Abstract
Aims
While traumatic experiences can be distressing, they may also foster psychological growth, a phenomenon known as post-traumatic growth (PTG). The aims were to determine 1) the prevalence of PTG, and 2) the influence of survivor characteristics during hospitalization on levels of PTG at follow-up in a Danish cohort of out-of-hospital cardiac arrest (OHCA) survivors.
Methods
A multicenter prospective cohort study including OHCA survivors, exploring soci-odemographic, clinical, and psychosocial characteristics using the Montreal Cognitive Assess-ment (MoCA), the Hospital Anxiety and Depression Scale (HADS), the Impact of Event Scale-Revised (IES-R), and the Crisis Support Scale (CSS) during hospitalization. At three-month follow-up, structured interviews were conducted to assess PTG at personal, relational, and institutional levels. The influence of survivor characteristics on PTG was explored using Pearson’s chi-square tests.
Results
Overall, 173 survivors were included. At follow-up, 87% of survivors reported hav-ing one or more levels of PTG. The analysis revealed that the absence of cognitive impairment (MoCA ≥ 26 vs. MoCA < 26) was associated with personal growth (p = 0.02), being younger (<58 years vs. ≥ 58 years) with relational growth (p = 0.03) and being female or having symp-toms of depression (HADS ≥ 8 vs. HADS < 8), with institutional growth (p = 0.02 and p = 0.04), respectively.
Conclusion
The OHCA survivors reported high levels of PTG at three-month follow-up. The type of PTG level was influenced by the absence of cognitive impairment, younger age, fe-male sex, and symptoms of depression during hospitalisation. Social support, symptoms of anxiety, and traumatic distress did not significantly influence the level of PTG.
Keywords: Post-traumatic growth, Out-of-hospital cardiac arrest, Positive psychology, Survivorship care, Protective factor
Introduction
Survivors of out-of-hospital cardiac arrest (OHCA) constitute a diverse group experiencing a broad spectrum of secondary physical, neurological, and psychological consequences of survival.1 Although most survivors experience a good neurological outcome, the sudden, life-threatening nature of OHCA and its typically low survival rates2 often result in profound psychological burdens for survivors including symptoms of post-traumatic distress.3, 4 However, the traumatic experiences can simultaneously lead to positive psychological changes known as post-traumatic growth (PTG).5
PTG acknowledges the hardships experienced after a traumatic event and is found to serve as a protective mechanism against psychological distress, emphasizing the positive changes that result in living a fulfilling and meaningful life, such as personal growth, improved relationships, and increased gratitude for life including spiritual advancement.5 To illustrate, in patients with myocardial infarction (MI), studies indicate that up to 65% experience PTG three months to five years after the event manifested as a positive psychological transformation that reshapes their perspectives on life.6, 7 Furthermore, a study involving 287 heart attack victims found that men who perceived benefits from a first heart attack were less likely to suffer reinfarction and exhibited reduced morbidity eight years post-event.8 Therefore, investigating PTG after OHCA is worthwhile, as PTG may facilitate better adaptation to survivorship.
Studies across different types of traumatic events indicate that individual sociodemographic, clinical, and self-reported characteristics may correlate positively with the experience of PTG,9, 10, 11 e.g., female sex,12, 13 younger age,14, 15 social support,11, 16 perceived life threats11, 17 and higher post-traumatic stress symptoms.11, 18 While evidence increasingly highlights the importance of understanding recovery after successful adjustment to life after cardiac arrest,19, 20 PTG research in cardiac patients is limited,21 but it similarly suggests that social support, coping mechanisms, and psychological well-being correlate positively to the experience of PTG.10, 15 To further develop preventive support strategies and psychosocial post-cardiac arrest care programs, more insight is needed to understand the nature of positive trauma reactions in survivors. Therefore, the aims of this study were to determine 1) the prevalence of PTG, and 2) the influence of survivor characteristics during hospitalization on levels of PTG at three months follow-up in a Danish cohort of OHCA survivors.
Methods
Study design, participants, and procedures
This study used data collected from the multicenter REVIVAL cohort investigating cognitive impairment and psychopathology in OHCA survivors ready for discharge to home. The design and methods of the overall REVIVAL study are described in detail in a previously published study protocol.22 The participants were included in coronary care- and cardiac wards at three cardiac arrest centers in Denmark between December 2018 and January 2022. For study inclusion, survivors had to be aged 18 years or older, with a first-time cardiac arrest, with no other severe illnesses, and with sufficient knowledge of the Danish language to participate in the cognitive screening and the PTG interview as well as to complete the questionnaires.22 Besides baseline characteristics (T0), the study had two assessment points: T1 = during hospitalisation, and T2 = at three months follow-up.
