All rats except those in the Control group underwent DOP modelling. The STZ‐induced DOP model was established as we previously described.All rats were randomly divided into four groups . Bone morphometric parameters including trabecular area (Tb.Ar), trabecular number (Tb.N), trabecular thickness (Tb.Th) and trabecular separation (Tb.Sp) were analysed using the Image‐Pro Plus Software version 6.0 (Media Cybernetics Inc). The histological scoring was conducted by a blind pathologist, following a previously described method.2.5The sections were deparaffinized in xylene, rehydrated by a graded series of alcohol, rinsed with PBS and then stained with an Alp kit as per the manufacturer's instructions. Triplicates of each sample were used for staining. The Alp‐positive staining area in the 4th lumbar vertebral body was analysed and quantified using a microscope (Carl Zeiss).2.6+ cells and Cd31+ cells were determined by counting the positively stained region in the indicated areas as we previously described.Sections were deparaffinized, rehydrated and subjected to antigen retrieval in 0.01 mol/L citrate buffer at 60°C for 6 h. Then, sections were treated with 0.3% hydrogen peroxide to reduce endogenous peroxidase activity and blocked with 5% normal goat serum for 30 min at room temperature. The sections were then incubated with respective primary antibody overnight at 4°C, and negative control sections were incubated with PBS. Subsequently, they were incubated with fluorescent‐conjugated secondary antibody for 1 h in the dark. Nonspecific fluorescence in the vertebral body was quenched with Vector® TrueVIEW® Autofluorescence Quenching Kit (Vector Laboratories Inc). After DAPI counterstaining, the sections were observed under the fluorescence microscope (Carl Zeiss). Each experiment was repeated in triplicates. Quantitative histomorphometric analysis was performed using the Image‐Pro Plus Software version 6.0, and the integrated optical density in indicated areas was calculated in a blinded manner. The percentages of Cgrp2.7anova) followed by Tukey's multiple comparisons test was performed using the GraphPad Prism 8 statistics software, to compare the statistical differences among groups. p < 0.05 was considered as statistical significance.All numerical data were expressed as mean ± SEM. One‐way analysis of variance  in DM mice.+ cells and the decline of Vegf levels within the vertebral bodies of DM rats in a dose‐dependent manner ; formal analysis ; methodology ; writing – original draft . Huan Luo: Data curation ; formal analysis ; methodology ; software . Yu Du: Data curation ; formal analysis ; methodology ; software . Yuying Chen: Formal analysis ; software . Kun Tian: Formal analysis ; methodology ; software . Jin Pan: Formal analysis ; methodology ; software . Jian Li: Formal analysis ; methodology ; software . Nani Wang: Formal analysis ; methodology ; software . Ronghua Bao: Formal analysis ; methodology ; software . Hongting Jin: Formal analysis ; methodology ; software . Peijian Tong: Formal analysis ; methodology ; software . Hongfeng Ruan: Conceptualization (lead); writing – original draft ; writing – review and editing . Chengliang Wu: Formal analysis ; methodology ; software ; writing – original draft ; writing – review and editing .This work was financially supported by National Natural Science Foundation of China , Natural Science Foundation of Zhejiang Province (no. LQ23H270003 and LY22H270003), Joint Funds of the Zhejiang Provincial Natural Science Foundation of China (no. LBY22H270008), Traditional Chinese Medical Administration of Zhejiang Province , Zhejiang Medical and Health Science and Technology Project , Research Project of Zhejiang Chinese Medical University , Research Project of Zhejiang Chinese Medical University Affiliated Hospital (no. 2022FSYYZZ05 and 2022FSYYZQ02), Zhejiang Chinese Medical University School‐level Education and Teaching Reform Project (no. CY22001).The authors confirm that there are no conflicts of interest.Figure S1Click here for additional data file.