Surgery 174 (2023) 1249e1254

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Surgery
journal homepage: www.elsevier.com/locate/surg

Presented at Academic Surgical Congress 2023

A prospective assessment of resilience in trauma patients using the

Connor-Davidson Resilience Scale
Penelope N. Halkiadakis, BSa,b, Sarisha Mahajana,c, Danyel R. Crosbya,d,
Avanti Badrinathan, MDe, Vanessa P. Ho, MD, MPH, PhDa,b,f,*
a
Department of Surgery, Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, MetroHealth Medical Center, Cleveland, OH
b
Case Western Reserve University School of Medicine, Cleveland, OH
c
University of Michigan, Ann Arbor, MI
d
Department of Nutritional Biochemistry and Metabolism, Case Western Reserve University, Cleveland, OH
e
Department of Surgery, University Hospitals Cleveland Medical Center, OH
f
Center for Health Equity Engagement, Education, and Research; Population Health and Equity Research Institute, The MetroHealth System and Case
Western Reserve University, Cleveland, OH

a r t i c l e i n f o a b s t r a c t

Article history: Background: Resilience, or the ability to adapt to difficult or challenging life experiences, may be an
Accepted 8 July 2023 important mediator in trauma recovery. The primary aim of this study was to describe resilience levels
Available online 19 August 2023 for trauma patients using the validated Connor-Davidson Resilience Scale.
Methods: Adult trauma patients admitted to a Level 1 trauma center (June 2022eAugust 2022) were
surveyed at the time of admission and by phone between 2 weeks and 1 month after the original survey
to obtain follow-up scores. We utilized the validated Connor-Davidson Resilience Scale score, a 25-
question survey with 5 subfactors (Tenacity, Positive Outlook, Social Support, Problem Solving, and
Meaning and Purpose). Each question was scored from 0 to 4 (maximum score 100, representing the
highest resilience). Patient factors were collected from the electronic medical record and trauma health
registry. Wilcoxon signed-rank test and multivariable linear regression were used to understand asso-
ciations with Connor-Davidson Resilience Scale scores.
Results: We enrolled 98 patients. The median age was 50 years (interquartile range 32e67), and 74%
were male sex. The baseline median Connor-Davidson Resilience Scale score on admission was 88
(interquartile range 81e94). Follow-up surveys (N ¼ 64) showed a median score of 89.5 (80e90.5) (P ¼
non-significant). No demographic variable was significantly associated with increasing baseline Connor-
Davidson Resilience Scale score. Increased length of stay (b ¼ 1.03), insurance (b ¼ 7.50), and unknown
race (b ¼ 23.69) were correlated with follow-up Connor-Davidson Resilience Scale scores. The subfactor
“Meaning and Purpose” decreased at follow-up but was not statistically significant (P ¼ .05).
Conclusion: Validated tools that can accurately distinguish variability in resilience scores are needed for
the trauma patient population to understand its relationship with long-term patient health outcomes.
© 2023 Elsevier Inc. All rights reserved.

Background
After sustaining a major injury, 80% of severe trauma survivors
score below normal for overall well-being at an 18-month follow-
This manuscript was presented as a Quick Shot and Oral Presentation at the
18th Annual Academic Surgical Congress in Houston, TX, February 7e9, 2023
(Abstract #: ASC20230644 and ASC20231098).
* Reprint requests: Vanessa P. Ho, MD, MPH, MetroHealth Medical Center,
Division of Trauma Surgery, Acute Care Surgery, Critical Care, and Burns, 2500
MetroHealth Drive, Cleveland, OH 44109.
E-mail address: vho@metrohealth.org (V.P. Ho);
Twitter: @vanessapho
up.1 Two years after injury, trauma patients suffer from persisting
pain, functional deficit, socioeconomic difficulties, and mental
health impairment.2 After more than 20 years from the initial
injury, nearly half of the patients suffer from 1 symptom of post-
traumatic stress disorder (PTSD).3 This lasting impact can predis-
pose a patient to future injury, as mental illness is a risk factor for
traumatic revictimization.4 It is vital to explore the role of resilience
in trauma patients' psychological and physical recovery, yet
research seeking to understand and promote resilience in trauma
patients is limited.5
The American Psychological Association defines resilience as the
process and outcome of successfully adapting to difficult or

https://doi.org/10.1016/j.surg.2023.07.012
0039-6060/© 2023 Elsevier Inc. All rights reserved.
1250 P.N. Halkiadakis et al. / Surgery 174 (2023) 1249e1254

