{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,23]],"date-time":"2026-10-23T19:21:05Z","timestamp":1792783265160,"version":"4.5.0"},"reference-count":30,"publisher":"Springer Science and Business Media LLC","issue":"5","license":[{"start":{"date-parts":[[2026,9,22]],"date-time":"2026-09-22T00:00:00Z","timestamp":1790035200000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"},{"start":{"date-parts":[[2026,9,22]],"date-time":"2026-09-22T00:00:00Z","timestamp":1790035200000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0"}],"funder":[{"name":"Pontif\u00edcia Universidade Cat\u00f3lica De Campinas","id":[{"id":"https:\/\/ror.org\/01wjxn842","id-type":"ROR","asserted-by":"crossref"}]}],"content-domain":{"domain":["link.springer.com"],"crossmark-restriction":false},"short-container-title":["Sleep Breath"],"published-print":{"date-parts":[[2026,10]]},"abstract":"<jats:title>Abstract<\/jats:title>\n                  <jats:sec>\n                    <jats:title>Purpose<\/jats:title>\n                    <jats:p>The apnea-hypopnea index (AHI), traditionally used to assess obstructive sleep apnea (OSA) severity and surgical outcomes, has limitations in reflecting cardiovascular risk and pathophysiological burden. Although lateral pharyngoplasty has demonstrated favorable outcomes regarding AHI reduction, its impact on hypoxic burden (HB) remains unknown. This study evaluated HB changes after lateral pharyngoplasty in patients with OSA, including those classified as surgical failures according to Sher\u2019s criteria.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>This observational, longitudinal study with a mixed retrospective and prospective design included 27 adults with OSA who underwent lateral pharyngoplasty (version 6) between 2016 and 2025, with complete preoperative and postoperative polysomnographic data for HB assessment. HB was calculated using validated commercial software. Nonparametric tests were used for intra- and intergroup comparisons. Surgical success was defined according to Sher\u2019s criteria.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>\n                      A significant reduction in HB was observed across all variants: total sleep time (median from 97.1%\u00b7min\/h to 35.0%\u00b7min\/h,\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u20090.0001), REM sleep, NREM sleep, and supine and non-supine positions, with a significant reduction in median AHI (median from 33.8 to 12.3 events\/h,\n                      <jats:italic>p<\/jats:italic>\n                      \u2009&lt;\u20090.0001). Even among surgical failures according to Sher\u2019s criteria, HB decreased significantly (median from 102.5%\u00b7min\/h to 67.3%\u00b7min\/h,\n                      <jats:italic>p<\/jats:italic>\n                      \u2009=\u20090.0107), suggesting pathophysiological improvement not captured by AHI alone.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>HB is a potentially more sensitive metric to assess therapeutic response in OSA, incorporating multiple dimensions of nocturnal hypoxemia beyond AHI. Lateral pharyngoplasty promoted consistent HB reduction, including in surgical failures, supporting HB as a complementary tool for therapeutic evaluation, with potential applications in cardiovascular risk stratification.