## 3 Results
### Quality Assessment  
The quality of the included in vitro studies was systematically evaluated using the OHAT tool, which was tailored for non-human studies. The assessment focused on key domains, such as randomization, blinding, selection bias, performance bias, attrition bias, reporting bias, and statistical methods (Table 4). Overall, the studies exhibited a low-to-moderate risk of bias across most domains. Randomization was lacking in most studies, leading to a moderate risk of bias in this domain. Only two studies, [PERSON] et al., 2023, and [PERSON] et al., 2024, incorporated randomization, contributing to a lower risk of bias in their methodology [34; 35]. Most studies adequately addressed blinding, particularly in the outcome assessment, reducing detection bias risk. However, studies, such as the study by [PERSON] et al., 2019, and [PERSON] et al., 2024, did not employ blinding, resulting in moderate bias concerns for these studies [32; 36].  
Selection bias was generally low, as most studies used appropriate and well-defined sample selection criteria. Performance bias and reporting bias were moderate in several studies, notably in the study by [PERSON] et al., 2019, [PERSON] et al., 2022, and [PERSON] et al., 2024, where variations in the experimental conditions or incomplete outcome reporting were observed [31; 33; 36]. Despite these limitations, the statistical methods used across all the studies were deemed appropriate, supporting the validity of the results.  
One notable limitation of the studies concerned the controlled in vitro environment, which could affect the generalizability of the findings to clinical settings. This issue raised concerns about the applicability of the results, particularly in translating laboratory findings to real-world clinical practice.  
The inter-reviewer reliability was high, with [PERSON]'s kappa value exceeding 0.80, indicating strong agreement between the reviewers during the quality assessment. This  
\begin{table}
\begin{tabular}{c c c c c c c c} \hline \hline
**Study** & **Randomization** & **Blinding** & \begin{tabular}{c} **Selection** \\ **Bias** \\ \end{tabular} & \begin{tabular}{c} **Performance** \\ **Bias** \\ \end{tabular} & \begin{tabular}{c} **Atttition** \\ **Bias** \\ \end{tabular} & \
\begin{tabular}{c} **Reporting** \\ **Bias** \\ \end{tabular} &
\begin{tabular}{c} **Statistical** \\ **Methods** \\ \end{tabular} \\ \hline [PERSON] et al., & & & & & & & \\
2018 [30] & No & Yes & Low & Low & Low & Appropriate \\ [PERSON] et al., & & & & & & & \\
2019 [31] & No & Yes & Moderate & Low & Low & Moderate & Appropriate \\ [PERSON] et al., & & & & & & & \\
2019 [32] & No & No & Low & Low & Low & Low & Appropriate \\ [PERSON] et al., & & & & & & & \\
2022 [33] & No & Yes & Moderate & Low & Low & Moderate & Appropriate \\ [PERSON] et al., & & & & & & & \\
2023 [34] & Yes & Yes & Low & Low & Low & Appropriate \\ [PERSON] et al. & & & & & & & \\
2024 [36] & No & No & Moderate & Low & Low & Moderate \\ \hline \hline \end{tabular}
\end{table}
Table 4: OHAT assessment.  
comprehensive evaluation provides confidence in the robustness of the evidence synthesized in this meta-analysis, while identifying areas for improvement in future research.  
In summary, the overall low-to-moderate risk of bias across most domains supports the validity of the meta-analysis findings. However, the moderate risks in terms of randomization, performance bias, and reporting bias suggest that future studies should improve the randomization methods used, ensure consistent reporting practices, and address the limitations inherent to in vitro studies for better applicability to clinical practice.