568414

research-article2015
POI0010.1177/0309364614568414Prosthetics and Orthotics InternationalQuigley et al.

INTERNATIONAL
SOCIETY FOR PROSTHETICS
AND ORTHOTICS

Original Research Report

Prosthetics and Orthotics International

Comparison of quality of life in people 2016, Vol. 40(4) 467­–474

© The International Society for
Prosthetics and Orthotics 2015
with partial foot and transtibial Reprints and permissions:
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amputation: A pilot study DOI: 10.1177/0309364614568414
poi.sagepub.com

Matthew Quigley1, Michael P Dillon1 and Emily J Duke2

Abstract
Background: Quality of life is often cited as a key influence in decisions about partial foot and transtibial amputations
despite there being no studies comparing quality of life in these groups.
Objectives: To compare quality of life in people with partial foot amputation or transtibial amputation secondary to
peripheral vascular disease and determine factors influencing quality of life in these cohorts.
Study design: Cross-sectional.
Methods: Mail-out, mail-back version of the SF-36v2 Health Survey and an adapted version of the demographic section
of the Trinity Amputation and Prosthesis Experience Scales–Revised were sent to people recruited through a large
metropolitan hospital.
Results: Both the SF-36v2 mental health component summary and physical component summary scores were comparable
in the partial foot amputation (n = 10) and transtibial amputation (n = 23) cohorts. A multivariate linear regression showed
that age, time with diabetes and the presence of retinopathy significantly influenced either the SF-36v2 mental health
component summary or physical component summary whereas amputation level did not.
Discussion: Results support existing descriptive data that indicate quality of life is comparable in cohorts with partial foot
and transtibial amputation.
Conclusion: Our results suggest that quality of life need not to be a consideration when deciding between partial foot and
transtibial amputation for persons with vascular disease. Surgeons and patients may wish to focus on other considerations,
such as the relative risk of ulceration and subsequent amputation, when choosing between partial foot and transtibial
amputation.

Clinical relevance
The similarity in quality of life between people with partial foot and transtibial amputation helps inform difficult decisions
about amputation surgery by focusing on surgery that will reduce the risk of complications and secondary amputation
without fear of compromising quality of life.

Keywords
Quality of life, partial foot, transtibial, amputation, SF-36
Date received: 30 July 2014; accepted: 18 November 2014

