Non-Cochrane · intervention · PM41801520
Robotic versus non-robotic posterior midline glossectomy for obstructive sleep apnea: a systematic review and meta-analysis.
Alhedaithy Alhanouf A, Alghamdi Fatima A, AlOtaibi Saad, et al. · Sleep & breathing = Schlaf & Atmung · 2026 · PubMed · doi:10.1007/s11325-026-03637-8
Findings
Population Adults with obstructive sleep apnea
30 findings
| Robotic (TORS) posterior midline glossectomy | None (single-arm pre/post change or absolute value) | Apnea-hypopnea index (AHI), change Postoperative; mean follow-up 7.5 months in robotic studies · Not specified · Robotic | MD -25.93 [-31.82, -20.03] GRADE not reported 9 studies |
| Robotic (TORS) posterior midline glossectomy | None (single-arm pre/post change or absolute value) | Oxygen nadir (minimum oxygen saturation), change Postoperative; mean follow-up 7.5 months in robotic studies · Not specified · Robotic | MD 5.48 [2.21, 8.75] GRADE not reported 6 studies |
| Robotic (TORS) posterior midline glossectomy | None (single-arm pre/post change or absolute value) | Postoperative pain (VAS) Postoperative; mean follow-up 7.5 months in robotic studies · Not specified · Robotic | MEAN 5.48 [0.19, 10.78] GRADE not reported 2 studies |
| Robotic (TORS) posterior midline glossectomy | None (single-arm pre/post change or absolute value) | Snoring score (VAS), change Postoperative; mean follow-up 7.5 months in robotic studies · Not specified · Robotic | MD -5.59 [-7.12, -4.06] GRADE not reported 4 studies |
| Robotic (TORS) posterior midline glossectomy | None (single-arm pre/post change or absolute value) | Epworth Sleepiness Scale (ESS), change Postoperative; mean follow-up 7.5 months in robotic studies · Not specified · Robotic | MD -7.43 [-8.65, -6.21] GRADE not reported 9 studies |
| Robotic (TORS) posterior midline glossectomy | None (single-arm pre/post change or absolute value) | Respiratory disturbance index (RDI), change Postoperative; mean follow-up 7.5 months in robotic studies · Not specified · Robotic | MD -30.3 [-36.57, -24.03] GRADE not reported 1 study |
| Robotic (TORS) posterior midline glossectomy | None (single-arm pre/post change or absolute value) | Time to oral intake (days to diet) Postoperative; mean follow-up 7.5 months in robotic studies · Not specified · Robotic | MEAN 3.39 [-1.3, 8.07] GRADE not reported 2 studies |
| Robotic (TORS) posterior midline glossectomy | None (single-arm pre/post change or absolute value) | Operative time Postoperative; mean follow-up 7.5 months in robotic studies · Not specified · Robotic | MEAN 50.26 [31.79, 68.73] GRADE not reported 3 studies |
| Robotic (TORS) posterior midline glossectomy | None (single-arm pre/post change or absolute value) | Surgical success rate (Sher criteria) Postoperative; mean follow-up 7.5 months in robotic studies · Not specified · Robotic | Proportion 0.64 [0.56, 0.73] GRADE not reported 9 studies |
| Robotic (TORS) posterior midline glossectomy | None (single-arm pre/post change or absolute value) | Oxygen desaturation index (ODI), change Postoperative; mean follow-up 7.5 months in robotic studies · Not specified · Robotic | MD -23.9 [-31.04, -16.76] GRADE not reported 1 study |
| Non-robotic posterior midline glossectomy (coblation, laser, radiofrequency or conventional) | None (single-arm pre/post change or absolute value) | Surgical success rate (Sher criteria) Postoperative; mean follow-up 13 months in non-robotic studies · Not specified · Non-robotic | Proportion 0.57 [0.47, 0.69] GRADE not reported 13 studies |
| Non-robotic posterior midline glossectomy (coblation, laser, radiofrequency or conventional) | None (single-arm pre/post change or absolute value) | Snoring score (VAS), change Postoperative; mean follow-up 13 months in non-robotic studies · Not specified · Non-robotic | MD -5.62 [-6.35, -4.9] GRADE not reported 6 studies |
| Non-robotic posterior midline glossectomy (coblation, laser, radiofrequency or conventional) | None (single-arm pre/post change or absolute value) | Oxygen nadir (minimum oxygen saturation), change Postoperative; mean follow-up 13 months in non-robotic studies · Not specified · Non-robotic | MD 8.11 [5.06, 11.16] GRADE not reported 17 studies |