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1007\/s11325-026-03808-7","type":"journal-article","created":{"date-parts":[[2026,9,22]],"date-time":"2026-09-22T05:45:45Z","timestamp":1790055945000},"update-policy":"https:\/\/doi.org\/10.1007\/springer_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Hypoxic burden reduction after lateral pharyngoplasty in patients with obstructive sleep apnea: Beyond the apnea-hypopnea index"],"prefix":"10.1007","volume":"30","author":[{"ORCID":"https:\/\/orcid.org\/0009-0006-7782-9230","authenticated-orcid":false,"given":"Andr\u00e9 Lu\u00eds Pereira","family":"Vieira","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4821-5102","authenticated-orcid":false,"given":"Bruno Bernardo","family":"Duarte","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6579-9456","authenticated-orcid":false,"given":"Aurelio Rochael","family":"Almeida","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2848-4812","authenticated-orcid":false,"given":"M\u00e1rio Edvin","family":"Greters","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2623-6471","authenticated-orcid":false,"given":"V\u00e2nia Aparecida","family":"Leandro-Merhi","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-0604-9054","authenticated-orcid":false,"given":"Jos\u00e9 Lu\u00eds Braga","family":"de Aquino","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"297","published-online":{"date-parts":[[2026,9,22]]},"reference":[{"issue":"1","key":"3808_CR1","doi-asserted-by":"publisher","first-page":"1","DOI":"10.5935\/1808-8694.2014S001","volume":"80","author":"E Zancanella","year":"2014","unstructured":"Zancanella E, Haddad FM, Oliveira LAMP et al (2014) Obstructive sleep apnea and primary snoring: Diagnosis. Braz J Otorhinolaryngol 80(1):1\u201316. https:\/\/doi.org\/10.5935\/1808-8694.2014S001","journal-title":"Braz J Otorhinolaryngol"},{"issue":"5","key":"3808_CR2","doi-asserted-by":"publisher","first-page":"441","DOI":"10.1016\/j.sleep.2009.10.005","volume":"11","author":"S Tufik","year":"2010","unstructured":"Tufik S, Santos-Silva R, Taddei JA, Bittencourt LRA (2010) Obstructive sleep apnea syndrome in the Sao Paulo epidemiologic sleep study. Sleep Med 11(5):441\u2013446. https:\/\/doi.org\/10.1016\/j.sleep.2009.10.005","journal-title":"Sleep Med"},{"issue":"4","key":"3808_CR3","doi-asserted-by":"publisher","first-page":"310","DOI":"10.1016\/S2213-2600(15)00043-0","volume":"3","author":"R Heinzer","year":"2015","unstructured":"Heinzer R, Vat S, Marques-Vidal P et al (2015) Prevalence of sleep-disordered breathing in the general population: the HypnoLaus study. Lancet Respir Med 3(4):310\u2013318. https:\/\/doi.org\/10.1016\/S2213-2600(15)00043-0","journal-title":"Lancet Respir Med"},{"issue":"11","key":"3808_CR4","doi-asserted-by":"publisher","first-page":"4021","DOI":"10.1007\/s00405-016-4131-1","volume":"273","author":"LK Huon","year":"2016","unstructured":"Huon LK, Liu SYC, Shih TTF et al (2016) Dynamic upper airway collapse observed from sleep MRI: BMI-matched severe and mild OSA patients. Eur Arch Oto-Rhino-Laryngol 273(11):4021\u20134026. https:\/\/doi.org\/10.1007\/s00405-016-4131-1","journal-title":"Eur Arch Oto-Rhino-Laryngol"},{"issue":"2","key":"3808_CR5","doi-asserted-by":"publisher","first-page":"624","DOI":"10.1378\/chest.128.2.624","volume":"128","author":"F Campos-Rodriguez","year":"2005","unstructured":"Campos-Rodriguez F, Pe\u00f1a-Gri\u00f1an N, Reyes-Nu\u00f1ez N et al (2005) Mortality in obstructive sleep apnea-hypopnea patients treated with positive airway pressure. Chest 