Background
The global diabetes epidemic is expected to affect 550  (PFA) has increased proportionately.4–6 If current trend con-
million people by 2030,1 and the increasing incidence is tinues, the incidence of PFA will triple across the first half of
recognised as a major health care challenge.1,2 Along with this century.6
increased health care costs, there is significant disability
that arises from complications including peripheral vascu- 1La Trobe University, Melbourne, VIC, Australia
lar disease (PVD) and lower limb amputation.3 2The Royal Melbourne Hospital, Melbourne, VIC, Australia
Despite the increasing incidence of diabetes and vascular
Corresponding author:
disease, data from industrialised nations show that the num- Matthew Quigley, La Trobe University, Plenty Road, Bundoora,
ber of transfemoral and transtibial amputations (TTA) has Melbourne, VIC 3083, Australia.
fallen. Meanwhile, the incidence of partial foot amputation Email: M.Quigley@latrobe.edu.au
468 Prosthetics and Orthotics International 40(4)
The shift to more distal amputation has been influenced
by improvements in diabetic care – better management of
diabetes at a community level,7,8 greater access to special-
ist high-risk foot clinics,9 as well as advances in revascu-
larisation surgery10 – that have made PFA an increasingly
more feasible option where previously a TTA may have
been necessary. There is also a strong preference for PFA
given the belief that surgical and functional outcomes are
improved compared with TTA.11–13
Recent expert opinion has called into question this pref-
erence,14,15 highlighting that 30%–50% of people with a
PFA experience complications such as dehiscence, ulcera-
tion and wound failure. By comparison, these complica-
tions affect just 10%–20% of people with TTA.12,16–18
Subsequent amputation surgery on the same limb is neces-
sary in about one-third of people with PFA, more than dou-
ble that observed in people with TTA.17,18 Efforts to
achieve wound healing in people with PFA often occur
over many months and come at a considerable financial
and personal cost.16 By comparison, healing of the TTA
residuum tends to be much more predictable and compara-
tively short.19
The high rates of complications and secondary amputa-
tion affecting people with PFA are of particular concern
given that many functional outcomes are similar in people
with PFA and TTA. For example, once the metatarsal
heads are affected, walking is virtually indistinguishable
between people with PFA and TTA.14,20,21 The limited
literature describing energy expenditure suggests this
outcome is also similar between people with PFA and
TTA.14,22,23 The similarities in functional outcomes between
PFA and TTA have turned attention to more holistic
measures such as quality of life (QoL).14,24
Based on a recent systematic review,24 just two studies
report QoL data for people with PFA or TTA secondary to
diabetes and PVD.25,26 Neither of these investigations were
designed to compare QoL in people with PFA or TTA and
as such, there is only descriptive data available. These data
suggest that QoL may be very similar for people with TTA
and PFA.
The paucity of research comparing QoL in people with
PFA and TTA has allowed poorly evidenced beliefs to per-
petuate. For example, QoL is thought to be better in people
with PFA because of the ability to ambulate short distances
without a prosthesis.11–13 However, physical functioning
has been shown to be a poor predictor of QoL,27 and per-
sons with limb loss report that social support and participa-
tion are more important than physical functioning.28 It may
be that the poor wound healing, readmissions to hospital
and higher risk of revision surgery associated with PFA
have a greater impact on QoL than does the comparative
ease of being able to walk to the toilet at night without a
prosthesis.14
There is a compelling need for research that compares
QoL in groups with PFA and TTA secondary to vascular
disease. Given that there are no experiments that compare
QoL in people with PFA and TTA, and only descriptive data
available in the literature, there is inadequate evidence to
inform decisions about amputation surgery from a QoL per-
spective. Similarly, there is inadequate data to inform deci-
sions about the sample size requirements for such an
experiment, particularly given the need for sophisticated
inferential analysis techniques that can control for the con-
founding influence of demographic and health factors (e.g.
age, sex, duration of diabetes, the presence of diabetic com-
plications such as retinopathy, neuropathy and nephropathy
as well as time since amputation) that have all been shown to
influence QoL.29–34 Results from a pilot study might provide
preliminary evidence to assist patients and surgeons to make
a more informed decision about the level of amputation from
a QoL perspective and guide future research efforts.
The purpose of this pilot study was to compare QoL in
people with PFA or TTA secondary to PVD. We hypothe-
sised that QoL would be comparable in people with PFA
and TTA. We also sought to understand which demo-
graphic or health factors influenced QoL in these cohorts.
Method
Participants
Participants were recruited through the prosthetics and
orthotics department of a major metropolitan hospital. We
wrote to all patients who met the following inclusion crite-
ria: adults over 18 years of age, amputation due to vascular
disease, either a unilateral TTA or PFA, and minimum
6 months post-amputation given that improvements in
QoL plateau 6 months following amputation.35
Apparatus
The apparatus included a revision to the demographic infor-
mation page from the Trinity Amputation and Prosthesis
Experience Scales–Revised (TAPES-R) and the SF-36v2
Health Survey.
The TAPES-R is a survey designed to measure the psy-
chosocial adaptation of lower limb amputees fitted with a
prosthesis.36,37 The demographic section records information
including age, sex, cause of amputation and time since
amputation. We added additional questions to identify the
presence of common complications that have been shown to