| Non-robotic posterior midline glossectomy (coblation, laser, radiofrequency or conventional) | None (single-arm pre/post change or absolute value) | Oxygen desaturation index (ODI), change Postoperative; mean follow-up 13 months in non-robotic studies · Not specified · Non-robotic | MD -13.68 [-20.15, -7.22] GRADE not reported 3 studies |
| Non-robotic posterior midline glossectomy (coblation, laser, radiofrequency or conventional) | None (single-arm pre/post change or absolute value) | Operative time Postoperative; mean follow-up 13 months in non-robotic studies · Not specified · Non-robotic | MEAN 48.79 [32.12, 65.45] GRADE not reported 3 studies |
| Non-robotic posterior midline glossectomy (coblation, laser, radiofrequency or conventional) | None (single-arm pre/post change or absolute value) | Epworth Sleepiness Scale (ESS), change Postoperative; mean follow-up 13 months in non-robotic studies · Not specified · Non-robotic | MD -5.58 [-7.83, -3.34] GRADE not reported 12 studies |
| Non-robotic posterior midline glossectomy (coblation, laser, radiofrequency or conventional) | None (single-arm pre/post change or absolute value) | Respiratory disturbance index (RDI), change Postoperative; mean follow-up 13 months in non-robotic studies · Not specified · Non-robotic | MD -33.94 [-41.31, -26.58] GRADE not reported 6 studies |
| Non-robotic posterior midline glossectomy (coblation, laser, radiofrequency or conventional) | None (single-arm pre/post change or absolute value) | Apnea-hypopnea index (AHI), change Postoperative; mean follow-up 13 months in non-robotic studies · Not specified · Non-robotic | MD -24.99 [-30.97, -19.0] GRADE not reported 19 studies |
| Non-robotic posterior midline glossectomy (coblation, laser, radiofrequency or conventional) | None (single-arm pre/post change or absolute value) | Time to oral intake (days to diet) Postoperative; mean follow-up 13 months in non-robotic studies · Not specified · Non-robotic | MEAN 4.72 [3.74, 5.7] GRADE not reported 2 studies |
| Non-robotic posterior midline glossectomy (coblation, laser, radiofrequency or conventional) | None (single-arm pre/post change or absolute value) | Postoperative pain (VAS) Postoperative; mean follow-up 13 months in non-robotic studies · Not specified · Non-robotic | MEAN 3.97 [2.45, 5.49] GRADE not reported 5 studies |
| Posterior midline glossectomy, robotic and non-robotic combined | None (single-arm pre/post change or absolute value) | Oxygen nadir (minimum oxygen saturation), change Postoperative; follow-up varied · Not specified · Overall (robotic and non-robotic) | MD 7.42 [5.16, 9.69] GRADE not reported 23 studies |
| Posterior midline glossectomy, robotic and non-robotic combined | None (single-arm pre/post change or absolute value) | Time to oral intake (days to diet) Postoperative; follow-up varied · Not specified · Overall (robotic and non-robotic) | MEAN 4.04 [1.27, 6.82] GRADE not reported 4 studies |
| Posterior midline glossectomy, robotic and non-robotic combined | None (single-arm pre/post change or absolute value) | Surgical success rate (Sher criteria) Postoperative; follow-up varied · Not specified · Overall (robotic and non-robotic) | Proportion 0.61 [0.54, 0.69] GRADE not reported 22 studies |
| Posterior midline glossectomy, robotic and non-robotic combined | None (single-arm pre/post change or absolute value) | Snoring score (VAS), change Postoperative; follow-up varied · Not specified · Overall (robotic and non-robotic) | MD -5.61 [-6.2, -5.01] GRADE not reported 10 studies |
| Posterior midline glossectomy, robotic and non-robotic combined | None (single-arm pre/post change or absolute value) | Apnea-hypopnea index (AHI), change Postoperative; follow-up varied · Not specified · Overall (robotic and non-robotic) | MD -25.33 [-29.86, -20.81] GRADE not reported 28 studies |
