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Article History

Received: 6 August 2024

Accepted: 30 June 2025

First Online: 19 July 2025

Declarations

:

: This study was approved by the Ethics Review Committee of Hirosaki University School of Medicine (Approval code: 2022–119) and was conducted using an opt-out method according to the ethical guidelines for medical and health research involving human subjects in Japan and the principles of the World Medical Association (WMA) Declaration of Helsinki. Detailed information regarding the purpose, methods, and scope of data usage for the study was provided to all participants in advance through a dedicated publicly accessible webpage and posters at each participating institution. Informed consent was obtained from all participants using the opt-out approach, which is recognized as a form of informed consent under Japanese ethical guidelines. Participants who wished to decline participation could do so by contacting the designated phone number, and their personal data was immediately deleted from the database and excluded from the analysis.

: Not applicable.

: The authors declare no competing interests.