challenging life experiences.6 Resilience is a dynamic characteristic and Unknown), ethnicity (including categories of Hispanic, non-
that external events can positively or negatively modify.7,8 There is Hispanic, declined to answer, and unavailable), marital status,
ongoing research examining the utility of resilience measures and employment status, trauma activation level (level 1, or full team
the potential mediating effects of resilience in the context of activation; level 2, or limited trauma activation; level 3, or emer-
trauma.9e12 Exploring how a patient’s resilience will change after gency department team activation only; or trauma consult without
trauma is beneficial to healthcare workers and policy-makers so activation), and patient origin (scene or transfer from another fa-
that they can identify necessary interventions to support patient cility). Injury mechanism, hospital length of stay, number of days in
recovery. Several scales exist to measure resilience.13 The the intensive care unit, emergency department and discharge
ConnoreDavidson Resilience Scale (CD-RISC) is a well-studied, disposition, comorbidities, insurance status, and primary payor
validated, and internally consistent 25-item self-report measure were also retrieved from the trauma registry.
developed in 2003 to assess resilience levels in clinical practice,
treatment-outcome studies, and biological research.7 Analysis
The aim of our study was to measure resilience in trauma pa-
tients using the CD-RISC scale at admission and after discharge. We The data analysis for this study was generated using Stata/SE
hypothesized that certain patient factors or injury-specific char- v17.0 (StataCorp, LLC, College Station, TX). Descriptive analysis was
acteristics are associated with high resilience. used to illustrate patient demographics. Categorical variables are
presented as counts and proportions. Normally distributed
Methods continuous variables are presented as the mean, SD, and range.
Skewed variables are presented with the median and interquartile
Patient population range. Wilcoxon rank sum test and c2 analysis were performed, as
appropriate, to test for differences in patient characteristics be-
We performed this study prospectively at an urban Level 1 tween those who followed up and were lost to follow-up. The
Trauma Center. Patients were selected from our inpatient census, Wilcoxon signed-rank test was used to describe the relationship
including those admitted to the Trauma Service or the Orthopedic between admission and follow-up CD-RISC scores. Multivariable
Trauma Service. Patients were enrolled between June 27, 2022, and linear regression was performed to describe the relationship be-
August 5, 2022. Only patients over 18 years of age and who had tween baseline and follow-up CD-RISC scores with various patient
been admitted to the hospital for more than 2 midnights were demographics and injury characteristics.
eligible for inclusion. We included patients admitted to the trauma Based on a power calculation assuming the baseline CD-RISC
service for 2 midnights to ensure that our study would include score would be 80 ± 5, a sample of 25 patients at baseline and 25
patients with a serious traumatic injury. Prisoners, pregnant pa- patients at follow-up would be powered to detect a 5% decrease in
tients, patients who were not able to speak, did not speak English, score. Per our protocol, we enrolled patients for a specified period
were physically or cognitively unable to consent, or required acute and were overpowered to detect this difference. This prospective
psychiatric hospitalization were excluded from this study. The observational study was approved by the Institutional Review
trauma units were rounded on weekdays between 11 AM and 2 PM to Board.
enroll eligible patients during index hospitalization to the study.
Study enrollment and baseline screening were performed by 2 Results
research personnel (S.M. and D.R.C.) under supervision by the
principal investigator of the study). Eligible patients who were A total of 98 patients were included in this study, of which 64
awake, willing to participate in the study, and signed informed (65.3%) were reached for follow-up (Figure 1; Table I). The median
consent forms were administered the CD-RISC.
The 25-question version of the CD-RISC was used. The CD-RISC
can be subdivided into the following 5 lifestyle factors: (1) personal
competence, high standards, and tenacity (Tenacity); (2) trust in
one’s instincts, tolerance of negative affect, strengthening effects of
stress (Positive Outlook); (3) positive acceptance of change and
secure relationships (Social Support); (4) control (Problem-Solv-
ing); and (5) spiritual influences (Meaning and Purpose).7 These
factors were not shared with patients. Patients were read out the
questions and asked to give a score on a 5-point scale (0e4), with
0 representing “Not at all confident” and 4 representing
“Completely confident.” The patient’s score on each question was
recorded, and the scores for the 25 total questions were summed
together. The score ranges from 0 to 100, with higher scores
reflecting greater resilience.
Study participants were contacted by phone beginning 2 weeks
and up to 1 month after the initial survey; follow-up was performed
by 3 of the coauthors (S.M., D.R.C., P.N.H.). During the second con-
tact, patients were readministered to the CD-RISC. Each statement
was read, and the answer was recorded. To minimize bias, the
survey administrator provided only the directions written on the
survey as would have been available had the respondent completed
the questionnaire individually.
Demographics and prehospital data were collected from the
electronic medical record and the trauma registry. These variables Figure 1. Flow diagram of prospective cohort enrollment. CD-RISC, ConnoreDavidson
included age, sex, race (including categories of White, Black, Other, Resilience Scale.
 P.N. Halkiadakis et al. / Surgery 174 (2023) 1249e1254 1251