| Posterior midline glossectomy, robotic and non-robotic combined | None (single-arm pre/post change or absolute value) | Postoperative pain (VAS) Postoperative; follow-up varied · Not specified · Overall (robotic and non-robotic) | MEAN 4.39 [3.05, 5.72] GRADE not reported 7 studies |
| Posterior midline glossectomy, robotic and non-robotic combined | None (single-arm pre/post change or absolute value) | Oxygen desaturation index (ODI), change Postoperative; follow-up varied · Not specified · Overall (robotic and non-robotic) | MD -16.41 [-23.45, -9.37] GRADE not reported 4 studies |
| Posterior midline glossectomy, robotic and non-robotic combined | None (single-arm pre/post change or absolute value) | Epworth Sleepiness Scale (ESS), change Postoperative; follow-up varied · Not specified · Overall (robotic and non-robotic) | MD -6.32 [-7.94, -4.7] GRADE not reported 21 studies |
| Posterior midline glossectomy, robotic and non-robotic combined | None (single-arm pre/post change or absolute value) | Respiratory disturbance index (RDI), change Postoperative; follow-up varied · Not specified · Overall (robotic and non-robotic) | MD -33.12 [-38.89, -27.35] GRADE not reported 7 studies |
| Posterior midline glossectomy, robotic and non-robotic combined | None (single-arm pre/post change or absolute value) | Operative time Postoperative; follow-up varied · Not specified · Overall (robotic and non-robotic) | MEAN 49.34 [38.29, 60.4] GRADE not reported 6 studies |
Included primary studies 38
Open in Studies| Study | Year | Also included by | Outcomes it informs here | Trial data |
|---|---|---|---|---|
| Abushab 2021 matched by author and year (probable) | NR | this review only | Apnea-hypopnea index (AHI), change; Oxygen nadir (minimum oxygen saturation), change; Epworth Sleepiness Scale (ESS), change; Oxygen desaturation index (ODI), change; Respiratory disturbance index (RDI), change; Time to oral intake (days to diet); Snoring score (VAS), change; Postoperative pain (VAS) | not extracted yet |
| Andsberg 2000 Eight years of follow-up--uvulopalatopharyngoplasty combined with midline glossectomy as a treatment for obstructive sleep apnoea syndrome. PMID:10909013 | 2000 | this review only | not stated | not extracted yet |
| Babademez 2011 Comparison of minimally invasive techniques in tongue base surgery in patients with obstructive sleep apnea. PMID:21825096 | 2011 | this review only | Apnea-hypopnea index (AHI), change; Operative time; Epworth Sleepiness Scale (ESS), change; Postoperative pain (VAS); Time to oral intake (days to diet); Respiratory disturbance index (RDI), change; Snoring score (VAS), change | not extracted yet |
| Babademez 2019 Prospective randomized comparison of tongue base resection techniques: Robotic vs coblation. PMID:31464082 | 2019 | this review only | Apnea-hypopnea index (AHI), change; Operative time; Epworth Sleepiness Scale (ESS), change; Surgical success rate (Sher criteria); Snoring score (VAS), change; Time to oral intake (days to diet); Oxygen desaturation index (ODI), change | not extracted yet |
| Bahgat 2021 Effect of Cooling Irrigating Saline in Tongue Base Ablation in Obstructive Sleep Apnea. PMID:33598600 | 2021 | this review only | Apnea-hypopnea index (AHI), change; Operative time; Postoperative pain (VAS); Respiratory disturbance index (RDI), change | not extracted yet |
| Baptista 2022 TORS as Part of Multilevel Surgery in OSA: The Importance of Careful Patient Selection and Outcomes. PMID:35207264 | 2022 | this review only | Apnea-hypopnea index (AHI), change; Epworth Sleepiness Scale (ESS), change; Time to oral intake (days to diet); Snoring score (VAS), change | not extracted yet |
| Bonnecazea 2018 Transoral robotic surgery of the tongue base for obstructive sleep apnea: Preliminary results. PMID:30430999 | 2018 | this review only | Apnea-hypopnea index (AHI), change; Epworth Sleepiness Scale (ESS), change | not extracted yet |