128(2):624\u2013633. https:\/\/doi.org\/10.1378\/chest.128.2.624","journal-title":"Chest"},{"issue":"4","key":"3808_CR6","doi-asserted-by":"publisher","DOI":"10.1111\/jsr.13066","volume":"29","author":"DA Pevernagie","year":"2020","unstructured":"Pevernagie DA, Gnidovec-Strazisar B, Grote L et al (2020) On the rise and fall of the apnea\u2212hypopnea index: a historical review and critical appraisal. J Sleep Res 29(4):e13066. https:\/\/doi.org\/10.1111\/jsr.13066","journal-title":"J Sleep Res"},{"issue":"1","key":"3808_CR7","doi-asserted-by":"publisher","first-page":"36","DOI":"10.1016\/j.arbres.2022.08.005","volume":"59","author":"MA Martinez-Garcia","year":"2023","unstructured":"Martinez-Garcia MA, S\u00e1nchez-de-la-Torre M, White DP, Azarbarzin A (2023) Hypoxic burden in obstructive sleep apnea: present and future. Arch Bronconeumol 59(1):36\u201343. https:\/\/doi.org\/10.1016\/j.arbres.2022.08.005","journal-title":"Arch Bronconeumol"},{"issue":"6","key":"3808_CR8","doi-asserted-by":"publisher","first-page":"2300828","DOI":"10.1183\/13993003.00828-2023","volume":"62","author":"L Pinilla","year":"2023","unstructured":"Pinilla L, Esmaeili N, Labarca G et al (2023) Hypoxic burden to guide CPAP therapy allocation in patients with obstructive sleep apnoea: a post hoc study of the ISAACC trial. Eur Respir J 62(6):2300828. https:\/\/doi.org\/10.1183\/13993003.00828-2023","journal-title":"Eur Respir J"},{"issue":"2","key":"3808_CR9","doi-asserted-by":"publisher","first-page":"739","DOI":"10.1016\/j.chest.2020.03.053","volume":"158","author":"A Azarbarzin","year":"2020","unstructured":"Azarbarzin A, Sands SA, Taranto-Montemurro L et al (2020) The Sleep Apnea-Specific Hypoxic Burden Predicts Incident Heart Failure. Chest 158(2):739\u2013750. https:\/\/doi.org\/10.1016\/j.chest.2020.03.053","journal-title":"Chest"},{"issue":"6","key":"3808_CR10","doi-asserted-by":"publisher","first-page":"3504","DOI":"10.1002\/ehf2.14526","volume":"10","author":"B Huang","year":"2023","unstructured":"Huang B, Huang Y, Zhai M et al (2023) Association of hypoxic burden metrics with cardiovascular outcomes in heart failure and sleep-disordered breathing. ESC Heart Fail 10(6):3504\u20133514. https:\/\/doi.org\/10.1002\/ehf2.14526","journal-title":"ESC Heart Fail"},{"issue":"7","key":"3808_CR11","doi-asserted-by":"publisher","first-page":"802","DOI":"10.1164\/rccm.202209-1808OC","volume":"208","author":"G Labarca","year":"2023","unstructured":"Labarca G, Vena D, Hu WH et al (2023) Sleep Apnea Physiological Burdens and Cardiovascular Morbidity and Mortality. Am J Respir Crit Care Med 208(7):802\u2013813. https:\/\/doi.org\/10.1164\/rccm.202209-1808OC","journal-title":"Am J Respir Crit Care Med"},{"issue":"14","key":"3808_CR12","doi-asserted-by":"publisher","first-page":"1149","DOI":"10.1093\/eurheartj\/ehy624","volume":"40","author":"A Azarbarzin","year":"2019","unstructured":"Azarbarzin A, Sands SA, Stone KL et al (2019) The hypoxic burden of sleep apnoea predicts cardiovascular disease-related mortality: The Osteoporotic Fractures in Men Study and the Sleep Heart Health Study. Eur Heart J 40(14):1149\u20131157. https:\/\/doi.org\/10.1093\/eurheartj\/ehy624","journal-title":"Eur Heart J"},{"issue":"4","key":"3808_CR13","doi-asserted-by":"publisher","first-page":"359","DOI":"10.1016\/S2213-2600(19)30271-1","volume":"8","author":"M S\u00e1nchez-de-la-Torre","year":"2020","unstructured":"S\u00e1nchez-de-la-Torre M, S\u00e1nchez-de-la-Torre A, Bertran S et al (2020) Effect of obstructive sleep apnoea and its