affect QoL such as retinopathy, nephropathy and neuropa-
thy.29–32 To aid comprehension by participants, we used lay
terms from diabetes education sources (e.g. describe retin-
opathy as ‘eye disease’).38,39 With the modifications, this
demographic section will be referred to as the TAPES-R-M.
A range of QoL measures have been used in amputee
populations, with little agreement as to the most appropri-
ate.33 Generic measures (e.g. SF-36) have been criticised for
not being sensitive to the psychosocial adaptation involved
Quigley et al. 469
in limb loss.37,40 Amputee-specific measures (e.g. Prosthetic
Evaluation Questionnaire) tend to focus on the prosthesis
and do not provide a holistic picture of QoL. Given that we
know so little about which domains of QoL are affected by
PFA and TTA, and that previous work has reported descrip-
tive data in these groups using the SF-36,25 we chose to con-
tribute to the creation of a pool of data in people with PFA or
TTA by using the same outcome measure.
The SF-36 has a low burden to respondents, taking
approximately 10  minutes to complete, and has been
shown to be a valid and reliable instrument across a range
of populations.36,41 Although there have been no validation
studies in an amputee population, it has been widely used,
suggesting its widespread acceptance as a QoL measure in
this population.42–45
Results from the SF-36v2 are reported using a physical
component summary (PCS) and a mental health compo-
nent summary (MCS). The PCS is a summary of the
domains of Physical Functioning, Role Physical, Bodily
Pain and General Health. The MCS is a summary of the
domains of Vitality, Social Functioning, Role Emotional
and Mental Health.41,46
The SF-36v2 differs from previous versions of the
instrument in that data are transformed to a ‘T-score’ to
facilitate comparison between the different subscales and
population norms. Given that the population norm for any
subscale is always 50, an individual’s score of 45 would be
deemed to be ‘below average’.
Procedures
Ethics approval for this study was granted by the Faculty
Human Ethics Committee, La Trobe University and
Melbourne Health Human Ethics committees.
The survey package was sent to all potential partici-
pants, which included a cover letter, participant informa-
tion sheet, the SF-36v2 and the TAPES-R-M.
Persons, who wished to participate in the study, returned
the survey using the reply-paid envelope. Consent was
implicit in return of the survey given that no identifying
information was contained in the survey.47
A reminder letter was sent 2 weeks after the initial invi-
tation, as the response rates for postal surveys can be sig-
nificantly improved with this approach.48,49
Data analysis
Upon receipt of the surveys, the demographic information
was entered into a database. Paper copies of the SF-36v2
were checked for missing items and out-of-range values
before entering the responses into the QualityMetric
Incorporated Health Outcomes Scoring software
(QualityMetric Incorporated, Lincoln, RI) for further pro-
cessing.46 The use of such software is recommended to
minimise errors with data analysis and makes the process
of summing raw scores, transforming data to population-
based norm (i.e. T-score) and checking data quality more
accurate.46 Following data entry, results were available for
the SF-36v2 PCS and MCS.
The reduced data were entered into IBM SPSS Statistics
22 (IBM Corporation, Armonk, NY) for analysis. To com-
pare QoL between the PFA and TTA cohorts, we used a
multivariate analysis of covariance (MANCOVA) given
the outcome measure consisted of two related dependent
variables (i.e. SF-36v2 PCS and MCS) and the need to
control for factors known to influence QoL (i.e. age, sex,
time with diabetes, time since amputation and the presence
of retinopathy, nephropathy, neuropathy and tissue break-
down). The MANCOVA was conducted following the
techniques described by Mayers.50 Accordingly, we tested
for violations of the assumptions of correlation, variance–
covariance, normality, multicollinearity and homogeneity
of the regression slopes. To better understand factors influ-
encing QoL, we used a standard multivariate regression
model in accordance with the techniques described by
Pallant51 including assumption testing for multicollinear-
ity, normality, linearity and homoscedasticity.51
Results
Of the 122 survey packages sent, 47 were returned and a
number were excluded because of incomplete demo-
graphic information (e.g. level of amputation had not been
specified), insufficient data to calculate the SF-36v2 PCS
or MCS scores, participants did not meet the inclusion cri-
teria (e.g. bilateral amputation) or data were deemed to be
outliers as described in detail as part of the inferential anal-
ysis. As such, data for 33 people were analysed including
23 people with TTA and 10 people with PFA (toes: n = 1,
forefoot: n = 5 and midfoot: n = 4).
Participants were representative of the population of
interest in terms of their age and sex distribution, time
since amputation, duration of diabetes and prevalence of
diabetic complications (Table 1). While groups were simi-
lar in terms of the proportion with nephropathy, the PFA
cohort had double the rate of retinopathy, neuropathy and
tissue breakdown (Table 1). Also, the length of time living
with diabetes was also lower in the PFA cohort (Table 1).
Comparison of SF-36v2 PCS and MCS between PFA
and TTA cohorts was undertaken using a MANCOVA,
whereby the influence of covariates – age, sex, time since
amputation, duration of diabetes and the presence of dia-
betic complications including retinopathy, nephropathy,
neuropathy and tissue breakdown – was controlled.
Assumption testing showed that the assumption of nor-
mality had been violated (Shapiro–Wilk: W = 0.895, df = 35,
p = 0.003). Two participants had PCS or MCS scores that
were deemed to be outliers based on inspection of the SPSS
box and whisker plots. These two cases were therefore
excluded from the analysis. With these participants excluded,
470 Prosthetics and Orthotics International 40(4)

