Research paper

Death after head injury: the 13 year outcome of

a case control study
T M McMillan,1 G M Teasdale,2 C J Weir,3 E Stewart1
1

Psychological Medicine, Faculty

of Medicine, University of
Glasgow, Glasgow, UK
2
NHS Quality Improvement
Scotland, Glasgow, UK
3
MRC Hub for Trials
Methodology Research, Centre
for Population Health Sciences,
University of Edinburgh,
Edinburgh, UK
Correspondence to
Professor T M McMillan,
Psychological Medicine, Faculty
of Medicine, University of
Glasgow, Gartnavel Royal
Hospital, 1055 Great Western
Road, Glasgow G12 0XH, UK;
t.m.mcmillan@clinmed.gla.ac.uk
Received 25 June 2010
Revised 3 November 2010
Accepted 17 November 2010
Published Online First
31 January 2011

ABSTRACT
Background Head injury is common, and the risk of
subsequent disability and death is high. Increased risk of
death years after injury might be explained by factors
associated with, but not a consequence of, the head
injury. This unique prospective study investigates
mortality over 13 years after injury.
Methods A cohort of n767 with head injury was
compared with two case control groups, matched for
age, gender and deprivation, and in one control group,
matched for duration of hospital admission following
(non-head) injury.
Results Two-fifths of the head injury cohort had died.
The death rate (30.99 per 1000 per year) was much
higher than in community controls (13.72 per 1000 per
year). More than 1 year after injury, the death rate in
younger (15e54 years) adults was much higher than in
community controls (17.36 vs 2.36 per 1000 per year)
whereas in older adults the difference was more
marginal (61.47 vs 42.36). Death rate was elevated after
mild and after more severe head injury, including in
younger adults after mild head injury (14.82 per 1000 per
year mild head injury vs 2.21 community). Female gender
and greater deprivation were not associated with
increased death rates after head injury. Late after injury,
deaths occurred from the same main causes as for the
general population.
Conclusion Head injury is associated with increased
vulnerability to death from a variety of causes for at least
13 years after hospital admission. There is a need to
understand how head injury influences mortality,
particularly in younger adults and after mild head injury.

INTRODUCTION
Head injury accounts for the majority of trauma
deaths in young adults.1 Previous work has largely
focused on early mortality during hospital admission or in the rst year after head injury, where
a high death rate in those with severe head injury is
well recognised.2e4 Some suggest that the risk of
death continues to be raised thereafter but this is
not a consistent nding.4e8 A denitive view is
lacking because of important methodological
shortcomings in existing studies.1 8 These include
limitations associated with retrospective study
design, potential biases from recruitment, including
the use of unrepresentative samples from clinic or
rehabilitation populations, military casualties or
specic databases, or where the sample was
restricted by age or severity of brain injury. These
limitations may prevent agreement about factors
that might be associated with survival such as
gender and age at injury and with potential
consequences of head injury such as self-harm.4e25
J Neurol Neurosurg Psychiatry 2011;82:931e935. doi:10.1136/jnnp.2010.222232

Surprisingly few studies have compared the

occurrence of deaths after head injury with the
death rate expected in the demographic population
from which the head injured come. Where this has
been attempted, an elevated risk of death more
than 6 months after head injury has not been found
consistently.4 7 8 26 However, these studies do not
include comparators that are matched to the
demographics of the head injured, who are often
young, male and from socially deprived backgrounds.27 We report the results of a unique study
in which late mortality in a prospectively identied
cohort of people admitted to hospital after head
injury was compared with matched hospitalised
and community control groups.

METHODS
Design
A comparison of cumulative death rates between
a cohort admitted to hospital after a head injury
and two case control groups was conducted. The
rst control group was hospitalised for an injury
other than head injury. The second was a community control group. Control groups were matched
to the head injury cohort for age, gender and
deprivation; the other injury group was, in addition, matched for duration of hospital admission
and admission date. Information collected in head
injury survivors at follow-up 1 year after injury was
considered in relation to survival outcome.