Data collection and measures
Baseline demographics and clinical characteristics (T0)
We collected self-reported baseline sociodemographic variables (T0 data) which included age, sex, ethnicity, cohabitation status, and educational level. Further, clinical characteristics related to the cardiac arrest event, such as the return of spontaneous circulation (ROSC) time (minutes), length of intensive care unit (ICU) stay (hours), length of hospital stay (days), ejection fraction (EF) (%), and cardiovascular history (hypertension, ischemic heart disease, myocardial infarction, heart failure, coronary artery bypass grafting, arrhythmia and/or percutan coronary intervention) were retrieved from pre-hospital records and medical charts.
Assessment instruments collected during hospitalisation (T1)
During hospitalisation, a trained cardiac nurse assessed cognitive status screening using the paper version 7.0 of the Montreal Cognitive Assessment (MoCA), the preferred tool for detecting cognitive impairment following cardiac arrest23 and collected the following psychosocial patient-reported outcome measures (PROMs): the Hospital Anxiety and Depression Scale (HADS),24 the Impact of Event Scale-Revised (IES-R),25 and the Crisis Support Scale (CSS).26 See Supplementary Table S1 for a detailed description of the tools and assessment method used, the total scores and thresholds applied, and the time point at which each measure was captured. The T1 screening procedure involving the MoCA, the HADS, and the IES-R has been described in earlier studies.4, 22
Posttraumatic growth interview collected at three-month follow-up (T2)
At follow-up, the qualitative individual PTG interview27 was scheduled and conducted as part of the structured follow-up at the hospital to reduce participant burden. Flexibility in interview timing e.g. rescheduling was provided to accommodate participants availability and preferences. The participants were informed about the purpose of the qualitative assessment, which was conducted using a Danish manual, administered, and interpreted by either a clinical psychology student or an experienced cardiac nurse, both of whom were trained and supervised. The interview consisted of three questions involving positive experiences related to the cardiac event: 1) personal growth: “Have you experienced increased personal strength or maturity”? 2) relational growth: “Have you experienced increased closeness to others”? and 3) institutional growth “Have you experienced an increased sense of purpose or meaning in life”? The scoring of each question is dichotomized as either no = 0 or yes = 1 for each growth level, Initially, individual points are assigned after considering the narrative responses provided by the survivor. Any disputed points were discussed with the second last author (DSS) before final scoring.
Data analyses
The present analysis is based on data from OHCA survivors (n = 173) who responded to the outcome of interest, PTG at T2, while survivors who did not participate in the PTG interview were excluded (n = 124).4 We compared T0 and T1 sociodemographic, clinical, and self-reported characteristics of participants of the PTG interview to non-participating survivors, using independent t-tests or Mann-Whitney U-tests tests for means and medians respectively, and Pearson’s chi square tests for binary variables (Supplementary Table S2).
The included cohort (n = 173) was stratified by experiencing one or more levels of PTG (n = 150) or no PTG (n = 23), to describe differences between the groups. Categorical variables are presented as frequencies (n) and percentages (%), while continuous variables are presented as medians with interquartile ranges (IQR) or means with standard deviations (±SD) where appropriate. Group comparisons (PTG vs. no-PTG) were made by using independent t-tests or Mann-Whitney U-tests depending on whether the variable had a normal distribution. Pearson's chi-square tests were used for binary variables.
To determine the influence of survivor characteristics at T0 and T1 and levels of PTG at T2, all included survivor characteristics; sex, cognition (MoCA), symptoms of anxiety (HADS-A), symptoms of depression (HADS-D), reactions of traumatic distress (IES-R) and perceived social support (CSS) were dichotomized according to a recommended cut-off score, except for CSS, which was dichotomized according to the 25th percentile, and for age which was dichotomized according to the mean value. A Pearson's chi-square test was conducted for having PTG at each growth level in relation to no-PTG. Levels of significance were set at p < 0.05. Data descriptions are reported according to STROBE guidelines for observational study reporting.28 All analyses were performed using IBM SPSS version 29.0.1.0.
