Published online September 1, 2006
PEDIATRICS Vol. 118 No. 3 September 2006, pp. 1140-1148 (doi:10.1542/peds.2006-0119)
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ARTICLE

Self-Perceived Health-Related Quality of Life of Former Extremely Low Birth Weight Infants at Young Adulthood

Saroj Saigal, MD, FRCP Ca, Barbara Stoskopf, RN, MHSca, Janet Pinelli, RNC, MScN, DNSa,b, David Streiner, PhDc, Lorraine Hoult, BAa, Nigel Paneth, MD, MPHd,e and John Goddeeris, PhDf

a Department of Pediatrics
b School of Nursing, McMaster University, Hamilton, Ontario, Canada
c Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
d Departments of Epidemiology
e Human Development
f Economics, Michigan State University, East Lansing, Michigan


   ABSTRACT
TOP
 ABSTRACT
METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
OBJECTIVES. The goals were to compare the self-reported, health-related quality of life of former extremely low birth weight and normal birth weight infants at young adulthood and to determine whether there were any changes over time.

METHODS. A prospective, longitudinal, population-based study with concurrent control subjects was performed. We interviewed 143 of 166 extremely low birth weight survivors (birth weight: 501–1000 g; 1977–1982 births) and 130 of 145 sociodemographically comparable, normal birth weight, reference subjects. Neurosensory impairments were present for 27% extremely low birth weight and 2% normal birth weight young adults. Health Utilities Index 2 was used to assess health status, and standard gamble technique was used to measure directly the self-reported, health-related, quality of life and 4 hypothetical health states.

RESULTS. Extremely low birth weight young adults reported more functional limitations in cognition, sensation, mobility, and self-care, compared with control subjects. There were no differences between groups in the mean self-reported, health-related, quality of life or between impaired (n = 38) and nonimpaired (n = 105) extremely low birth weight subjects. However, with a conservative approach of assigning a score of 0 for 10 severely disabled, extremely low birth weight subjects, the mean health-related quality of life was significantly lower than control values. Repeated-measures analysis of variance to compare health-related quality-of-life measurements obtained for young adults and teens showed the same decline in scores over time for both groups. There were no differences between groups in the ratings provided for the hypothetical health states.

CONCLUSIONS. At young adulthood, health-related quality of life was not related to size at birth or to the presence of disability. There was a small decrease in health-related quality-of-life scores over time for both groups.

Key Words: quality of life • extremely low birth weight • young adulthood

Abbreviations: ELBW—extremely low birth weight • NBW—normal birth weight • HRQL—health-related quality of life • HUI—Health Utilities Index • NSI—neurosensory impairment • CI—confidence interval • CB—chance board • YA—young adult

The importance of incorporating health-related quality-of-life (HRQL) measures in research on health outcomes is now accepted more widely.1–4 Conventional measures of health status, such as clinical and laboratory indices, provide extremely important information but have been shown to be of limited value for assessing the effects of chronic illness on the psychosocial health and well-being of an individual.5 In fact, these surrogate measures often do not correlate with patient-reported outcomes.6 Consequently, to obtain a holistic picture of the overall outcome, both the traditional clinical indices and the individual's self-reported HRQL must be measured.4,6,7

The term HRQL, although restrictive in principle (important parameters such as income, environment, and freedom are not included),8 refers to the impact of health conditions on the person's total well-being, including his or her psychological, social, and physical health status.9 Initially, measures of HRQL were applied exclusively to adults. The need to measure the perceptions of children has been recognized only recently.10–14 In the past decade, several generic10,11 and disease-specific15,16 HRQL measures for children have been developed and validated. Among them, the Health Utilities Index (HUI) systems (HUI2 and HUI3)17,18 (which include a health status classification system and a preference-based scoring function) are the most widely used generic, preference-based measures; they have been shown to be reliable, responsive, and valid and have been used in a variety of clinical studies.19–25

We reported previously on the health status and HRQL of former extremely low birth weight (ELBW) (<1000 g) infants at 8 years of age19,20 and at adolescence,21 in comparison with same-age, normal birth weight (NBW), term peers. At their last self-report assessment, although ELBW teenagers suffered from a significantly greater burden of morbidity, the vast majority of respondents viewed their HRQL as satisfactory.21 However, children are developing and changing constantly,6,12,13 and their preferences and the impact of their illness often differ from those of their parents and caregivers.22,26 It is possible that, as children mature and begin to live independently, their recent life experiences may change their earlier perceptions and definition of psychological well-being.27