Setting
The head injury group was recruited from people
admitted with a head injury to the ve general
hospitals in Greater Glasgow. Survival outcome and
cause of death were ascertained 13 years after
admission from the General Register Ofce for
Scotland (GROS). Previous reports describe outcome
in this cohort at 1 and 5e7 years after injury.7 27 28

Participants
The Hospitalised Head Injury Study identied 2995
people admitted to a general hospital with a head
injury between February 1995 and February 1996.
Head injuries were identied by frequent visits by
research workers to hospitals and by collaboration
with hospital staff; in this way bias inherent in
diagnostic coding inaccuracies was minimised.27
The original cohort that was selected for followup included all severe and moderate cases and
a random sample of those with head injuries of
mild and unclassied severity.27 Exclusions were
not made on the basis of age. In this way the cohort
selected for follow-up was able to represent the full
range of severity of injury of hospital admissions
with head injury over a 12 month period.
931

Research paper

Quantitative variables
Early and late effects of injury are distinguished by reporting
outcome at 1 and 2e13 years. Age was an important determinant of outcome 7 years after injury.7 We subdivided age as #54
versus >54. These cut-offs were adopted on the basis of cut-offs
used by the GROS in data published by them and used in our
earlier work. Comparisons are made with GROS statistics for
the Greater Glasgow or Scottish populations for 2002 (the
midpoint of the 13 year follow-up) because the community
control group was matched with the head injury group and
therefore differs from the general population. Data on variables
pertinent only to the head injury cohort were obtained from the
existing research database, which in turn was obtained by
research workers from hospital records and interview during
admission to hospital at the study onset and at the 1 year
follow-up.

Table 1

Demographic characteristics and matching of groups

Parameter

Levels

Head injury
(n[757)

Gender

Male
Female
Mean (SD)
1
2
3
4
5

602
155
43.4
40
32
48
89
463

Age (years)
SIMD 2006 (quintile)*

(79.5%)
(20.5%)
(20.9)
(6.0%)
(4.8%)
(7.1%)
(13.2%)
(68.9%)

Other injury
controls
(n[757)

Community
controls
(n[757)

603
154
43.8
44
31
58
101
435

603
154
44.4
51
63
57
126
454

(79.7%)
(20.3%)
(20.8)
(6.6%)
(4.6%)
(8.7%)
(15.1%)
(65.0%)

(79.7%)
(20.3%)
(20.9)
(6.8%)
(8.4%)
(7.6%)
(16.8%)
(60.5%)

*Higher quintiles are associated with greater deprivation.

group multiple logistic regressions assessed the associations of

the covariates age, gender and SIMD deprivation score with
survival. The OR and its 95% CI were calculated for each
covariate after adjusting for the others in the model. Interactions
between each covariate and study group were tested to assess if
associations varied signicantly across groups. Overall and cause
specic death rates over the entire 13 years of follow-up were
summarised using the rate per 1000 per annum and its 95% CI.

RESULTS
Participants
Of the 767 cases in the original head injury cohort, 99% were
successfully linked to survival outcome by ISD. The 10 cases
that were not linked and their corresponding matched controls
were omitted. Hence analyses are based on three groups each of
757. The control groups were comparable for age, gender and for
deprivation on SIMD 2006 (see table 1).

Main findings
In the head injury cohort, 305/757 (40.3%) people had died
within 13 years of injury. The proportion of deaths was higher
in the head injury than in other injury (215; 28.2%) or
community (135; 19.0%) groups (gure 1). This remained the
case beyond the early period in year 1 where mortality was
particularly high (deaths after year 1: 229, 33.6%; 168, 23.7%;
116, 15.7%, respectively; log rank test, c265.35, df2,
p<0.0001). For other injury controls the death rate was higher
than for community controls.
The rate of death in the community control group over the
13 year period (13.72 per 1000 per year) was similar to that in