Table I
Patient cohort characteristics

Variable Total cohort* Follow-up* Lost to follow-up* P value

N ¼ 98 N ¼ 64 N ¼ 34

Age, median (IQR), y 50 (32e67) 44 (29e65) 56 (40e71) .09

Male sex, n (%) 72 (73.5) 47 (65.3) 25 (34.7) .99
Race, n (%)
Black patients 27 (27.6) 20 (74.1) 7 (25.9) .26
White patients 64 (65.3) 38 (59.4) 26 (40.6) .09
Employment, n (%) .76
Employed 29 (29.6) 20 (31.3) 9 (26.5)
Unemployed 52 (53.1) 33 (51.6) 19 (55.9)
Retired 11 (11.2) 8 (12.5) 3 (8.8)
Unknown 6 (6.1) 3 (4.7) 3 (8.8)
Comorbidities, n (%)
Hypertension 33 (33.7) 21 (32.8) 12 (35.3) .80
Smoking 20 (20.4) 13 (20.3) 7 (20.6) .97
Alcohol use 11 (11.2) 4 (6.3) 7 (20.6) .03
Mental or personality disorders 10 (10.2) 5 (7.8) 5 (14.7) .28
Trauma activation levels, n (%) .47
Category 1 31 (32.3) 19 (30.2) 12 (36.4)
Category 2 52 (52.2) 37 (58.7) 15 (45.45)
Category 3 3 (3.1) 1 (1.6) 2 (6.1)
Consult 10 (10.4) 6 (9.5) 4 (12.12)
Patient origin, n (%) .43
Direct from scene 54 (56.8) 35 (56.5) 19 (57.6)
Transfer 36 (37.9) 25 (40.3) 11 (33.3)
Injury severity score, n (%) .865
1e9 (mild) 30 (30.6) 21 (32.8) 9 (26.5)
10e15 (moderate) 19 (19.4) 13 (20.3) 6 (17.7)
16e24 (severe) 23 (23.5) 14 (21.9) 9 (26.5)
25þ (profound) 26 (26.53) 16 (25.0) 10 (29.4)
Hospital LOS, median (IQR), d 9 (4e14) 9 (4e14) 9.5 (6e14) .62
Victim of violence, n (%) 27 (27.8) 19 (29.7) 8 (24.2) .57
Penetrating injury mechanism, n (%) 22 (22.5) 17 (26.6) 5 (14.7) .18
In-hospital complications, n (%) 35 (35.7) 19 (29.7) 16 (47.1) .08
30-d Readmission, n (%) 8 (8.2) 6 (9.4) 2 (5.9) .54
Discharge disposition, n (%) .26
Inpatient rehabilitation 18 (19.0) 9 (14.5) 9 (27.3)
Home or self-care (routine discharge) 41 (43.2) 31 (50.0) 10 (30.3)
Skilled nursing facility 31 (32.6) 18 (29.0) 13 (39.4)
Insurance, n (%) .068
Yes 87 (88.8) 57 (89.1) 30 (88.2)
No 6 (6.1) 2 (3.1) 4 (11.8)
Unknown 5 (5.1) 5 (7.8) 0 (0.0)

LOS, length of stay.