Results
Sample characteristics
Between January 2018 and February 2023, a total of 297 eligible survivors were enrolled consecutively in the REVIVAL study. Due to loss to follow-up and as presented in Table 1, a total of n = 173 survivors participated in this cohort. Participants were predominantly Caucasian of Danish descent (98%), male (81%), living with a partner/spouse (87%), and had a mean age of 57.5 (±11.9) years. Further clinical and cognitive data is detailed in Table 1.
Table 1.
Baseline sociodemographic, clinical, and cognitive characteristics during hospitalization (T0 + T1) of OHCA survivors stratified by PTG and no PTG at three-month follow-up (T2).
| Timepoint |
Total population (n = 173) |
PTG (n = 150) |
No PTG (n = 23) |
p▪ | |
|---|---|---|---|---|---|
| Demographics | T0 | ||||
| Age, mean (SD) | 57.5 (11.9) | 57.0 (12.1) | 61.0 (10.5) | 0.12 | |
| Male sex, n (%) | 140 (80.9) | 120 (85.7) | 20 (87.0) | 0.43 | |
| Caucasian/White, n (%) | 170 (98.0) | 147 (98.0) | 23 (100.0) | 0.56 | |
| Living with partner/ spouse, n (%) | 150 (86.7) | 129 (86.0) | 21 (91.3) | 0.49 | |
| Education ≥ 12 years, n (%) | 130 (75.1) | 115 (76.7) | 15 (65.2) | 0.24 | |
| Clinical characteristics | T0 | ||||
| Time to ROSC, median (IQR) (minutes) | 10 (6–15) | 12 (7–17) | 10 (5–15) | 0.04* | |
| Length of ICU stay, median (IQR), (hours) | 69 (29-96) | 72 (26-97) | 66 (41-84) | 0.50 | |
| Length of hospital stay, median (IQR) (days) | 11.5 (8–16) | 11 (8–16) | 13 (9–22) | 0.44 | |
| Ejection Fraction, median (IQR), (%) | 50 (45–60) | 50 (45–60) | 50 (40–60) | 0.67 | |
| Cardiovascular history, i.e., one or more*, n (%) | 77 (44.5) | 64 (42.7) | 13 (56.5) | 0.23 | |
| Cognitive characteristics | T1 | ||||
| Total MoCA, median (IQR) | 25 (22–28) | 25 (22–28) | 25 (22–27) | 0.54 |
PTG: Post-traumatic growth, T0: At hospital admission, T1: During hospitalisation, OHCA: Out-of-hospital cardiac arrest, ROSC: Return of spontaneous circulation, ICU: Intensive Care Unit, MoCA: Montreal Cognitive Assessment.
*Cardiovascular history: Hypertension, myocardial infarction, ischemic heart disease, heart failure, coronary artery bypass grafting, arrhythmia and/or percutan coronary intervention.
Continuous variables are presented as means (SD) (age) using independent t-tests or medians (IQR) (time to ROSC, length of ICU stay, length of hospital stay and total MoCA score) using wilcoxon rank-sum tests, and categorical variables as numbers (percentages) (sex, ethnicity, cohabitation, education, ejection fraction and cardiovascular history) using pearsons chi squared tests.
▪Levels of significance set at p < 0.05.
Non-participants of the PTG interview at follow-up
As shown in Supplementary Table S2, the group of non-participants of the PTG interview n = 124 were more often living alone (75,0% vs. 86.7%, p = 0.01), less well-educated (56.5% vs. 75.1%, p = 0.01), had a lower EF (45% vs. 50%, p < 0.01, a lower MoCA total score (23 vs. 25, p < 0.01), and lower perceived social support (39.2 (±5.0) vs. 40.9 (±6.0), p = 0.02) before hospital discharge, than the PTG interview participants.
Prevalence of PTG at three-month follow-up
Of the survivors who participated in the PTG interview (n = 173), the majority (86.7%) reported having one or more levels of PTG (Table 2). Overall, the survivors reported high levels of growth at all levels ranging from 50.0% to 88.2%, though it was most pronounced at a relational growth level (Table 3, Table 4).
Table 2.