| Duan 2024 Evaluation of modified coblation endoscopic lingual lightening in multilevel surgery for obstructive sleep apnea hypopnea syndrome: an… PMID:37843682 | 2024 | this review only | Apnea-hypopnea index (AHI), change; Oxygen nadir (minimum oxygen saturation), change; Epworth Sleepiness Scale (ESS), change; Surgical success rate (Sher criteria); Snoring score (VAS), change; Oxygen desaturation index (ODI), change | not extracted yet |
| Elasfour 1998 Evaluation of uvulopalatopharyngoplasty in treatment of obstructive sleep apnea syndrome. PMID:9870650 | 1998 | this review only | Apnea-hypopnea index (AHI), change; Oxygen nadir (minimum oxygen saturation), change | not extracted yet |
| Folk 2017 Transoral robotic surgery vs. endoscopic partial midline glossectomy for obstructive sleep apnea. PMID:29204587 | 2017 | this review only | Apnea-hypopnea index (AHI), change; Oxygen nadir (minimum oxygen saturation), change; Epworth Sleepiness Scale (ESS), change; Surgical success rate (Sher criteria) | not extracted yet |
| Friedman 2008 Evaluation of submucosal minimally invasive lingual excision technique for treatment of obstructive sleep apnea/hypopnea syndrome. PMID:18722216 | 2008 | this review only | Apnea-hypopnea index (AHI), change; Oxygen nadir (minimum oxygen saturation), change; Epworth Sleepiness Scale (ESS), change; Surgical success rate (Sher criteria); Snoring score (VAS), change; Postoperative pain (VAS); Oxygen desaturation index (ODI), change; Respiratory disturbance index (RDI), change | not extracted yet |
| Friedman 2012 Transoral robotic glossectomy for the treatment of obstructive sleep apnea-hypopnea syndrome. PMID:22247514 | 2012 | this review only | Apnea-hypopnea index (AHI), change; Oxygen nadir (minimum oxygen saturation), change; Epworth Sleepiness Scale (ESS), change; Surgical success rate (Sher criteria); Snoring score (VAS), change; Postoperative pain (VAS); Oxygen desaturation index (ODI), change; Respiratory disturbance index (RDI), change | not extracted yet |
| Fujita 1991 Laser midline glossectomy as a treatment for obstructive sleep apnea. PMID:1865726 | 1991 | this review only | Apnea-hypopnea index (AHI), change; Oxygen nadir (minimum oxygen saturation), change; Surgical success rate (Sher criteria); Respiratory disturbance index (RDI), change; Time to oral intake (days to diet) | not extracted yet |
| Hoff 2014 Body mass index predicts success in patients undergoing transoral robotic surgery for obstructive sleep apnea. PMID:25413253 | 2014 | this review only | Surgical success rate (Sher criteria) | not extracted yet |
| Hou 2012 Treatment of obstructive sleep apnea-hypopnea syndrome with combined uvulopalatopharyngoplasty and midline glossectomy: outcomes from a… PMID:22709822 | 2012 | this review only | Apnea-hypopnea index (AHI), change; Oxygen nadir (minimum oxygen saturation), change | not extracted yet |
| Hsieh 2005 Simultaneous midline laser glossectomy with palatopharyngeal surgery for obstructive sleep apnoea syndrome. PMID:15853871 | 2005 | this review only | Oxygen nadir (minimum oxygen saturation), change; Respiratory disturbance index (RDI), change; Time to oral intake (days to diet) | not extracted yet |
| Hwang 2017 Predictors of success in combination of tongue base resection and lateral pharyngoplasty for obstructive sleep apnea. PMID:28224280 | 2017 | this review only | not stated | not extracted yet |
| Kayhan 2016 Multilevel Combined Surgery With Transoral Robotic Surgery for Obstructive Sleep Apnea Syndrome. PMID:27171954 | 2016 | this review only | Apnea-hypopnea index (AHI), change; Operative time; Oxygen nadir (minimum oxygen saturation), change; Epworth Sleepiness Scale (ESS), change; Surgical success rate (Sher criteria) | not extracted yet |
| Kim 2020 Transoral Robotic Surgery (TORS) Versus Non-TORS Tongue Resection for Obstructive Sleep Apnea. PMID:33314211 | 2021 | this review only | not stated | not extracted yet |
| Lan 2019 Trans-oral robotic surgery versus coblation tongue base reduction for obstructive sleep apnea syndrome. PMID:31592178 | 2019 | this review only | Apnea-hypopnea index (AHI), change; Oxygen nadir (minimum oxygen saturation), change; Epworth Sleepiness Scale (ESS), change; Surgical success rate (Sher criteria); Postoperative pain (VAS); Respiratory disturbance index (RDI), change | not extracted yet |