*
Categories are shown if samples are small.

age was 50 years (IQR 32e67), and over half (53.1%) were unem-
ployed. Nearly 74% of patients were male sex. Most patients (65.3%)
were of White race. Black patients accounted for 27.6% of the total
cohort. Most patients (52.2%) presented as Category 2 activation,
and more than half (56.8%) were brought directly from the injury
scene. Less than one-third (27.8%) of patients were a victim of
violence. The injury severity score ranged from 1 to 50, with similar
distribution between mild (1e9), moderate (10e15), severe
(16e24), and profound (25þ). The median hospital length of stay
was 9 days (IQR 4e14), during which over one-third (35.7%) of
patients experienced an in-hospital complication. Five patients did
not answer at least 1 question in the baseline survey, with 1 to 3
questions omitted; 3 patients did not answer at least 1 question in
the follow-up survey, with a range of 1 to 11 questions omitted.
Follow-up CD-RISC scores were obtained at a median of 17 days
(14e38) after the baseline score. There was no significant difference
in patient characteristics between the patients who were able
follow-up and those who did not (Table 1).
On admission, patients had a median (IQR) baseline CD-RISC
score of 88 (81e94) (Table II). The median CD-RISC score at
follow-up increased to 89.5 (80e90.5), P ¼ NS. On the Wilcoxon
signed-rank test, baseline CD-RISC subgroup and follow-up CD-
RISC scores were not significantly different, although factor 5
(Meaning and Purpose) approached significance (P ¼ .054). The
range and distribution of each factor are depicted in Figure 2. On
multivariable linear regression, no variable was significantly
correlated with increasing baseline CD-RISC score (Table III).
When examining follow-up scores, increased length of stay and
unknown race identity were associated with an increased CD-RISC
score at follow-up. Insurance was significantly correlated with a
decreased CD-RISC score at follow-up (Table IV).
Discussion
Increasing evidence suggests resilience plays an important role
in trauma recovery. This study examined the psychometric prop-
erties of CD-RISC in a sample of 98 trauma patients. The patients’
median baseline CD-RISC score was 88 (81e94). Approximately 65%
of patients were able to follow up, and the median follow-up CD-
RISC score was 89.5 (80e90.5). On multivariable linear regression,
no patient or injury characteristic was significantly correlated with
increasing baseline CD-RISC score. On follow-up, increased length
of stay and unknown race were significantly positively correlated
with CD-RISC score, whereas insurance was significantly negatively
correlated with CD-RISC score.
Overall, our patients had high CD-RISC scores at baseline and
follow-up. In Connor and Davidson’s original study, the CD-RISC
score in the general population was reported as 82 (IQR 73e90).7
1252 P.N. Halkiadakis et al. / Surgery 174 (2023) 1249e1254