treatment with continuous positive airway pressure on the prevalence of cardiovascular events in patients with acute coronary syndrome (ISAACC study): a randomised controlled trial. Lancet Respir Med 8(4):359\u2013367. https:\/\/doi.org\/10.1016\/S2213-2600(19)30271-1","journal-title":"Lancet Respir Med"},{"issue":"6","key":"3808_CR14","doi-asserted-by":"publisher","first-page":"923","DOI":"10.1177\/019459988108900609","volume":"89","author":"S Fujita","year":"1981","unstructured":"Fujita S, Conway W, Zorick F, Roth T (1981) Surgical correction of anatomic abnormalities in obstructive sleep apnea syndrome: Uvulopalatopharyngoplasty. Otolaryngol Head Neck Surg 89(6):923\u2013934. https:\/\/doi.org\/10.1177\/019459988108900609","journal-title":"Otolaryngol Head Neck Surg"},{"issue":"1","key":"3808_CR15","doi-asserted-by":"publisher","first-page":"13","DOI":"10.1067\/mhn.2002.126477","volume":"127","author":"M Friedman","year":"2002","unstructured":"Friedman M, Ibrahim H, Bass L (2002) Clinical staging for sleep-disordered breathing. Otolaryngol Head Neck Surg 127(1):13\u201321. https:\/\/doi.org\/10.1067\/mhn.2002.126477","journal-title":"Otolaryngol Head Neck Surg"},{"issue":"11","key":"3808_CR16","doi-asserted-by":"publisher","first-page":"1961","DOI":"10.1097\/00005537-200311000-00020","volume":"113","author":"MB Cahali","year":"2003","unstructured":"Cahali MB (2003) Lateral pharyngoplasty: A new treatment for obstructive sleep apnea hypopnea syndrome. Laryngoscope 113(11):1961\u20131968. https:\/\/doi.org\/10.1097\/00005537-200311000-00020","journal-title":"Laryngoscope"},{"issue":"1","key":"3808_CR17","doi-asserted-by":"publisher","first-page":"311","DOI":"10.1002\/lary.24312","volume":"124","author":"CF De Paula Soares","year":"2014","unstructured":"De Paula Soares CF, Cavichio L, Cahali MB (2014) Lateral pharyngoplasty reduces nocturnal blood pressure in patients with obstructive sleep apnea. Laryngoscope 124(1):311\u2013316. https:\/\/doi.org\/10.1002\/lary.24312","journal-title":"Laryngoscope"},{"issue":"4","key":"3808_CR18","doi-asserted-by":"publisher","DOI":"10.1016\/j.amjoto.2020.102500","volume":"41","author":"S Elzayat","year":"2020","unstructured":"Elzayat S, El-Sobki A, El-Deeb ME, Moussa HH (2020) Managing obstructive sleep apnea patients with CPAP failure with a novel lateral pharyngoplasty as a stand-alone procedure. Am J Otolaryngol 41(4):102500. https:\/\/doi.org\/10.1016\/j.amjoto.2020.102500","journal-title":"Am J Otolaryngol"},{"issue":"2","key":"3808_CR19","doi-asserted-by":"publisher","first-page":"156","DOI":"10.1093\/sleep\/19.2.156","volume":"19","author":"AE Sher","year":"1996","unstructured":"Sher AE, Schechtman KB, Piccirillo JF (1996) The efficacy of surgical modifications of the upper airway in adults with obstructive sleep apnea syndrome. Sleep 19(2):156\u2013177. https:\/\/doi.org\/10.1093\/sleep\/19.2.156","journal-title":"Sleep"},{"key":"3808_CR20","volume-title":"Tratado de otorrinolaringologia","author":"SSN Pignatari","year":"2018","unstructured":"Pignatari SSN, Anselmo-Lima WT (2018) Tratado de otorrinolaringologia, 3a ed. Elsevier, Rio de Janeiro","edition":"3a ed"},{"issue":"3","key":"3808_CR21","doi-asserted-by":"publisher","first-page":"1125","DOI":"10.1007\/s11325-022-02706-y","volume":"27","author":"FA Mendes","year":"2023","unstructured":"Mendes FA, Almeida AR, Duarte BB, Mendon\u00e7a J\u00c1 (2023) Lateral pharyngoplasty: polysomnographic results and phenotype-based