| Li 2004 Same-stage palatopharyngeal and hypopharyngeal surgery for severe obstructive sleep apnea. PMID:15370567 | 2004 | this review only | Oxygen nadir (minimum oxygen saturation), change; Surgical success rate (Sher criteria); Respiratory disturbance index (RDI), change; Time to oral intake (days to diet) | not extracted yet |
| Li 2013 Lingual artery CTA-guided midline partial glossectomy for treatment of obstructive sleep apnea hypopnea syndrome. PMID:23448355 | 2013 | this review only | Apnea-hypopnea index (AHI), change; Epworth Sleepiness Scale (ESS), change | not extracted yet |
| Lin 2013 Transoral robotic surgery for treatment of obstructive sleep apnea-hypopnea syndrome. PMID:23553290 | 2013 | this review only | Apnea-hypopnea index (AHI), change; Operative time; Oxygen nadir (minimum oxygen saturation), change; Epworth Sleepiness Scale (ESS), change; Surgical success rate (Sher criteria); Snoring score (VAS), change; Oxygen desaturation index (ODI), change | not extracted yet |
| Lin 2014 Z-palatopharyngoplasty Combined with Endoscopic Coblator Open Tongue Base Resection for Severe Obstructive Sleep Apnea/Hypopnea Syndrome. PMID:24596237 | 2014 | this review only | Apnea-hypopnea index (AHI), change; Oxygen nadir (minimum oxygen saturation), change; Epworth Sleepiness Scale (ESS), change; Surgical success rate (Sher criteria); Oxygen desaturation index (ODI), change; Snoring score (VAS), change; Postoperative pain (VAS) | not extracted yet |
| MacKay 2013 Coblation-assisted Lewis and MacKay operation (CobLAMO): new technique for tongue reduction in sleep apnoea surgery. PMID:24252605 | 2013 | this review only | Apnea-hypopnea index (AHI), change; Epworth Sleepiness Scale (ESS), change; Snoring score (VAS), change; Oxygen desaturation index (ODI), change | not extracted yet |
| Mickelson 1997 Midline glossectomy and epiglottidectomy for obstructive sleep apnea syndrome. PMID:9149162 | 1997 | this review only | Surgical success rate (Sher criteria); Respiratory disturbance index (RDI), change; Time to oral intake (days to diet) | not extracted yet |
| Spector 2015 Addressing the Retrolingual Space in Obstructive Sleep Apnea: Outcomes Stratified by Friedman Stage in Patients Undergoing Transoral… PMID:26540370 | 2016 | this review only | not stated | not extracted yet |
| Suh 2013 Evaluation of open midline glossectomy in the multilevel surgical management of obstructive sleep apnea syndrome. PMID:23064209 | 2013 | this review only | Apnea-hypopnea index (AHI), change; Oxygen nadir (minimum oxygen saturation), change | not extracted yet |
| Suslu 2021 Results of coblation midline glossectomy for obstructive sleep apnea. PMID:33246747 | 2021 | this review only | Apnea-hypopnea index (AHI), change; Epworth Sleepiness Scale (ESS), change; Oxygen desaturation index (ODI), change; Postoperative pain (VAS) | not extracted yet |
| Thaler 2015 Outcomes for multilevel surgery for sleep apnea: Obstructive sleep apnea, transoral robotic surgery, and uvulopalatopharyngoplasty. PMID:26153069 | 2016 | this review only | Surgical success rate (Sher criteria) | not extracted yet |
| Toh 2014 Transoral robotic surgery for obstructive sleep apnea in Asian patients: a Singapore sleep centre experience. PMID:24921220 | 2014 | this review only | Apnea-hypopnea index (AHI), change; Oxygen nadir (minimum oxygen saturation), change; Epworth Sleepiness Scale (ESS), change; Surgical success rate (Sher criteria); Oxygen desaturation index (ODI), change; Respiratory disturbance index (RDI), change; Snoring score (VAS), change; Time to oral intake (days to diet); Postoperative pain (VAS) | not extracted yet |
| Tungkeeratichai 2014 matched by author and year (probable) | NR | this review only | Apnea-hypopnea index (AHI), change; Oxygen nadir (minimum oxygen saturation), change; Surgical success rate (Sher criteria) | not extracted yet |