Table II
CD-RISC score
CD-RISC score, which contrasts with Rainey et al who found the
baseline CD-RISC 10 score was positively correlated with educa-
Variable, median (IQR) Baseline score Follow-up score P value tion level and employment at baseline.24 There may be other
N ¼ 98 N ¼ 64
factors that we did not capture in the CD-RISC or the electronic
CD-RISC 25 88 (81e94) 89.5 (80e90.5) .57 medical record that more accurately predict resilience. In studies
Factor 1 3.68 (3.50e4.00) 3.75 (3.25e4.00) .49
of patients after traumatic brain injury, higher preinjury produc-
(tenacity)
Factor 2 3.28 (2.85e3.71) 3.42 (3.00e3.71) .66 tivity, life satisfaction, and social connection, as well as lower
(positive outlook) preinjury substance misuse, were associated with higher resil-
Factor 3 3.60 (3.20e4.00) 3.70 (3.30e4.00) .69 ience levels.9,10 Patient frailty has also been suggested as a
(social support) correlate of patient resilience.25
Factor 4 3.66 (3.00e4.00) 3.66 (3.00e4.00) .95
(problem-solving)
Interestingly, having insurance was correlated with decreasing
Factor 5 4 (3.50e4.00) 3.50 (3.00e4.00) .05 CD-RISC follow-up scores (b ¼ 7.50). Of the patients able to follow
(meaning and purpose) up, 57 patients (89.1%) were insured, of whom 18 patients (31.6%)
CD-RISC, ConnoreDavidson Resilience Scale. were on Medicaid and 24 (42.1%) were on Medicare. There are
documented disparities in surgery rates, time to surgery, and com-
plications based on insurance type across the general trauma and
orthopedic trauma literature.26e28 In our patient population, many
patients are uninsured up until receiving care and application for
insurance occurs in the hospital, which may have skewed our results.
Increased length of stay correlated with increasing CD-RISC follow-
up scores (b ¼ 1.03). Our prior research has shown that patients with
greater indicators of major trauma, such as longer hospitalization,
will likely engage with trauma recovery services (TRS). The TRS is the
psychosocial support program at our institution that provides
various services, such as peer mentors, counseling, referrals to
wraparound service programs, and more.29 It is possible that access
to hospital-based support programming improved patient resilience
at follow-up or enabled providers to identify support services.
Akin to the disease-specific quality-of-life tools that have been
developed for different clinical populations, including trauma pa-
tients, a validated and specific resilience tool may be better suited to
measure resilience in the trauma patient population. Ideally, a resil-
ience screening tool specific for the trauma patient population would
help identify individuals at high risk of poor long-term recovery early.
Figure 2. ConnoreDavidson Resilience Scale factor groups at baseline and follow-up. We obtained follow-up CD-RISC scores a median of 17 days (IQR
CD-RISC, ConnoreDavidson Resilience Scale. 14e38) after baseline because our research team is interested in the
ability to distinguish a patient’s resilience trajectory soon after injury.
A disease-specific resilience tool would also provide sufficient gran-
The CD-RISC is responsive to change in many groups, including ularity and variability in resilience scores by asking about outcomes
clinical populations, students, and healthcare workers.9e11,14e20 and resources most pertinent to the trauma patient population. This
Other studies of trauma subpopulations have shown similar or contrasts with our results using the CD-RISC, which revealed rela-
lower CD-RISC scores (patients with traumatic brain injury had a tively high scores for our entire population at baseline and follow-up.
mean of 76.8 ± 17.3, and geriatric patients with orthopedic fractures Our concern about the CD-RISC scale for the trauma population is
had a mean of 73.03).9,20 A shorter version, the CD-RISC 10, has that, in our study, it did not reveal sufficient variation in our study
been used in patients with spinal cord injuries and has shown high population to identify high-risk individuals. Accurately measuring
reliability, validity, and practicality.21 Future study is needed to resilience is especially needed, as the literature suggests resilience
demonstrate adequate reliability and validity of the CD-RISC within mediates long-term patient outcomes, such as medication adherence,
the larger trauma patient population. An alternative would be to life satisfaction, anxiety, depression, return to work, substance misuse,
develop trauma-specific scales. In a study of 3 trauma centers, the and long-term chronic pain.11,12,14,30 Large decreases or persistent low
Functional Outcomes and Recovery after Trauma Emergencies scores could indicate the need for early and targeted delivery of
project, resilience was measured using an unvalidated subscale of heightened support and care, such as case management, to aid in
the trauma-specific quality of life (T-QoL) questionnaire. In the recovery. Conceptualizations of resilience posit that it can be taught
Functional Outcomes and Recovery after Trauma Emergencies and strengthened.31 Future study is needed to evaluate whether
project, patients with low resilience were less likely to have intensive interventions, such as evidence-based trauma psychosocial
returned to work or school and more likely to report chronic pain, support programs, can modify resilience. The TRS participation has
functional limitations, and PTSD symptoms.22 More recently, a already been shown to be associated with higher patient satisfaction
revised T-QoL has been developed for the trauma population that and better treatment adherence to follow-up plans.29,32
measures recovery and resilience as part of a combined domain
with physical well-being.23 Study limitations
In our study, subgroup and total baseline CD-RISC and follow-
up CD-RISC scores were not significantly different. Rainey et al Our study should be interpreted considering several limitations.
reported a similar finding, whereby resilience scores remained Resilience may be a baseline characteristic, but we were unable to
stable from the time of injury and 12-month follow-up, regardless ascertain resilience scores before the injury. Another limitation is
of injury type, etiology, or severity.24 In our study, no patient or that participants may have been reluctant to report lower scores
injury characteristic was significantly associated with baseline because of attitudes, beliefs, and perceptions on sensitive
 P.N. Halkiadakis et al. / Surgery 174 (2023) 1249e1254 1253