Psychosocial characteristics collected during hospitalization (T1) of OHCA survivors, stratified by PTG and no PTG at three-month follow-up (T2).
| Timepoint |
Total population (n = 173) |
PTG (n = 150) |
No PTG (n = 23) |
p▪ | |
|---|---|---|---|---|---|
| Symptoms of anxiety | T1 | n = 173 | n = 150 | n = 23 | |
| HADS-A, mean, (SD) | 5.5 (3.8) | 5.6 (3.9) | 5.0 (3.0) | 0.48 | |
| Symptoms of depression | T1 | n = 173 | n = 150 | n = 23 | |
| HADS-D, mean, (SD) | 4.3 (3.6) | 4.5 (3.7) | 2.9 (2.3) | 0.06 | |
| Traumatic distress | T1 | n = 173 | n = 150 | n = 23 | |
| IES-R, mean, (SD) | 19.8 (13.8) | 20.4 (13.7) | 15.2 (13.4) | 0.09 | |
| Avoidance subscale, mean, (SD) | 0.8 (0.7) | 0.9 (0.7) | 0.8 (0.6) | 0.45 | |
| Intrusion subscale, mean, (SD) | 1.0 (0.8) | 1.1 (0.8) | 0.7 (0.7) | 0.05 | |
| Hyperarousal subscale, mean, (SD) | 0.8 (0.7) | 0.8 (0.7) | 0.6 (0.6) | 0.08 | |
| Social support following a crisis | T1 | n = 173 | n = 150 | n = 23 | |
| CSS, mean, (SD) | 40.9 (5.0) | 40.9 (5.1) | 41.4 (4.2) | 0.67 |
PTG: Post-traumatic growth, HADS-A: Hospital Anxiety and Depression Scale – Anxiety, HADS-D: Hospital Anxiety and Depression Scale – Depression, IES-R: Impact of Event Scale – Revised, CSS: Crisis Support Scale.
Continuous variables are presented as means (SD) (HADS-A, HADS-D, IES-R and CSS) using t-tests.
▪Levels of significance set at p < 0.05.
Table 3.
The influence of survivor characteristics on PTG growth levels stratified by sex, age, and cognitive status.
| Levels of PTG |
Sex (n = 173) |
Age (n = 173) |
Cognition (n = 173) |
||||||
|---|---|---|---|---|---|---|---|---|---|
|
Males n = 140 |
Females n = 33 |
p▪ |
Age < 58 n = 83 |
Age ≥ 58 n = 90 |
p▪ |
MoCA < 26 n = 98 |
MoCA ≥ 26 n = 75 |
p▪ | |
| Personal growth, n (%) | 90 (62.3) | 23 (69.7) | 0.56 |
58 (69.8) |
55 (61.1) |
0.23 |
57 (58.2) |
56 (74.7) |
0.02* |
| Relational growth, n (%) | 104 (74.3) | 27 (81.8) | 0.37 |
69 (83.1) |
62 (68.8) |
0.03* |
75 (76.5) |
56 (74.7) |
0.78 |
| Institutional growth, n (%) | 70 (50.0) | 24 (72.7) |
0.02* |
49 (59.0) |
45 (50.0) |
0.23 |
50 (51.0) |
44 (58.7) |
0.32 |
PTG: Post-traumatic growth, MoCA: Montreal Cognitive Assessment.
▪Levels of significance set at p < 0.05.
Table 4.
The influcence of survivor characteristics on PTG growth levels stratified by psychosocial characteristics.
| Levels of PTG |
Symptoms of anxiety (n = 173) |
Symptoms of depression (n = 173) |
Traumatic distress (n = 173) |
Social support (n = 173) |
||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
|
HADS-A < 8 (n = 127) |
HADS-A ≥ 8 (n = 46) |
p▪ |
HADS-D < 8 (n = 139) |
HADS-D ≥ 8 (n = 34) |
p▪ |
IES-R < 30 n = 129 |
IES-R ≥ 30 n = 44 |
p▪ |
CSS < 40 n = 53 |
CSS ≥ 40 n = 120 |
p▪ | |
| Personal growth, n (%) |
85 (66.9) |
28 (60.9) |
0.46 |
91 (65.5) |
22 (64.7) |
0.93 |
85 (65.9) |
28 (63.6) |
0.78 |
34 (64.2) |
79 (65.8) |
0.83 |
| Relational growth, n (%) |
96 (75.6) |
35 (76.1) |
0.95 |
101 (72.7) |
30 (88.2) |
0.06 |
94 (72.9) |
37 (84.1) |
0.13 |
41 (77.4) |
90 (75.0) |
0.74 |
| Institutional growth, n (%) |
71 (55.9) |
23 (50.0) |
0.49 |
70 (50.4) |
24 (70.6) |
0.04* |
68 (52.7) |
26 (59.1) |
0.46 |
30 (56.6) |
64 (53.3) |
0.69 |
PTG: Post-traumatic growth, HADS-A: Hospital anxiety and depression Scale – Anxiety, HADS-D: Hospital anxiety and depression Scale – Depression, IES-R: Impact of Event Scale – Revised, CSS: Crisi support scale.
