The relationship between the subclavian vessels and brachial plexus and the overlying clavicle: Anatomical study with application to plate osteosynthesis.

A subclavian artery aneurysm after clavicle fracture and plate osteosynthesis in a suspected case of a screw that was too long led us to investigate body donor cadavers. The aim was to verify clavicle variability, and the course of the neurovascular bundle in relation to the clavicle and to the osteosynthesis plate, in order to clarify safe zones for plate and screw fixation. We used one fresh frozen and 25 embalmed donors for in situ measurements: (1) length and craniocaudal thickness of the clavicle, (2) distances between the sternal end of the clavicle and the center of parts of the neurovascular bundle. The clavicle was 15.15 cm long. The mean distances from the sternal end of the clavicle were 5.62 cm to the subclavian vein, 6.75 cm to the subclavian artery and 8.42 cm to the cords of the brachial plexus. The subclavius muscle was 1 cm thick. Because of sex differences in length and distances, we recorded the distances between the sternal end and parts of the neurovascular bundle as ratios of clavicle length (at-risk area) to provide sex-independent parameters: 0.379 for the vein, 0.449 for the artery and 0.554 for the nerve. The neurovascular bundle runs below the clavicle between the medial fourth and three fifths of clavicle length. To avoid iatrogenic neurovascular injuries, special caution is necessary during drilling and screwing the osteosynthesis. We also recommend using screws shorter than 1.4 cm.

Pearls and Pitfalls of Interpretation in CT Colonography.

The accuracy of computed tomography (CT) colonography (CTC) requires that the radiologist be well trained in the recognition of pitfalls of interpretation. In order to achieve a high sensitivity and specificity, the interpreting radiologist must be well versed in the causes of both false-positive and false-negative results. In this article, we review the common and uncommon pitfalls of interpretation in CTC.

Brain lesion correlates of fatigue in individuals with traumatic brain injury.

The purpose of this study was to investigate the neurological correlates of both subjective fatigue as well as objective fatigability in individuals with traumatic brain injury (TBI). The study has a cross-sectional design. Participants (N = 53) with TBI (77% male, mean age at injury 38 years, mean time since injury 1.8 years) underwent a structural magnetic resonance imaging (MRI) scan and completed the Fatigue Severity Scale (FSS), while a subsample (N = 36) was also tested with a vigilance task. While subjective fatigue (FSS) was not related to measures of brain lesions, multilevel analyses showed that a change in the participants' decision time was significantly predicted by grey matter (GM) lesions in the right frontal lobe. The time-dependent development of the participants' error rate was predicted by total brain white matter (WM) lesion volumes, as well as right temporal GM and WM lesion volumes. These findings could be explained by decreased functional connectivity of attentional networks, which results in accelerated exhaustion during cognitive task performance. The disparate nature of objectively measurable fatigability on the one hand and the subjective experience of fatigue on the other needs further investigation.

Predictors of the On-Road Driving Assessment After Traumatic Brain Injury: Comparing Cognitive Tests, Injury Factors, and Demographics.

OBJECTIVES: (1) To examine the relations between performance on cognitive tests and on-road driving assessment in a sample of persons with traumatic brain injury (TBI). (2) To compare cognitive predictors of the on-road assessment with demographic and injury-related predictors. PARTICIPANTS: Ninety-nine people with mild-severe TBI who completed an on-road driving assessment in an Australian rehabilitation setting. DESIGN: Retrospective case series. MAIN MEASURES: Wechsler Test of Adult Reading or National Adult Reading Test-Revised; 4 subtests from the Wechsler Adult Intelligence Scale-III; Rey Auditory Verbal Leaning Test; Rey Complex Figure Test; Trail Making Test; demographic factors (age, sex, years licensed); and injury-related factors (duration of posttraumatic amnesia; time postinjury). RESULTS: Participants who failed the driving assessment did worse on measures of attention, visual memory, and executive processing; however, cognitive tests were weak correlates (r values <0.3) and poor predictors of the driving assessment. Posttraumatic amnesia duration mediated by time postinjury was the strongest predictor of the driving assessment-that is, participants with more severe TBIs had later driving assessments and were more likely to fail. CONCLUSION: Cognitive tests are not reliable predictors of the on-road driving assessment outcome. Traumatic brain injury severity may be a better predictor of on-road driving; however, further research is needed to identify the best predictors of driving behavior after TBI.

A Model of Fatigue Following Traumatic Brain Injury.

OBJECTIVE: Fatigue is one of the most frequent sequelae of traumatic brain injury (TBI), although its causes are poorly understood. This study investigated the interrelationships between fatigue and sleepiness, vigilance performance, depression, and anxiety, using a structural equation modeling approach. METHODS: Seventy-two participants with moderate to severe TBI (78% males) were recruited a median of 305 days postinjury. They completed the Fatigue Severity Scale, a vigilance task, the Epworth Sleepiness Scale, and Hospital Anxiety and Depression Scale. A model of the interrelationships between the study variables was developed, tested, and modified with path analysis. RESULTS: The modified model had a good overall fit (χ2 = 1.3, P = .54; comparative fit index = 1.0; root-mean square error of approximation = 0.0; standardized root-mean square residual = 0.02). Most paths in this model were significant (P < .05). Fatigue predicted anxiety, depression, and daytime sleepiness. Depression predicted daytime sleepiness and poor vigilance, whereas anxiety tended to predict reduced daytime sleepiness. CONCLUSIONS: This model confirms the complexity of fatigue experience. It supports the hypothesis that fatigue after TBI is a cause, not a consequence, of anxiety, depression, and daytime sleepiness, which, in turn (especially depression), may exacerbate fatigue by affecting cognitive functioning. These findings suggest that to alleviate fatigue, it is important to address each of these factors. However, the findings need to be confirmed with a longitudinal research design.