Table III
Multivariate linear regression for baseline CD-RISC score

Variable ß coefficient (SE) 95% CI P value

Age 0.001 (0.108) 0.22 to 0.22 .992

Sex
Male patients Ref Ref Ref
Female patients 2.4 (3.66) 4.87 to 9.78 .505
Race
Black patients Ref Ref Ref
White patients 3.65 (3.76) 11.17 to 3.87 .335
Other 5.61 (15.10) 24.59 to 35.81 .712
Unknown 7.31 (10.04) 12.76 to 27.38 .469
Employment
Employed Ref Ref Ref
Unemployed 4.05 (3.49) 11.02 to 2.92 .250
Retired 1.02 (5.75) 12.52 to 10.48 .860
Unknown 2.40 (6.84) 16.07 to 11.27 .727
Victim of violence 7.84 (6.42) 20.68 to 5.01 .227
Injury severity score
1e9 (mild) Ref Ref Ref
10e15 (moderate) 3.08 (4.40) 5.73e11.88 .488
16e24 (severe) 3.14 (4.45) 5.77 to 12.05 .484
25þ (profound) 2.16 (4.30) 6.43 to 10.75 .617
Hospital LOS, d 0.10 (0.23) 0.37 to 0.56 .680
Penetrating or blunt mechanism 8.42 (6.42) 4.42 to 21.26 .195
Insured 0.57 (2.72) 6.84 to 5.70 .857
Discharge disposition
Rehab (inpatient) Ref Ref Ref
Home or self-care (Routine Discharge) 1.93 (5.00) 11.93 to 8.07 .701
Skilled nursing facility 0.54 (4.26) 9.05 to 7.97 .899
Long-term care 1.15 (19.36) 39.87 to 37.58 .953
Home with services 1.83 (7.74) 17.31 to 13.66 .814
Comorbidities
Hypertension 1.35 (4.10) 6.84 to 9.54 .743
Smoking 3.14 (4.10) 11.34 to 5.06 .447
Diabetes 6.00 (4.39) 2.78 to 14.78 .177
Alcohol use disorder 1.80 (5.67) 9.54 to 13.14 .752

CD-RISC, ConnoreDavidson Resilience Scale; LOS, length of stay.

questions. Some patients opted to skip certain questions, express-
ing dissatisfaction with the wording of or lack of comfortability
with certain CD-RISC statements, which may have introduced
reporting bias and inflated CD-RISC scores. Future studies could
consider methods that provide greater privacy, such as audio
computer-assisted self-interviewing technology. Multiple attempts
were made to contact patients, resulting in variation in the time
that passed between baseline and follow-up assessments. The loss
of 35% of the sample to follow-up may have introduced non-
response bias that inflated follow-up CD-RISC scores. However,
patients who did and did not follow up were similar in de-
mographic and injury characteristics.
It is possible that the groups differed in unmeasured charac-
teristics that can affect resilience, such as food security, housing
stability, and financial stability. These are among the specific social
needs of our patients that our institution measures in social de-
terminants of health screening tools.33 This screening tool has yet
to be routinely administered to our trauma patient population, and
future studies will investigate its expansion to this patient group.
The only resilience assessment used in this study was CD-RISC. The
CD-RISC score assesses characteristics of resilience and does not
assess the resiliency process.7 Alternative resilience surveys, like
the Brief Resilience Scale or the revised T-QoL survey, or other as-
sessments of mental health, like depression or PTSD, could be used
in the future to assess validity. Lastly, this is a single-center study
with a small sample size.
In conclusion, trauma patients had relatively high baseline and
follow-up resilience scores per the CD-RISC self-report measure.
Possession of insurance and unknown race were correlated with a
decreased CD-RISC score on follow-up, whereas the increased length of
stay was correlated with an increased CD-RISC score on follow-up.
While we did find some variation in CD-RISC scores in our study,
there was not strong evidence that this score would sufficiently iden-
tify patients with high risk for poor outcomes. Overall, these results
highlight the need for a validated, effective, and specific tool to assess
resilience in the trauma patient population and further investigate the
mechanisms to modify resilience to improve trauma patient outcomes.
Funding/Support
Vanessa P. Ho, MD, MPH, is supported by the Clinical and
Translational Science Collaborative of Cleveland (KL2TR002547)
from the National Center for Advancing Translational Sciences
component of the National Institutes of Health and National In-
stitutes of Health Roadmap for Medical Research. SM and DRC
received a stipend to complete this work as part of the Edward M.
Chester, M.D. Summer Scholars Program at MetroHealth Medical
Center.
Conflict of interest/Disclosure
V.P.H.’s spouse is a consultant for Medtronic, Zimmer Biomet,
Atricure, and Astra Zeneca. P.N.H., S.M., D.Y., and A.B. have no
conflicts of interest or financial ties to disclose.
Acknowledgments
The authors would like to thank the Edward M. Chester, MD,
Summer Scholars Program at MetroHealth, for which this publi-
cation was made possible.
1254 P.N. Halkiadakis et al. / Surgery 174 (2023) 1249e1254

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Age 0.16 (0.11) 0.06 to 0.38 .15
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