In this study, we compare the health status and HRQL of our longitudinal cohort of ELBW and NBW subjects at young adulthood from their individual perspectives; we compare these HRQL scores with those obtained at adolescence, to determine whether there were changes over the 2 time periods, and we identify factors accounting for the changes. We hypothesized that the overall mean self-perceived HRQL scores for ELBW young adults (YAs) would be lower than those for their NBW peers and the overall scores for both cohorts would be lower than the scores obtained at adolescence.21 Factors that predicted HRQL scores at young adulthood would include individual factors (birth weight group, gender, chronic illness, neurosensory impairments [NSIs], depression,28 low self-esteem,29 low social support,30 and fewer years of education) and family factors (maternal depression,28 lower socioeconomic status, and single-parent family). We also hypothesized that there would be no differences in the mean HRQL scores assigned by ELBW and NBW YA respondents to the previously developed 4 hypothetical health states.21 These hypothetical health states served as methodologic reference states to illustrate the range of possible outcomes (from mild to severe impairments) and provided a context within which respondents could rate their own health states.


   METHODS
TOP
 ABSTRACT
 METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Study Subjects
ELBW
A total of 179 ELBW survivors (birth weight: 501–1000 g), born to residents of a geographically defined region in central-west Ontario between 1977 and 1982, were monitored longitudinally from birth. They were assessed previously in several waves, with a broad range of measures, at 3 years,31 5 years,32 8 years,33 and 12 to 16 years of age.34–36

NBW
A total of 145 term control subjects (>2500 g birth weight) were recruited at 8 years of age, from a random list of children provided by the local school boards and matched with the ELBW cohort with respect to gender, age, and social class.31 These subjects were assessed with the same measures as the ELBW cohort, at 8 years33 and 12 to 16 years of age.34–36

Measurement of Health Status and HRQL
We used the HUI2 comprehensive, multiattribute, health status classification system described in our previous studies to obtain information on health status from the perspective of the respondents.19–23 The HUI2 system includes 7 attributes, namely, sensation (vision, hearing, and speech), mobility, emotion, cognition, self-care, pain, and fertility (not applied here, because the subjects are still young), with 3 to 5 levels per attribute.10,17 HUI systems have been used in several studies and can discriminate among levels of illness severity in populations of children with childhood cancer and school-aged ELBW and NBW children, generate little burden to respondents, and have been well accepted by children, parents, and health care professionals.17,18,21–25

The same 4 hypothetical health states developed for our adolescent study21 were used to provide a context within which YA respondents could rate their own HRQL. For ease of reference, each hypothetical health state was given a non-gender-specific name and the scenarios were always presented in the same order. These hypothetical health states were based on the HUI2 system and ranged from a mild single-attribute problem (Jamie, with learning problems) to involvement of multiple attributes (Chris, with motor and emotional problems), with significant limitations in function in almost all attributes (Sandy and Pat). Respondents were asked to imagine themselves living in these health states for the rest of their lives. A detailed description of the hypothetical health states is available in our previous publications.21,22

We used the well-validated, standard gamble, preference-measurement technique to measure directly the value of the self-reported health status of the respondents and the hypothetical health states.37–39 The standard gamble (using a chance board [CB]) measures preferences under conditions of uncertainty and involves a lottery approach.21 Each respondent was asked to select between the health state in question, which had a 100% certainty, and a chance on 2 health outcomes, 1 of which was more preferred (perfect health) and the other least desirable (dead). The probabilities were varied across the board until the subject was indifferent between the sure thing and the lottery. With the conventional scales, the CB provides a single cardinal HRQL score (also known as utility score) between 0.00 and 1.00, where 0.00 indicates dead and 1.00 indicates perfect health.

Interview Protocol
ELBW and NBW respondents were interviewed by trained, lay, professional interviewers who were blinded to the group status; demographic information was elicited with scripted questionnaires.40 Information on parental demographic features was elicited from the parents themselves. The first step in the measurement of health status and HRQL was to determine the level of function of the respondent within each attribute of health, by using a questionnaire from the HUI2 system.10,18 Next, using the CB, the participants rated the 4 hypothetical health states, followed by his or her own health state. For severely impaired subjects, proxy responses were elicited from the parents with the same protocol. Parents were asked to imagine themselves living in their own child's health state, or the hypothetical health states, for the rest of their lives.