▪Levels of significance set at p < 0.05.
Survivor characteristics influencing PTG vs no-PTG at follow-up
No statistically significant difference in age was observed between the PTG group and the no-PTG group (57.0 vs. 61.0 years, p = 0.12). However, a statistically significant longer time to ROSC in the PTG group vs. the no-PTG group (12 vs. 10 min, p = 0.04) was found.
Table 2 shows that survivors who reported PTG at follow-up had higher mean scores on depressive symptoms (4.5 vs. 2.9, p = 0.06) and traumatic distress (20.4 vs. 15.2, p = 0.09), and reported more intrusive thoughts during hospitalisation (1.1 vs. 0.7, p = 0.05) compared to the no-PTG group. However, none of these differences reached statistical signficance.
The influence of survivor characteristics on levels of PTG at follow-up
At follow-up, survivors with no cognitive impairment (MoCA ≥ 26) during hospitalisation experienced more personal growth when compared to those with cognitive impairment (MoCA < 26) (74.7 vs. 58.2, p = 0.02). Further, those of younger age < 58 years reported more relational growth when compared to those of older age ≥ 58 years at the time of OHCA (83.1% vs. 68.8, p = 0.03). Female survivors exhibited higher institutional growth when compared to the males (72.2% vs. 50.0%, p = 0.02), and so did survivors with symptoms of depression (HADS ≥ 8) during hospitalisation when compared to those without symptoms of depression (70.6 vs. 50.4, p = 0.04). Symptoms of anxiety, traumatic distress and social support during hospitalisation did not influence the level of PTG at follow-up.
Discussion
In this study, we aimed to determine the prevalence and levels of PTG, and the potential influence of survivor characteristics during hospitalization on PTG at three months follow-up in a population of OHCA survivors. Our study suggests that OHCA survivors report high levels of PTG at the three-month follow-up. Importantly, PTG at follow-up was influenced by the absence of cognitive impairment, younger age, female sex, and symptoms of depression during hospitalisation.
Prevalence of PTG
Through individual PTG interviews conducted three months post-arrest, our study revealed that nine out of 10 survivors reported perceived psychological benefits from surviving OHCA, i.e., as either personal, relational and/or institutional growth. This result is consistent with another study on cardiac populations, which likewise find moderate to high levels of PTG.15 Yet, their finding revealed a slightly lower range of growth with our prevalence being greater than that. Such variability may reflect different patient populations, small sample sizes, and methodological differences e.g., the PTG instruments used. We used the three-dimensional PTG interview suggested by Elklit and colleagues31 however it only consisted of one question related to each growth level. This may have contributed to the high prevalence of PTG, as the interview format that detects any level of PTG is likely to yield higher prevalence rates compared to a PTG scoring instrument with a cut-off score, such as e.g., the 21-item PTGI targeting five growth domains would have.32 In contrast to the PTG interview, the PTGI does not reflect the differences between these levels, and the possibility of eliciting unique qualitative growth experiences is minimal. On the other hand, a reliable instrument that includes dimensional growth levels with subscales for each growth level is warranted, to create an individualized, patient-centered treatment approach that enhances the continuity of post-resuscitation care, as suggested for MI patients.