analysis of OSA. Sleep Breath 27(3):1125\u20131134. https:\/\/doi.org\/10.1007\/s11325-022-02706-y","journal-title":"Sleep Breath"},{"issue":"4","key":"3808_CR22","doi-asserted-by":"publisher","first-page":"e389","DOI":"10.1055\/S-0043-1776744","volume":"16","author":"N Solcia-Filho","year":"2023","unstructured":"Solcia-Filho N, Duarte BB, Almeida AR, de Aquino JLB (2023) The impact of clinical and craniofacial changes on the surgical outcomes of lateral pharyngoplasty in the treatment of obstructive sleep apnea. Sleep Sci 16(4):e389\u2013e398. https:\/\/doi.org\/10.1055\/S-0043-1776744","journal-title":"Sleep Sci"},{"issue":"2","key":"3808_CR23","doi-asserted-by":"publisher","first-page":"e278","DOI":"10.1055\/s-0043-1776718","volume":"28","author":"SRPF Zanco","year":"2024","unstructured":"Zanco SRPF, Duarte BB, Almeida AR, Mendon\u00e7a J\u00c1 (2024) Cephalometric evaluation in patients with obstructive sleep apnea undergoing lateral pharyngoplasty. Int Arch Otorhinolaryngol 28(2):e278\u2013e287. https:\/\/doi.org\/10.1055\/s-0043-1776718","journal-title":"Int Arch Otorhinolaryngol"},{"key":"3808_CR24","doi-asserted-by":"publisher","first-page":"45","DOI":"10.1016\/j.smrv.2016.12.003","volume":"37","author":"DJ Eckert","year":"2018","unstructured":"Eckert DJ (2018) Phenotypic approaches to obstructive sleep apnoea: New pathways for targeted therapy. Sleep Med Rev 37:45\u201359. https:\/\/doi.org\/10.1016\/j.smrv.2016.12.003","journal-title":"Sleep Med Rev"},{"issue":"5 Part I","key":"3808_CR25","doi-asserted-by":"publisher","first-page":"1673","DOI":"10.1164\/ajrccm.152.5.7582313","volume":"152","author":"RJ Schwab","year":"1995","unstructured":"Schwab RJ, Gupta KB, Gefter WB et al (1995) Upper airway and soft tissue anatomy in normal subjects and patients with sleep-disordered breathing: Significance of the lateral pharyngeal walls. Am J Respir Crit Care Med 152(5 Part I):1673\u20131689. https:\/\/doi.org\/10.1164\/ajrccm.152.5.7582313","journal-title":"Am J Respir Crit Care Med"},{"issue":"1","key":"3808_CR26","doi-asserted-by":"publisher","first-page":"7","DOI":"10.1016\/j.smrv.2013.01.005","volume":"18","author":"SA Joosten","year":"2014","unstructured":"Joosten SA, O\u2019Driscoll DM, Berger PJ, Hamilton GS (2014) Supine position related obstructive sleep apnea in adults: Pathogenesis and treatment. Sleep Med Rev 18(1):7\u201317. https:\/\/doi.org\/10.1016\/j.smrv.2013.01.005","journal-title":"Sleep Med Rev"},{"issue":"1","key":"3808_CR27","doi-asserted-by":"publisher","first-page":"2004022","DOI":"10.1183\/13993003.04022-2020","volume":"57","author":"M Blanchard","year":"2020","unstructured":"Blanchard M, Gerv\u00e8s-Pinqui\u00e9 C, Feuilloy M et al (2020) Hypoxic burden and heart-rate variability predict stroke incidence in sleep apnoea. Eur Respir J 57(1):2004022. https:\/\/doi.org\/10.1183\/13993003.04022-2020","journal-title":"Eur Respir J"},{"issue":"1","key":"3808_CR28","doi-asserted-by":"publisher","first-page":"00511","DOI":"10.1183\/23120541.00511-2024","volume":"11","author":"DR Mazzotti","year":"2025","unstructured":"Mazzotti DR, Magalang UJ, Keenan BT et al (2025) OSA symptom subtypes and hypoxic burden independently predict distinct cardiovascular outcomes. ERJ Open Res 11(1):00511\u201302024. https:\/\/doi.org\/10.1183\/23120541.00511-2024","journal-title":"ERJ Open Res"},{"key":"3808_CR29","doi-asserted-by":"publisher","first-page":"A5200","DOI":"10.1164\/ajrccm.2025.211.abstracts.a5200","volume":"211","author":"N