45%
40%

Cumulative frequency

The Information Services Division (ISD) is Scotlands national

organisation for health information, statistics and IT services.
Tracing of the head injury cohort and identication of the two
control groups at 13 years was undertaken by ISD, who
provided the GROS information on the deceased. Information
necessary for participant identication comprising name,
surname, date of birth and postcode was obtained from the
existing research database, and sent to ISD, except in two cases
where date of birth was not recorded. ISD then identied
survival outcome and cause of death from GROS data for up to
13 years after hospital admission. ISD identied two control
groups, each of n767, based on 1:1 matching with the head
injury cohort. The other injury control group was identied
from the Scottish Morbidity Records (SMR01). It comprised
people admitted to Glasgow hospitals because of other injury
(not admitted due to head injury) in the same year as the head
injury cohort and matched to the head injury group by gender,
age, social deprivation (Scottish Index of Multiple Deprivation
200629 (SIMD) quintiles), date and duration of admission.
Duration of admission was used as an approximation for
severity of admitting condition. The community control group
was identied via community health index numbers and focused
on social deprivation by matching to the postcode area of the
head injured group, by age and by gender.
Potential controls with a history of head injury were excluded.
For the purpose of creating the control groups, a head injury was
dened by ICD diagnoses in the following categories: ICD 9:
800e804 and 850e854; ICD 10: S02.0-S02.9 and S06.0-S06.9.
The other injury control group was dened by ICD-9 codes
805e848 and 860e959. Cases with the following codes were
excluded: 925 crushing injury of face scalp and neck and 929
crushing injury of multiple unspecied sites, as intracranial
injury would have been possible in such cases. Also excluded
were injuries where there might have been associated anoxic or
metabolic causes of brain injury: poisoning by drugs 960e979
(includes analgesics and psychotropic agents); toxic effects of
non-medicinal substances 980e989 (includes carbon monoxide,
solvents, alcohol and metals); other and unspecied effects
990e995 (including heat exhaustion, drowning); and complications of surgical care 996e999. In terms of ICD-10 codes the
following were included: S00, S01, S03-S05, S10e99; T00-T19
(excluding T04; crushing injuries); and T33e35. Other codes not
included refer to exclusions (such as poisoning) as for ICD-9.

35%
30%
25%
20%
15%
10%
5%
0%

10

12

14

Time (years)
Head Injury _____

Other Injury Control _ _ _ _

Community Control ........

Statistical methods
Cumulative death rates during follow-up are summarised by
KaplaneMeier estimates for each group. Within each study
932

Figure 1 KaplaneMeier curves with CIs for cumulative deaths over

13 years in head injury and control groups (n757 per group at time 0).
J Neurol Neurosurg Psychiatry 2011;82:931e935. doi:10.1136/jnnp.2010.222232

Research paper

1.02 (0.97 to 1.06)

1.53 (1.44 to 1.63)

controls and in younger than in older injury patients, particularly in the head injury group. More than 1 year after head or
other injury, death rates were lower, and for older adults were
closer to the rates for community controls and Greater Glasgow
and Scottish populations. For younger adults more than 1 year
after injury, death rates were higher for head injury (OR 9.40;
95% CI 5.35 to 16.50) and other injury (OR 4.32; 95% CI 2.40 to
7.80) groups compared with community controls. The death
rate after head injury was higher than other injury (OR 2.17;
95% CI 1.50 to 3.14) (multiple logistic regression adjusting for
gender and SIMD scores).

0.99 (0.58 to 1.69)

Cause of death (see table 4)

Table 2 Associations between age at study onset, gender and

Scottish Index of Multiple Deprivation with survival outcome 13 years
after study entry
Group

Variable

Head injury

Age
Gender
Male
Female
SIMD 2006 score
Age
Gender
Male
Female
SIMD 2006 score
Age
Gender
Male
Female
SIMD 2006 score

Other injury
control

Community
control

Alive at
13 years*

Dead at
13 yearsy

OR for deathy
(95% CI)

32.8 (14.6)

59.0 (18.9)

1.52 (1.43 to 1.62)

376
76
46.1
35.9

(62.5)
(49.0)
(22.8)
(15.9)

226
79
44.5
63.7

(37.5)
(51.0)
(22.1)
(18.2)

0.78 (0.47 to 1.31)

450
92
45.1
38.7

(74.6)
(59.7)
(22.8)
(17.6)

153
62
40.5
70.3

(25.4)
(40.3)
(22.7)
(14.2)

507 (84.1)
115 (74.7)
41.3 (22.9)

96 (15.9)
39 (25.3)
43.0 (23.4)

1.00 (0.96 to 1.05)

1.69 (1.55 to 1.85)
0.47 (0.25 to 0.87)
1.09 (1.03 to 1.15)

ORs and confidence limits are from multiple logistic regression within each study group.
*Mean and SD except for gender, where number and percentage alive or dead are stated.
yORs for gender are for female versus male; for age are per 5 additional years; and for
SIMD are per 5 additional points.
SIMD, Scottish Index of Multiple Deprivation.

the Glasgow population aged over 14 in 2002 (14.88 per 1000 per
year). Death rate in the head injury group (30.99 per 1000 per
year) was more than twice that for community controls or for
the Glasgow population.