Table 1.  Clinical and demographic characteristics of the partial foot and transtibial samples.

Amputation level Transtibial (n = 23) Partial foot (n = 10)

  n % n %
Male 14 60 7 70
Female 9 40 3 30
Presence of
  Tissue breakdown 3 13 3 30
 Diabetes 16 70 8 80
 Retinopathy 7 30 6 60
 Nephropathy 6 26 3 30
 Neuropathy 3 13 3 30
  x (SD) Range x (SD) Range
Age (years) 68 ± 10 43–86 63 ± 10 41–74
Time since amputation (years) 7.2 ± 8.2 1.1–40 5.1 ± 3.25 1.5–11.7
Duration of diabetes (years) 25 ± 12 10–50 16 ± 12 6–35

SD: standard deviation.

there was no violation of the assumptions of normality, line-
arity, multicollinearity, homoscedasticity, correlation
between covariates and dependent variables, independence
of covariates or homogeneity of the regression slopes.
To understand the influence of the covariates in our
comparison of QoL between the PFA and TTA groups, we
first ran a multivariate analysis of variance (MANOVA)
which showed no significant differences in the SF-36v2
PCS and MCS scores between groups (Wilk’s Lambda:
l = 0.964, F(2, 30) = 0.556, p = 0.58, η2 = 0.036). This was
confirmed across both dependent variables (PCS (F(1,
31) = 0.077, p = 0.79, η2  = 0.002) and MCS (F(1,
31) = 0.674, p = 0.42, η2 = 0.021)). While the inclusion of
covariates reduced the error variance (I = 0.932, F(2,
16) = 0.584, p = 0.57, η2 = 0.68), there was still no statisti-
cally significant difference between the groups based
on amputation level (PCS (F(1, 17) = 0.184, p = 0.68,
η2 = 0.011) and MCS (F(1, 17) = 0.448, p = 0.51,
η2 = 0.026)) (Figure 1).
A standard multivariate linear regression was devel-
oped to explain which independent variables – age, sex,
time with diabetes, time since amputation and the presence
of retinopathy, nephropathy, neuropathy and tissue break-
down – explained a significant part of the variance in the
SF-36v2 PCS and MCS scores.
Assumption testing for the multivariate linear regres-
sion showed no violations to the assumptions of multicol-
linearity, normality, linearity and homoscedasticity, given
that the previously identified outliers were excluded.
PCS score
The regression model explained 47% of the variance
in PCS scores (r2 = 0.47), which approached statistical
significance (F(9, 23) = 2.229, p = 0.06).
The only independent variables that contributed signifi-
cantly to the PCS were time with diabetes (β = 0.565,
t = 2.874, p = 0.01) and age (β = −0.436, t = −2.149,
p = 0.04), explaining 19% and 11% of the variance, respec-
tively. While none of the other variables contributed
significantly to change in PCS, retinopathy (β = −0.376,
t = −1.818, p = 0.08) and nephropathy (β = −0.399,
t = −1.566, p = 0.08) approached significance and each
explained a further 8% of the variance. Level of amputa-
tion explained less than 1% of the variance in the PCS and
was not statistically significant (β  = 0.097, t = 0.551,
p = 0.59) (Table 2).
MCS score
The regression model explained 45% of the variance in
MCS scores (r2 = 0.45), which approached statistical sig-
nificance (F(9, 23) = 2.070, p = 0.08).
Only the presence of retinopathy contributed signifi-
cantly to the MCS (β = −0.587, t = −2.786, p = 0.01),
explaining 19% of the variance. None of the other varia-
bles contributed significantly to changes in MCS, includ-
ing level of amputation (β = −0.016, t = −0.091, p = 0.93),
which explained less than 1% of the variance in the MCS
(Table 2).
Discussion
In response to our original research question comparing
QoL in these two groups, we found no statistically signifi-
cant differences in either the SF-36v2 PCS or MCS
between groups with PFA or TTA.
The level of amputation was not a statistically signifi-
cant contributor to QoL, explaining just 1% of the variance
in the SF-36v2 PCS and MCS. It is noteworthy that the
Quigley et al. 471

Figure 1.  SF-36v2: (a) mental health component score and (b) physical component score for the partial foot amputation (PFA) and
transtibial amputation (TTA) groups.