The majority of interviews were conducted in a private room at the McMaster University Medical Center. The entire interview took ~1 hour.

Ethics Approval
The study was approved by the research ethics board of the Hamilton Health Sciences. Written informed consent was obtained from all respondents.

Statistical Analyses
The same techniques as in our last assessment at adolescence were used to standardize preference scores across participants to the conventional scale of perfect health to dead.21 In instances in which dead was not considered to be the least-desirable health state, negative scores for states ranked worse than dead were calculated by using a linear transformation function. The scale for the transformed CB scores was defined from 1.0 to –1.0.41

The Pearson {chi}2 test was used to test the independence of ELBW and NBW subjects in reporting the number of attributes and the frequencies of the levels of attributes affected. Fisher's exact test was used when required. Student's t test was used to test equality in mean utility scores between the 2 groups. Levene's test was used to test homogeneity of variance between mean utility scores. Comparison of utility scores for the subjects' own health measured at 2 time points (teen and YA) was performed by using a group x time repeated-measures analysis of variance strategy. Unless otherwise stated, data are included for all respondents, including those with NSIs, with parental proxy responses for subjects who were unable to respond themselves. To investigate the impact of the worst possible scenarios on HRQL for ELBW subjects, we undertook sensitivity analyses by incorporating a score of 0 for subjects with severe impairments and for those who died after discharge from the NICU.

A hierarchical regression model was used to determine the predictive factors that influenced YAs' rating of their own health on the CB. The independent variables were entered into the equation in a temporally ordered, 4-step process. The goal was to assess (by examining R2 values) the relative influence of each step on a YA's perception of his or her HRQL. Fundamental physical characteristics of the respondents (birth weight, gender, NSIs, and number of chronic physical health conditions at young adulthood) were entered at step 1. Family factors (mother's depression score,28 socioeconomic status,42 and family composition [1- or 2-parent family]) were entered at step 2. Psychosocial factors of the YAs (depression score,28 self-esteem score,29 and social support score30) were entered at step 3. At step 4, the YAs' total years of education were entered. Holm's correction43 for multiple testing was used to establish statistical significance.


   RESULTS
TOP
 ABSTRACT
 METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
Study Participants
ELBW YAs
Of 179 ELBW neonates who survived to hospital discharge, 13 subjects died subsequently, leaving 166 long-term survivors. We were able to interview 143 (86%) of 166 eligible survivors, including 38 subjects with NSIs. Nonresponders included 9 subjects who were lost to follow-up monitoring, 4 who lived too far away, and 10 who refused (8 of 23 nonresponders had NSIs). Nonresponders were similar to responders in the prevalence of NSIs and parental sociodemographic features, except for lower maternal education (P = .01). Parental proxy responses were obtained for 7 subjects for health status and 10 subjects for CB. The mean ± SD age of the respondents was 23.3 ± 1.2 years.

NBW YAs
Of 145 control subjects, none died; 130 (90%) participated in the study, and 3 respondents (2%) had NSIs. Nonparticipants included 5 who were lost to follow-up monitoring, 1 who lived too far away, and 9 who refused (none impaired). The mean ± SD age of the respondents was 23.6 ± 1.1 years. Once again, maternal education was lower for nonresponders (P = .03).

Demographic Features of YA Respondents and Parents
The mean birth weight of the ELBW respondents was 840 g; 27% had birth weights of <750 g, and 22% were born at gestational ages of <26 weeks (Table 1). The proportions of male and female respondents were similar. The majority of subjects in both cohorts were white. There were no statistically significant differences between the groups in educational attainment, living arrangements, marital status, or permanent employment; 3% of ELBW respondents were in group homes or assisted-living apartments. The parents of both cohorts were from relatively advantaged background, in terms of social class,42 and >80% of subjects were from 2-parent families.