Factors associated with main findings

For all groups, older age at study onset was associated with
greater risk of death at 13 years (table 2). A higher proportion of
females than males died in each group (table 2). After adjustment for potential confounding effects from age and deprivation, an association between female gender and improved
survival prospects was statistically signicant for community
controls. The absence of a gender advantage for females in the
head injury and other injury groups did not reect a greater risk
of death in these groups relative to community controls, as
shown by the non-signicant interaction for gender between
head injury (p0.39) or other injury (p0.12) and community
controls. Relationships between survival and SIMD score in
patients admitted to hospital for head injury or other injury
were non-signicant (table 2). A weak association was found in
the community control group with a reduced survival prospect
in people living in more deprived areas that persisted after
adjusting for the potential confounding effects of age and gender
(multiple logistic regression modelling).
Higher rates of death during year 1 were evident in adults
admitted to hospital after a head or other injury, than in
community controls or Glasgow or Scottish populations
(table 3). Death rates were higher relative to community
Table 3

The six main causes of death in the Greater Glasgow population

account for 92e94% of deaths in each group (see table 4).
Deaths from each cause were compared by group using 95% CIs
for KaplaneMeier survival curve estimates at 13 years. The
frequency of deaths in the head injury group was signicantly
higher than for community controls for circulatory, respiratory,
digestive, mental/behavioural and external causes and higher in
the other injury group than in community controls for external
causes.
For 13 years after injury, the frequency of death from selfharm (ICD9 E950e958; ICD10 X60e84, Y87.0) did not differ
between groups. Some cases of undetermined intent (ICD9
E980e989; ICD10 Y10e34, Y87.2) could have resulted from an
intention to self-harm. Four cases of undetermined intent died
during hospital admission as a result of their injuries and all of
these were in the head injury group. Of the remaining 11 cases,
eight were head injury and three were other injury controls.
Hence the maximum number of deaths from self-harm after
injury (self-harm plus undetermined intent) was 14, 11 and two
for the head injury, other injury and community groups (rates of
death per 1000 per year 1.42, 1.12 and 0.20, respectively). Five
people died with dementia as a primary, secondary or tertiary
cause. Of these, four were in the head injury group and one was
in the other injury group. A further three (two in the head
injured group and one in the other injury group) died from
Korsakoff s disease. Seven people died from seizure disorder as
a primary cause (six head injury and one other injury); of these,
three head and one other injury died more than a year after
injury and two (head injury) died less than 6 months after
injury.

Additional findings in the head injured group

Further information was gathered prospectively for the head
injury group. In year 1 the frequencies of death were higher after
severe (28.3%) and moderate (12.1%) than after mild head injury
(MHI: 5.6%) (c2 test p<0.0001). In years 2e13, this effect was
no longer signicant, given a higher frequency of deaths in
moderate (37.9%) and mild (32.4%) cases (severe, 32.4%) (c2 test
p0.52). The death rate for MHI (27.85 per 1000 per year; 95%
CI 24.60 to 31.22) was higher than for community controls

Rates of death per year, per 1000 people in younger and older adults
Deaths in year 1

Deaths in years 2e13

Age

15e54 years

>54 years

Overall

15e54 years

>54 years

Overall

Head injury
Other injury control
Community control
Greater Glasgow 2002
Scotland 2002

40.15 (25.02, 60.73)

15.3 (6.63, 29.92)
0 (0.00, 7.03)
2.35
1.98

235.04 (182.25, 294.68)

166.67 (121.28, 220.72)
81.20 (49.59, 123.90)
42.36
37.66

100.40 (79.92, 124.05)

62.09 (45.97, 81.71)
25.10 (15.18, 38.92)
14.88
13.85

17.36 (13.30, 19.21)

8.82 (6.36, 10.86)
2.21 (1.34, 3.91)
2.35
1.98

61.47 (55.55, 66.69)

50.95 (43.53, 55.37)
39.45 (33.46, 44.90)
42.36
37.66

30.99 (25.07e31.09)
21.85 (17.15, 22.47)
13.72 (10.97, 15.46)
14.88
13.85

Reference groups for Greater Glasgow and Scotland are from the General Register Office for Scotland. In parentheses are 95% CIs for the number of deaths per 1000 per year.