Table 2.  Regression coefficients.

Model Physical component score Mental health component score

  β t Sig. Proportion of β t Sig. Proportion of

variance (%) variance (%)
Age −0.436 −2.149 0.04* 10.7 −0.038 −0.185 0.86 0.1
Sex −0.076 −0.465 0.65 0.5 0.283 1.701 0.10 7.0
Time since amputation 0.217 1.214 0.26 3.5 −0.205 −1.128 0.27 3.1
Amputation level 0.097 0.551 0.59 0.7 −0.016 −0.091 0.93 0.01
Time with diabetes 0.565 2.874 0.01* 19.2 0.258 1.289 0.21 4.0
Presence of
 Retinopathy −0.376 −1.818 0.08 7.7 −0.587 −2.786 0.01* 19.0
 Nephropathy −0.399 −1.845 0.08 7.9 0.139 0.633 0.53 0.1
 Neuropathy −0.273 −1.566 0.13 5.7 0.043 0.249 0.81 0.1
  Tissue breakdown −0.130 −0.733 0.47 1.3 −0.154 −0.854 0.40 1.7

t = t-statistic; β: standardised coefficients; Sig.: significance where α = 0.05.

Proportion of variance is derived from part correlation coefficients.
*Statistically significant result.

independent variables that influenced QoL in our sample Clinical implications

reflect advancing age and systemic diseases (e.g. time with
diabetes, retinopathy), factors that are not readily resolved
at the point of limb loss.
To the best of our knowledge, this is the first study
designed to directly compare QoL in people with PFA
and TTA. While previous investigations25,26 were not
designed to compare QoL in people with PFA and TTA,
the available descriptive data suggest that differences
were small and not likely to be clinically meaningful. For
example, approximation of the SF-36 MCS and PCS
from the eight subscales reported by Boutoille et al.25
showed similarity with our results. Moreover, the descrip-
tive data reported by Peters et al.26 also suggest that there
was no difference in QoL for persons with PFA or TTA
based on the Sickness impact profile (SIP).
Our preliminary results do not support common beliefs that
QoL is better for people with dysvascular PFA compared to
those living with TTA.11–13,52 While our findings require cor-
roboration by other investigators, they highlight the need to
reconsider the advice given to patients facing difficult deci-
sions about limb loss. Based on our sample, a patients’ age,
time living with diabetes and the presence of retinopathy
had a significant effect on QoL and should feature in discus-
sions about amputation at the partial foot or transtibial level.
We hope this preliminary evidence focuses decisions on fac-
tors that influence QoL in these cohorts and not on the per-
ceived differences between amputation at the partial foot or
transtibial level. In this way, patients and surgeons might
focus their decision-making on other factors such as the
472 Prosthetics and Orthotics International 40(4)
disproportionately high risk of comp-lications and revision
surgery in PFA compared to TTA.12,13,16–18,53–59
We were surprised that the MCS scores for both the PFA
and TTA cohorts were so close to population-based norms,
particularly given the effects of chronic disease and complica-
tions affecting these groups.60 Many participants rated their
overall health as ‘good’ or ‘very good’ and reported PCS or
MCS scores well above the population norm. This suggests
that expectations, goals and self-perceived health status may
change for some people as their health changes. This phe-
nomenon, known as ‘res-ponse shift’,61 has been reported in
previous studies of QoL in people with amputation.35,62–65
Studies into the process of psychosocial adaptation following
amputation have also found that people who strive to attain
goals and who have the ability to redefine goals to those
achievable with their current health status have higher QoL
and better community participation.60,66
While the provision of psychosocial support services
following amputation may contribute to improvements in
QoL and community participation,60,67 our results suggest
that optimal management of diabetes-related complica-
tions may also be of benefit.
Limitations and implications for future research
Recruitment for this study was challenging and our experi-
ence could help inform future investigations. Identification
of large subject samples was difficult given the limitations
of hospital records that may not, for example, always stipu-
late amputation level. We were unable to use data from a
number of participants due to incomplete surveys. Large
multicentre studies may be required to recruit sufficient par-
ticipants, and consideration should be given to alternative
methods of administering the surveys that make forgetting
to complete components difficult. One such option may be
to deliver the SF-36v2 in an online format where participa-
tion on a global scale is possible, and software could be used
to flag incomplete answers before submission.
During the course of our pilot study, we learnt that multi-
variate linear regression could also be used for the purpose
of comparison. In this example, separate regression models
would be developed for each of the PFA and TTA groups.