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  		TABLE 1 Birth and Current Demographic Information for ELBW and NBW Respondents

 
Health Status
By self-report, statistically significant differences were seen in the proportions of ELBW versus NBW subjects with any level of functional limitations in sensation (57% vs 24%; P < .001) and cognition (17% vs 3%; P < .001) (Fig 1). Although P values were .03 for mobility (13% vs 5%) and self-care (4% vs 0%), they did not achieve statistical significance with Holm's correction. The limitations in the sensation attribute among ELBW YAs were primarily attributable to visual problems. The severity of functional limitations (level ≥3) was also greater in the ELBW group for cognition (7% vs 0%; P = .002) and sensation (15% vs 2%; P < .001).


Figure 1
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  		FIGURE 1 Self-report of frequencies of HUI2 attributes affected (at any level), including 7 parental proxy responses.

 
Fewer ELBW than NBW respondents (24% vs 46%) reported perfect health (ie, they reported level 1 for each of the 6 attributes). The proportions of respondents who reported 1 or 2 affected attributes were 56% vs 50%; a greater proportion of ELBW subjects had ≥3 attributes affected (20% vs 4%). These differences were statistically significant (P < .001). On the basis of the 6 attributes of the HUI2 classification system, the health status of the 143 ELBW YAs was described with 54 unique health states, in contrast to 27 unique health states for the 130 NBW subjects, which underscores the complexity and multiplicity of functional problems among the ELBW subjects.

HRQL at Young Adulthood
There were no statistically significant differences in the mean utility scores between ELBW and NBW respondents (0.85; 95% confidence interval [CI]: 81–89; vs 0.88; 95% CI: 84–92; P = .32) (Table 2). There were no gender effects. These data include parental proxy responses for 10 severely disabled ELBW YAs. There was no statistically significant difference between the groups in the proportion with scores in the higher range, ie, ≥0.95 (62% vs 72%; P = .10). Within the ELBW cohort, there were no statistically significant differences in mean HRQL scores among those with and without NSIs (85; 95% CI: 77–93; vs 85; 95% CI: 80–90; P = .91). However, 3 ELBW and 2 NBW subjects reported their HRQL to be worse than dead (ie, <0). In 4 of the 5 cases, this very low utility score was associated with the presence of mental health problems without any physical disabilities.


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  		TABLE 2 Standard Gamble HRQL Scores for the Self-Reported Health Status of ELBW and NBW YA Respondents

 
To obtain a conservative estimate of HRQL, we performed sensitivity analyses of the mean utility score for the ELBW group, (1) by comparing only ELBW YAs who provided directly measured preferences; (2) by substituting a score of 0 (equivalent to being dead) for proxy responses for the 10 severely disabled subjects; and (3) by using the same procedure as in analysis 2 but, in addition, substituting a score of 0 for the 13 subjects who died after neonatal discharge. The resulting mean utility scores were not different for sensitivity analysis 1 but were significantly lower than scores for the NBW group for sensitivity analyses 2 and 3 (P = .009 and P < .001, respectively).

Comparison of Self-Reported HRQL Scores for Teens and YAs
Repeated-measures analysis of variance revealed that utility scores decreased over time within both groups [time: F(1,241) = 7.81; P = .006] (Table 3). The group effect (P = .14) and interaction of group x time (P = .97) were not significant. Between adolescence and young adulthood, the mean utility scores decreased by 0.05 within groups for both cohorts.


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  		TABLE 3 Comparison of Mean Self-Reported Standard Gamble HRQL Scores for YAs and Teens

 
Hypothetical Health States
There were no statistically significant differences between ELBW and NBW respondents in mean utility scores for the 4 hypothetical health states (Table 4). The ratings provided were in the same rank order and in accord with the severity of the health states (ie, Jamie was rated the highest, followed by Chris, Sandy, and Pat). The proportions of respondents who considered one or more of the aforementioned health states to be worse than being dead were 41% of ELBW respondents and 47% of NBW respondents (P = .38).


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  		TABLE 4 Standard Gamble HRQL Scores for Hypothetical Health States Provided by ELBW and NBW YAs

 
Regression Analyses
The regression equation to predict the HRQL of the YAs could account for only 11.7% of the explained variance. The variables entered at step 3 (YA psychosocial factors) accounted for the majority of the variance (7%). Of the step 3 variables, YA depression score was the best predictor of HRQL (t = –3.85; df = 217; P < .001).