The higher incidence of PTG may also be attributed to the fact that participants in the 3-month follow-up interview had higher MoCA total scores and greater perceived social support. This suggests they had more resources than non-participants and were therefore more predisposed to experiencing PTG as a result of the cardiac event. On the other hand, the high prevalence of PTG may be explained by the sudden and life-threatening nature of OHCA, which could lead individuals to confront their mortality more profoundly than patients with other cardiac conditions. This echoes Tedeschi & Calhoun, 199533 arguing that the greater the life threat posed by the stressor, the greater the opportunity for growth, and “being confronted with one's mortality may elicit a reevaluation and redefinition of life goals and priorities”. Similarly, qualitative findings have revealed that, survivors often report that their cardiac arrest have given them a second chance at life and a determination to stay healthy, facilitating a need to reorientate in coping with trauma.34
Survivor characteristics influencing PTG levels
The majority of survivors experienced growth in more than one growth level, with relational growth being the most common growth experience. To illustrate, female survivors reported more institutional growth (72.7% vs. 50.0%, p = 0.02) compared to males. This is in line with two previous meta-analyses examining sex differences on PTG35 and may be explained by the fact that females generally tend to be more inclined to explore issues of identity and meaning after a trauma, which is a key component of PTG. Additionally, we found younger age had a significant influence on relational growth (<58 years = 83.1% and ≥ 58 years = 68.8%), p = 0.03), a finding which reflects the literature in the field.15, 36 This correlation may be explained by the fact that OHCA in older individuals may have more severe consequences, which in return, hinder the experience of PTG.15 Another explanation could be that middle-aged patients often have a stronger social network than older patients,37 thus having more potential for experiencing relational PTG. However, surprisingly, relational growth was not influenced by perceived social support during hospitalization (low perceived social support = 77.4% vs. high perceived social support = 75.0%), which is otherwise a consistent finding across trauma populations.11, 15, 16 This contradictory finding may be based on the specific course of OHCA survivorship, as this trauma is sudden and life-threatening, which often results in close relatives becoming more involved during the early rehabilitation period. Consequently, there were very few individuals in our study who experienced lack of social support, which is otherwise known to be more impactful in predicting adjustment to trauma and trauma disclosure.38, 39 This deviation, observed among the non-participants, suggests that those with low baseline support were less likely to participate in the PTG interview at follow-up. Hence, the most vulnerable survivors might still lack social support.
Additionally, survivors without cognitive impairment reported significantly more personal growth than those with cognitive impairment (74.7% vs. 58.2%, p = 0.02). This aligns with Juan et al.40 who found cognitive impairments strongly correlated with negative perceptions of post-cardiac arrest recovery at six months. Brain injury, a potential consequence of OHCA due to interrupted blood circulation, can lead to varying degrees of cognitive impairment affecting neural circuits and emotional regulation.41 Since cognitive processing is essential for reflecting on traumatic experiences in close relationships, cognitive impairment may hinder these reflections. As cognitive impairment and depressive symptoms share some of the same symptoms,42 we found contrary to our expectations, that institutional growth was influenced by symptoms of depression during hospitalisation. One possible explanation for this could be that the HADS is a screening tool measuring a temporary mood state with symptoms of depression and not a diagnostic tool. This difference from results observed in other populations11 may be due to external factors like coping skills influencing our findings, rather than driven by pervasive clinical depression.
Limitations
Although perceived positive effects of recovery are absent in resuscitation research, the results of this study should be interpreted cautiously due to potential methodological limitations. First, the outcome PTG measure was self-reported which may have led to recall bias affecting the results. Second, PTG in this study was measured with a structured interview which on the one hand differentiates the various levels of PTG, but on the other hand, complicates the comparison of results across studies. Third, the small number of no-PTG survivors limits the conclusions that can be drawn from this study, and larger longitudinal studies with more comprehensive trauma assessments and survivor care approaches are warranted. Additionally, while PTG is a well-established concept and recognized as a protective mechanism that enhances resilience in trauma literature, it does not encompass the full spectrum, complexity, and role of PTG on post-traumatic distress experienced by several survivors of OHCA. Indeed, PTG may evolve beyond the initial phase of psychological adjustment observed during the first three months follow-up. Long-term follow-up is essential to examine the stability and progression of PTG over time, as well as its association with health-related quality of life.
Conclusion
OHCA survivors report high levels of PTG at three-month follow-up. The type of PTG level was influenced by the absence of cognitive impairment, female sex, younger age, and symptoms of depression during hospitalisation. Social support, symptoms of anxiety, and trauma reactions did not influence the level of PTG.
Ethics
The study protocol was approved by the Danish Data Protection Agency (RH-2017-325), I-Suite (05961), and the regional Research Ethic Committee (H-18046155). Other study results have been published.4, 29, 30 Written informed consent was obtained during hospitalization from all participants.
CRediT authorship contribution statement
M.K. Wagner: Writing – original draft, Methodology, Investigation, Formal analysis, Conceptualization. S.K. Berg: Writing – review & editing. C. Hassager: Writing – review & editing, Supervision. B. Borregaard: Writing – review & editing, Supervision. D. Petrova: Writing – review & editing. S. Agarwal: Writing – review & editing, Supervision. D.S. Stenbæk: Writing – review & editing, Supervision, Resources, Methodology, Investigation, Conceptualization. M. Blakoe: Writing – original draft, Resources, Methodology.
Declaration of competing interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Footnotes
Supplementary data to this article can be found online at https://doi.org/10.1016/j.resplu.2025.100980.
Appendix A. Supplementary material
The following are the Supplementary data to this article:
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