The 95% confidence interval of the regression coefficients
could then be compared with any overlap indicating that the
QoL outcomes were comparable between groups. This cer-
tainly extends the typical use of regression for the purpose
of prediction or, as was the case in our pilot study, to deter-
mine which variables contributed to changes in QoL.
Our pilot work provides some basis for discussing the
sample size requirements for future experiments. To inform
this discussion, we undertook a sample size calculation for
a multivariate linear regression using G*Power 3.1.5
(University of Kiel, Kiel) and data from our pilot study. An
a priori sample size was calculated for the transtibial group
using a multivariate linear regression: fixed model with R2
deviation from zero. We determined effect size from pre-
dictor correlations and halved the alpha level in recognition
of there being two dependent variables (i.e. SF-36v2 PCS
and MCS). As such, input parameters into the calculation
were effect size = 0.48, alpha = 0.025, beta = 0.8 and number
of predictors = 8. The required sample of people with TTA
would be 46 people. The same sample size calculation
would also need to be done to determine the required num-
ber of people with PFA; something we were not able to do
with any certainty given the smaller number of people with
PFA in this pilot study. This sample size estimate should
only be considered as indicative. The actual sample required
will vary based on the statistical approach chosen, number
of independent variables included and the effect size upon
which the calculation was based.
Both the amputee cohorts were similar in terms of the
distribution by sex, age and number of complications.
However, the TTA cohort was larger and had a longer dura-
tion of diabetes and time since amputation than the PFA
sample. Fortunately, such differences between the cohorts,
and their potential to influence QoL, were well controlled
for by virtue of the inferential analysis and we would rec-
ommend such an approach to other investigators.
We were deliberate in not comparing scores for the
SF-36v2 subscales, and some may view this as a limitation.
The use of the SF-36v2 PCS and MCS has been developed
in order to control ceiling and floor effects seen with report-
ing of the subscale scores alone.46 In our investigation,
there was no rationale to compare individual subscale
scores, as we did not see statistically significant differences
between the two amputation levels for the PCS or MCS.46
It was not our intention to compare groups with differ-
ent levels of PFA, and some may perceive this as a limita-
tion. Investigators would need to power a study specifically
to measure differences in QoL between levels of PFA.
Given the many different levels of PFA and our expecta-
tion that differences in QoL between groups would be
small, such a study would need to recruit a large number of
participants. In light of our results, the utility of an investi-
gation comparing QoL in different levels of PFA would
need to be carefully considered and justification given for
why differences in QoL might exist between levels of PFA.
There may be other variables that are important to include
in the regression model. Some authors have noted the influ-
ence of depression, anxiety and the presence of phantom or
stump pain on QoL,33,34 and future research should consider
the appropriateness of these additional independent variables
for people with PFA and TTA. This may explain part of the
variance not captured in our regression model.
Conclusion
We did not observe significant differences in QoL in
groups of people with PFA and TTA from dysvascular
causes. In our sample, factors such as age, time living with
Quigley et al. 473
diabetes and the presence of retinopathy had a significant
effect on QoL, whereas amputation level did not. While
further research is needed to corroborate these findings,
our results suggest that QoL need not be a factor influenc-
ing the choice between PFA and TTA. Other factors, such
as the high risk of complications and revision surgery, may
become more important in decisions about amputation sur-
gery at the PFA and TTA levels, rather than considerations
about QoL.
Acknowledgements
The authors wish to thank Associate Professor Brian Hafner for
his insightful and valuable comments on the draft version of the
manuscript.
Author contribution
Study concept and method design: M. Dillon, M. Quigley, E.
Duke. Acquisition of data: M. Quigley, E. Duke. Analysis and
interpretation of data: M. Quigley, M. Dillon. Drafting of manu-
script: M. Quigley. Critical revision of manuscript for important
intellectual content: M. Dillon, E. Duke.
Declaration of conflicting interests
The authors declare no conflict of interest regarding this
manuscript.
Funding
This research received no specific grant from any funding agency
in the public, commercial or not-for-profit sectors.
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