   DISCUSSION
TOP
 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
A prevailing perception among individuals without disabilities is that a good quality of life is not possible or, at least is unlikely, when serious ill health or disability is present.44 People with limitations in physical function are sometimes assumed to have parallel limitations in social and emotional function, making them unable to enjoy life to the fullest. Stigmatization, social isolation, and discrimination in job opportunities are seen as further decreasing the quality of life for disabled individuals.45,46 However, studies have shown that, when patients' perceptions of personal well-being and life satisfaction are elicited, they are often discordant with the patients' "objective" health status and disability, as viewed by health professionals and society.4,7,47 This phenomenon was termed the "disability paradox" by Albrecht and Devlieger.48 With a qualitative approach, 54% of respondents with moderate/severe disabilities in their study reported having an excellent or good quality of life; in contrast, 80% to 85% of persons with no disabilities reported in national surveys that they were satisfied or very satisfied with their quality of life. Other investigators also reported positive life experiences by physically dependent persons,46,49–52 adolescents with physical disabilities,53 and persons with neurologic disorders such as amyotrophic lateral sclerosis.54,55 However, the process and dynamics through which persons with disabilities make these adaptations require additional exploration.48

The subjects in the aforementioned studies generally sustained illness or injury or developed neurologic problems in adulthood, after leading a relatively normal life. Here the high quality of life is explained by some as "cognitive reappraisal,"50,51,54 "secondary gain,"48 or a "second chance,"56 a situation in which individuals with impairments adapt to their new condition, reinterpret their lives, and appreciate their lives more fully than they ever did before the unfortunate event. However, children born with impairments, such as those in our study, have never known life to be any different. They have adapted to their disabilities while growing up and perhaps made the necessary adjustments with less conscious effort. When we reported that adolescents who were ELBW viewed their lives fairly positively, despite the presence of disabilities,21 the findings were received with some skepticism and disbelief. Harrison,57,58 a parent and author, could not reconcile the objective measures of neurologic and cognitive deficits34 with the subjective positive self-perception of HRQL by a significant majority of ELBW respondents.21 She and others pointed to some element of denial57 and self-deception59 as mechanisms for coping. This is one interpretation. However, the consistency with which our cohort of respondents described themselves as having a good quality of life, taken together with the improvements in their life trajectories to adulthood, support the concept that this is real. Furthermore, in the only qualitative study on ELBW YAs with disabilities, we showed that the majority of respondents have taken control and adapted to their disabilities.60 Similar findings of comparable subjective quality-of-life scores for YAs of VLBW and NBW61–63 and preterm adolescents with brain hemorrhage64 were reported, using different techniques for measurement of quality of life.

In the current study, ELBW YAs reported a greater burden of morbidity in several attributes. Despite a greater proportion with functional limitations and complexity of deficits, a significant majority of ELBW respondents reported a relatively high HRQL at young adulthood. In fact, there were no statistically significant differences in the mean utility scores between ELBW and NBW respondents, even when parental proxy responses for 10 severely disabled ELBW YAs were included. The self-perception of HRQL at young adulthood is particularly valuable, because by this age most subjects have matured and many hold jobs and lead independent lives; therefore, they should be able to give serious consideration to the issue of their quality of life. We hypothesized that, when they reached young adulthood and had to face many challenges independently, ELBW YAs would rate their HRQL significantly lower than NBW YAs, perhaps even lower than the self-ratings they provided at adolescence.21 Contrary to our prediction, this was not the case. ELBW YAs continued to place a high valuation on their quality of life; 62% viewed their HRQL as 0.95 or better, in comparison with 72% of NBW YAs (not significant). Within the ELBW cohort, there were no differences in the self-perception of HRQL between those with and without disabilities. There were, however, many ELBW respondents who provided scores in the lower range, and they should not be forgotten.

Our other hypothesis pertained to a decline in utility scores between adolescence and young adulthood. ELBW and NBW subjects showed the same decline in HRQL scores of 0.05. This finding is not entirely unexpected, because HRQL is not a static concept. HRQL is dynamic and has the potential to change over time, depending on the circumstances of the individual at the time of measurement. Horsman et al65 reported that a difference of 0.03 is clinically relevant. Nevertheless, the change in utility scores between adolescence and young adulthood was not drastic, which supports the stability and robustness of the measure used and the positive self-perception of HRQL at both time periods.