J Neurol Neurosurg Psychiatry 2011;82:931e935. doi:10.1136/jnnp.2010.222232

933

Research paper
Table 4 Primary causes of death per 1000 people per year for Greater Glasgow in 2002 and for each
group 13 years after study onset
Cause of death

Greater
Glasgow

Circulatory
Neoplasms
Respiratory
Digestive
Mental/behavioural
External
(Self-harm)
(Undetermined)
(Drug related)
(Other external)
Other

4.61
3.34
1.89
0.44
0.53
0.51
0.13
0.06
0.15
0.00
1.01

Deaths at 13 years
Community control

Other injury

Head injury

6.40
2.54
2.03
0.71
0.71
0.51
0.20
0.00
0.00
0.30
0.81

7.42
3.45
3.76
1.73
1.63
2.64
0.91
0.20
0.30
1.22
1.42

9.45
4.17
4.17
2.85
2.54
5.89
0.51
1.22
0.81
3.35
2.44

(4.96,
(1.65,
(1.25,
(0.29,
(0.29,
(0.17,
(0.02,
(0.00,
(0.00,
(0.06,
(0.35,

8.09)
3.72)
3.12)
1.46)
1.46)
1.18)
0.73)
0.37)
0.37)
0.89)
1.59)

(5.87,
(2.41,
(2.66,
(1.01,
(0.93,
(1.74,
(0.42,
(0.02,
(0.06,
(0.63,
(0.78,

9.21)
4.78)
5.13)
2.75)
2.62)
3.84)
1.73)
0.73)
0.89)
2.12)
2.37)

(7.72,
(3.01,
(3.01,
(1.90,
(1.65,
(4.51,
(0.17,
(0.63,
(0.35,
(2.32,
(1.57,

11.41)
5.60)
5.60)
4.08)
3.72)
7.53)
1.18)
2.12)
1.59)
4.67)
3.60)

In parentheses are 95% CIs for the number of deaths per 1000 per year.

(13.72; 11.67 to 15.96) and this difference was emphasised in

younger adults (MHI 14.82; 11.75 to 18.29; community 2.21;
1.24 to 3.60) and was attenuated in older adults (MHI 59.13;
53.24 to 64.17; community 39.45; 34.37 to 44.50).
A previous history of head injury was not a risk factor for
death (OR 1.05; 95% CI 0.74 to 1.50). A pre-injury admission for
brain illness (ie, mental problems, stroke or other requiring
medical attention; OR 2.22; 95% CI 1.43 to 3.42) or pre-injury
mental health treatment (OR 1.94; 95% CI 1.26 to 2.99) was
associated with death. Factors relating to lifestyle, namely
history of physical disability (OR 6.41; 95% CI 4.44 to 9.26),
habitual excess use of alcohol (OR 2.46; 95% CI 1.77 to 3.42) or
living alone (OR 2.64; 95% CI 1.89 to 3.68) were associated with
death outcome at 13 years.

DISCUSSION
Main findings
More than 40% of young people and adults admitted to hospital
in Glasgow after a head injury were dead 13 years later. This
stark nding is not explained by age, gender or deprivation
characteristics. As might be expected following an injury, the
highest rate of death occurred in the rst year after head injury.
However, risk of death remained high for at least a further
12 years when, for example, death was 2.8 times more likely
after head injury than for community controls. Admission for
non-head injury was also associated with a greater late risk of
mortality but after head injury the risk of death was even higher.
However, this nding does imply that factors associated with
risk of injury in general or the consequences of an injury are
related to longevity and emphasises the importance of comparison groups in studies of this kind. A second major nding is that
in comparison with controls, younger adults are at greater risk of
death after head injury, whereas for older adults, the risk relative
to controls is marginal more than a year after injury. Thirdly, the
rate of death is elevated even after a mild head injury and
especially in younger adults.