Esmaeili","year":"2025","unstructured":"Esmaeili N, Kwon Y, Monteiro JL et al (2025) Association of High-risk OSA, Defined by Hypoxic Burden and Heart Rate Acceleration, With Non-dipping Blood Pressure. Am J Respir Crit Care Med 211:A5200. https:\/\/doi.org\/10.1164\/ajrccm.2025.211.abstracts.a5200","journal-title":"Am J Respir Crit Care Med"},{"issue":"4","key":"3808_CR30","doi-asserted-by":"publisher","first-page":"245","DOI":"10.1136\/thorax-2024-222462","volume":"80","author":"P Tank\u00e9r\u00e9","year":"2025","unstructured":"Tank\u00e9r\u00e9 P, Tailliard J, Petitjean T et al (2025) Residual sleepiness and impaired alertness in treated obstructive sleep apnoea: role of hypoxic burden and sleep fragmentation. Thorax 80(4):245\u2013247. https:\/\/doi.org\/10.1136\/thorax-2024-222462","journal-title":"Thorax"}],"container-title":["Sleep and Breathing"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s11325-026-03808-7.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/article\/10.1007\/s11325-026-03808-7","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/link.springer.com\/content\/pdf\/10.1007\/s11325-026-03808-7.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,10,19]],"date-time":"2026-10-19T11:31:44Z","timestamp":1792409504000},"score":1,"resource":{"primary":{"URL":"https:\/\/link.springer.com\/article\/10.1007\/s11325-026-03808-7"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,9,22]]},"references-count":30,"journal-issue":{"issue":"5","published-print":{"date-parts":[[2026,10]]}},"alternative-id":["3808"],"URL":"https:\/\/doi.org\/10.1007\/s11325-026-03808-7","relation":{},"ISSN":["1520-9512","1522-1709"],"issn-type":[{"value":"1520-9512","type":"print"},{"value":"1522-1709","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9,22]]},"assertion":[{"value":"25 May 2026","order":1,"name":"received","label":"Received","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"6 September 2026","order":2,"name":"revised","label":"Revised","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"14 September 2026","order":3,"name":"accepted","label":"Accepted","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"22 September 2026","order":4,"name":"first_online","label":"First Online","group":{"name":"ArticleHistory","label":"Article History"}},{"value":"All procedures performed in studies involving human participants were conducted in accordance with the ethical standards of the institutional and national research committee, as well as with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The study was approved by the Research Ethics Committee of Pontif\u00edcia Universidade Cat\u00f3lica de Campinas (PUC-Campinas), Campinas, S\u00e3o Paulo, Brazil, under approval number 7.126.817 (CAAE: 83167724700005481)","order":1,"name":"Ethics","label":"Ethical approval","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"Informed consent was obtained from all individual participants included in the study.","order":2,"name":"Ethics","label":"Informed consent","group":{"name":"EthicsHeading","label":"Declarations"}},{"value":"All authors certify that they have no affiliations with or involvement in any organization or entity with any financial or non-financial interest in the subject matter or materials discussed in this manuscript.","order":3,"name":"Ethics","label":"Conflict of interest","group":{"name":"EthicsHeading","label":"Declarations"}}],"article-number":"267"}}