There were no differences between groups in the mean utility scores assigned for the hypothetical health states. Although 40% of both cohorts rated one or more of the hypothetical health states to be worse than being dead, only 3 ELBW and 2 NBW YAs provided negative scores for their own health states. Of these, only 1 ELBW YA had an isolated NSI (unilateral blindness); the remaining subjects had emotional problems and depression. It seems that not all neurologic disabilities are viewed negatively and other factors, such as mental health issues, may contribute to poorer HRQL. For other people, however, certain severely disabling health states might be regarded as equivalent to being dead. Additional sensitivity analyses performed by substituting a score of 0 for parental proxy responses and for subjects who died after discharge did result in significantly lower mean HRQL scores for the ELBW cohort.

This is the first study of measurement of HRQL at young adulthood from the perspective of subjects who were of ELBW. We used the standard gamble approach, which is one of several preference-based techniques that provide an objective credible means of measuring a subjective phenomenon, such as self-perceived HRQL.4,37,39 The standard gamble technique has reasonably high intrarater and test-retest reliability and high predictive validity.39,66,67 Although the standard gamble is conceptually somewhat complex to administer, we and others showed that young adolescents are able to process the required tasks.21,68 This process is likely to be more insightful in adulthood. Despite the publication of our findings a decade ago,21 directly measured preferences have not been used by other investigators who have measured HRQL in preterm populations. Tideman et al63 used a visual analog scale, Feingold et al64 used 4 questionnaires from the Centers for Disease Control and Prevention, and Bjerager et al61 and Dinesen and Greisen62 used a 2-step questionnaire format. However, Gill and Feinstein4 made a strict distinction between measurement of certain aspects of health status and the value individuals place on a particular health state. They reported that most studies in the literature seem to use health status as a surrogate for quality of life. Such measures, which place a strong emphasis on functional and role limitations, would result in lower ratings of quality of life, compared with preference-based measures. However, HRQL, as defined by Gill and Feinstein,4 is a "uniquely personal perception" about how an individual feels or values his or her health state. For example, it is possible for individuals to assign different values to the same health state. Therefore, those authors maintain that HRQL can be measured only by determining the preferences of patients.4 Not everyone is in complete agreement.3,7 For evaluation of outcomes, however, most think that the patient's perspective is as important as that of the health care professional, if not more so.3,4,7

The positive valuation of HRQL by a significant majority of ELBW respondents is in accord with their successful transition to adulthood, in terms of educational status, employment, living independently, marrying, and having a family.69 Concerns that formerly preterm subjects would experience diminished quality of social engagement, interpersonal competence, and life satisfaction also were not borne out in our study.70 It seems that, despite their earlier struggles during childhood and adolescence, most ELBW subjects have made remarkable adjustments in many aspects of their lives by the time they reach young adulthood. It is therefore not surprising that their self-perception of HRQL is no different from that of their NBW peers. Such studies need to be replicated with different populations and racial and ethnic groups,71 and the factors that contribute to the positive attitudes and adjustment need to be studied more thoroughly. In addition, because the impairment profile of the current survivors may be somewhat different, future studies should consider incorporating self-reported HRQL measures in assessing outcomes for older children and adolescents.


   ACKNOWLEDGMENTS
 
The study was supported by grants from the Canadian Institutes of Health Research (grant MOP 42536) and the National Institute of Child Health and Human Development (grant HD40219).

We are extremely grateful to the ELBW and NBW YAs and their families for their participation. We thank David Feeny, University of Alberta, and William Furlong, McMaster University, for permission to use the HUI systems and for their advice; Jon Tyson, University of Texas, for his interest, encouragement, and insightful comments; Liz Merz for tracking study subjects; Mary Lou Schmuck for assisting with the statistical analysis; research support staff members for conducting interviews and data entry; and, Diane Turcotte for typing the manuscript.


   FOOTNOTES
 
Accepted Apr 19, 2006.

Address correspondence to Saroj Saigal, MD, FRCP C, Department of Pediatrics, McMaster University, 1200 Main St W, Room 4G40, Hamilton, Ontario, Canada L8N 3Z5. E-mail: saigal{at}mcmaster.ca

The authors have indicated they have no financial relationships relevant to this article to disclose.


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 ABSTRACT
 METHODS
 RESULTS
 DISCUSSION
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