Comparison with other studies

The nding that mortality after head injury is high during
hospital admission or for up to a year after injury is not
new.2 3 21 24 Studies with a later follow-up in survivors at 6 or
12 months are often cross sectional or retrospective and often
include participants over a wide range of time since injury (eg,
days to decades). Many use unrepresentative samples of the
head injury population, such as those from neurosurgery or
rehabilitation units, only include those with persisting disability
934

or exclude cases by factors relevant to mortality, such as age or

severity of injury.6 10e12 15 16 21 24 26 Few studies compare
survival outcome after head injury with a comparator,4 6 12 26
and with the exception of our own, none used case matched
controls. A recent 10 year outcome study reported no overall
increase in mortality in survivors at 6 months after head injury
in comparison with population data, similar in age and gender.4
When survival outcome in adults aged 16e65 years was
considered separately, a slight but signicant increase in
mortality was found after head injury, and this effect might
have been increased had there been a control for social deprivation.4 Another study, with a general population comparator,
reported 1.95 times greater mortality in those surviving 1 year
after injury. Here older people with head injury were at greater
risk although age subgroups were not considered separately.26
The death rate in our cohort 1e13 years after head injury was
higher than in these studies and, for example, was ve times
higher than in the study by Flaada and colleagues.4 Differences
between studies in age distribution and rates of death in
comparators may explain this, but only in part. Studies with26
and with no comparison group reported an association between
older age at head injury and mortality.11e13 18e21 23 Our study
also showed a high rate of death in older than in younger
adults but relative to controls there was a high risk in younger
adults and a marginal effect in older adults. We found no
adverse risk associated with gender. In the literature there is no
consensus9e17 and studies have not used comparators.
The main causes of death after head injury were similar to
those found in the general population. Others also report high
rates of death from respiratory, digestive25 and circulatory
causes.5 6 12 The particularly high death rate from external
causes is partly associated with deaths early after injury, and
partly from drug and alcohol associated deaths. Relationships
between head injury and suicide are difcult to adduce from the
present study. This is partly because of the low frequency of
actual or possible suicide, partly because of difculty in ascribing
intent and partly because of the overlap between sociodemographic risk factors for head injury and for suicide. These issues
are reected in the lack of consensus in the literature.5 6 12 22e25
The low frequency of deaths from dementia or seizures similarly
makes it difcult to interpret the ndings of a higher frequency
after head injury.

Factors influencing late mortality

The severity of head injury was not associated with survival
outcome beyond the rst year after injury. Even when head
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Research paper
injury was classied as mild by the Glasgow Coma Scale, death
rate was more than twice as high as in community controls.
Admission to hospital for injury (or factors associated with
admission) contributed to a poorer survival outcome. Poorer
survival outcome after head injury was related to factors associated with lifestyle prior to the injury (physical limitations,
habitual alcohol excess and living alone) and to a history of
mental health problems, as also reported elsewhere.20 23
The particularly high rate of death in younger adults is
important. Thirteen years after injury the death rate in those
aged 15e54 years was more than six times higher than in
community controls and this was not an artefact of gender or
deprivation. Factors associated with hospital admission are
relevant, but when controlling for this in addition the death rate
remained more than twice as high in the head injury than in the
other injury group. Beyond the early period of up to 1 year after
injury, the death rate in those aged over 54 years did not exceed
that found in community controls. The reason for greater
vulnerability in younger adults is unclear but requires further
consideration, especially given the particularly high risk of head
injury in younger adults27 together with economic concerns over
work force planning and demographic trends towards an ageing
population.30

Strengths and limitations

The prospective nature of the head injury cohort, the long
follow-up, the completeness of the follow-up data and the
comparison with matched controls make this study unique in
the world literature. The study was limited by reliance on GROS
cause of death information and by the absence of qualitative
information in the control groups whose data were obtained
retrospectively.

Implications of findings and future work

Survival beyond the early period after head injury has received
relatively little attention. Although mortality is increased by
factors associated with admission to hospital after (any) injury,
after a head injury the risk is greatly elevated. Demographic
factors do not explain the risk of death late after head injury, and
there is a need to further consider factors that might lead to
health vulnerability after head injury and in this way explain the
range of causes of death. The elevated risk of mortality after
mild head injury and in younger adults makes further study in
this area a priority.

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Funding The 13 year follow-up was funded by the Chief Scientist Office (CZG/2/397).
The original prospective study was also funded by the Chief Scientist Office
(K/OPR/2/2/D229).

26.

Competing interests None.

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Ethics approval This study was conducted with the approval of the NHS Greater
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Contributors TMMM was the primary investigator for the follow-up study and took
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prospective study and commented at all stages in the follow-up project. CJW
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follow-up project and contributed to the manuscript.
Provenance and peer review Not commissioned; externally peer reviewed.

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