| Williamson 2022 Base of Tongue Surgery and Pediatric Obstructive Sleep Apnea. PMID:35439065 | 2023 | this review only | Oxygen nadir (minimum oxygen saturation), change; Surgical success rate (Sher criteria) | not extracted yet |
| Woodson 1992 Clinical experience with lingualplasty as part of the treatment of severe obstructive sleep apnea. PMID:1528601 | 1992 | this review only | Oxygen nadir (minimum oxygen saturation), change; Surgical success rate (Sher criteria); Respiratory disturbance index (RDI), change; Time to oral intake (days to diet); Snoring score (VAS), change | not extracted yet |
| Woodson 2012 Lingual tonsillectomy and midline posterior glossectomy for obstructive sleep apnea DOI:10.1016/j.otot.2012.02.002 | 2012 | this review only | Apnea-hypopnea index (AHI), change | not extracted yet |
| Woodson 2012 matched by author and year (probable) | NR | this review only | Apnea-hypopnea index (AHI), change | not extracted yet |
| Zhen 2022 Midline posterior glossectomy and lingual tonsillectomy in children with refractory obstructive sleep apnoea: factors that influence… DOI:10.21037/ajo-21-35 | 2022 | this review only | Oxygen nadir (minimum oxygen saturation), change | not extracted yet |
| Zhen 2022 matched by author and year (probable) | NR | this review only | Oxygen nadir (minimum oxygen saturation), change | not extracted yet |
Review question
| Element | Planned (methods) | Found (results) |
|---|---|---|
| Population | Adults with confirmed obstructive sleep apnea | Adults with OSA (n=6,995 across 36 studies; mean age 47.0 years robotic, 41.0 years non-robotic) |
| Intervention | Posterior midline glossectomy using robotic (TORS) or non-robotic transoral techniques (coblation, laser, radiofrequency) | Robotic TORS (10 studies); non-robotic techniques (22 studies); 4 comparative studies |
| Comparison | Robotic versus non-robotic technique | Robotic vs non-robotic subgroup; preoperative baseline |
| Outcomes | AHI, ESS, oxygen nadir, snoring scores, surgical success (Sher criteria), complications, operative time, pain, time to oral intake | AHI (28 studies in forest plot), oxygen nadir (23), ESS (21), surgical success (22), snoring (10), pain (7), time to diet (4), ODI (4), RDI (7), operative time (6) |
| Study designs | Peer-reviewed studies in English with full text; case reports, letters, reviews and editorials excluded | 28 cohort studies, 3 RCTs, 3 non-randomized clinical trials, 2 case series |
| Timing | Not specified | Mean follow-up 7.5 months robotic and 13 months non-robotic |
AMSTAR 2 items
Two independent extractors rated each item. Their ratings are shown side by side because they have not been reconciled yet. The overall rating follows Shea et al. 2017: one critical flaw gives Low, more than one gives Critically Low.
| Item | Extractor A | Extractor B | Agree |
|---|---|---|---|
| 1Research question includes PICO components | Yes | Yes | yes |
| 2Protocol established before the reviewcritical | Partial Yes | Partial Yes | yes |
| 3Choice of study designs explained | No | No | yes |
| 4Comprehensive literature searchcritical | No | No | yes |
| 5Study selection in duplicate | Yes | Yes | yes |
| 6Data extraction in duplicate | Yes | Yes | yes |
| 7List of excluded studies with reasonscritical | No | No | yes |
| 8Included studies described in detail | Partial Yes | Partial Yes | yes |
| 9Risk of bias assessed satisfactorilycritical | RCT: Yes · NRSI: Yes | NRSI: Partial Yes · RCT: Yes | no |
| 10Funding of included studies reported | No | No | yes |
| 11Appropriate meta-analysis methodscritical | RCT: No · NRSI: No | NRSI: No · RCT: No | no |
| 12Impact of risk of bias on the pooled results | No | No | yes |
| 13Risk of bias accounted for in interpretationcritical | Yes | Yes | yes |
| 14Heterogeneity explained | Yes | Yes | yes |
| 15Publication bias investigatedcritical | No | No | yes |
| 16Conflicts of interest reported | Yes | Yes | yes |
| Overall | Critically Low | Critically Low | yes |