The factorial and discriminant validity of the German version of the Post-traumatic Growth Inventory in stroke patients.

Post-traumatic growth (PTG) is the experience of positive changes that can follow a traumatic event. The current study examined the factorial as well as the discriminant validity of the German version of the Post-traumatic Growth Inventory (PTGI-G) in stroke patients. A total of 188 adult stroke patients (63.3% male; median age 69 years) completed the PTGI-G and the German version of the Hospital Anxiety and Depression Scale (HADS-D) at the end of their inpatient rehabilitation. Confirmatory factor analyses indicate an acceptable model fit of both the original five-factor solution as well as a second-order factor model of the PTGI-G (CFI > .95; RMSEA < .01). Small and non-significant correlations between the PTGI-G subscales and the depression scale of the HADS-D support the discriminant validity of the PTGI-G. The PTGI-G appears to be a valid tool in the context of stroke research.

Fatigue as a cause, not a consequence of depression and daytime sleepiness: a cross-lagged analysis.

OBJECTIVES: To examine the temporal relation between fatigue, depression, and daytime sleepiness after traumatic brain injury. Fatigue is a frequent and disabling consequence of traumatic brain injury (TBI). However, it is unclear whether fatigue is a primary consequence of the structural brain injury or a secondary consequence of injury-related sequelae such as depression and daytime sleepiness. PARTICIPANTS: Eighty-eight adults with complicated mild-severe TBI (69% male). MAIN MEASURES: Fatigue Severity Scale; depression subscale of the Hospital Anxiety and Depression Scale; Epworth Sleepiness scale at baseline and 6-month follow-up. RESULTS: A cross-lagged path analysis computed within a structural equation modeling framework revealed that fatigue was predictive of depression (ß = .20, P < .05) and sleepiness (ß = .25, P < .05). However, depression and sleepiness did not predict fatigue (P > .05). CONCLUSIONS: The results support the view of fatigue after TBI as "primary fatigue"-that is, a consequence of the structural brain injury rather than a secondary consequence of depression or daytime sleepiness. A rehabilitation approach that assists individuals with brain injury in learning to cope with their neuropsychological and physical limitations in everyday life might attenuate their experience with fatigue.

Development and predictors of psychological adjustment during the course of community-based rehabilitation of traumatic brain injury: A preliminary study.

The aim of the study was to describe the development and predictors of psychological adjustment during community-based traumatic brain injury (TBI) rehabilitation. Forty-two adolescent and adult individuals with TBI (mean age 32 years, 88% male, median post-traumatic amnesia 11 days) participated in a single-group, longitudinal design study. The main measures used were the Reactions to Impairment and Disability Inventory, Adjustment subscale; Sydney Psychosocial Reintegration Scale; Hospital Anxiety and Depression Scale; and Self-awareness of Deficits Interview. At rehabilitation start, individuals differed significantly from each other with respect to their level of psychological adjustment. Individual trajectories of psychological adjustment were highly variable. However, for the sample as a whole, psychological adjustment did not change during the course of rehabilitation (multilevel regression models; p > .05). Good psychological adjustment was related to low levels of emotional distress and a small discrepancy between current and aspired functional status. Poor functional status had a more minor impact on psychological adjustment in individuals with poor self-awareness than in individuals with high levels of self-awareness. The results confirm parts of theoretical models of psychological adjustment to acquired brain injury, especially the importance of goal refinement. However, the results need to be treated cautiously, given the limited sample size.

Time-resolved MR venography of the pulmonary veins precatheter-based ablation for atrial fibrillation.

PURPOSE: To evaluate time-resolved magnetic resonance angiography (TR-MRA) of the pulmonary venous circulation using the time-resolved angiography with interleaved stochastic trajectories (TWIST) method and compare it with the more commonly used conventional contrast-enhanced magnetic resonance angiography (CE-MRA) approach in atrial fibrillation patients referred for preablation pulmonary vein mapping. MATERIALS AND METHODS: This study was approved by the Institutional Review Board. Twenty-six patients (15 males; age 59.6 ± 12.7 years) referred for preablation pulmonary vein mapping underwent both conventional CE-MRA and TR-MRA with TWIST. Imaging was performed on a 1.5 T (Magnetom Avanto, Siemens Healthcare, Erlangen, Germany) MRI scanner. Source partition and maximum intensity projection (MIP) images were evaluated retrospectively. For quantitative analysis, pulmonary vein ostium orthogonal dimensions were measured using double oblique multiplanar reformatting. The results were analyzed using paired t-tests, Lin's concordance correlation coefficient, and Bland-Altman plots. For qualitative analysis, both source partition images and MIP images were assessed by two observers (A.P. and M.G.). The presence of common ostiums or accessory veins was recorded and analyzed using unweighted Cohen's kappa. Pulmonary vein conspicuity was scored on a scale of 1-4 (1 = poor, 2 = fair, 3 = good, 4 = excellent) and analyzed using paired t-tests, intraclass correlation coefficients, and quadratic weighted kappa statistics. RESULTS: Orthogonal venous diameters were comparable for both TR-MRA and conventional CE-MRA (1.34 ± 0.37 vs. 1.38 cm ± 0.36, respectively). Results of paired t-tests, Lin's concordance correlation coefficient, and Bland-Altman analysis revealed relatively close comparison between methods. The magnitude of the mean difference for any of the statistical comparisons did not exceed 0.10 cm. The visualization of variant pulmonary vein anatomy was very similar for both techniques. Agreement between techniques was determined to be "good" to "very good" (κ = 0.78-0.85). Conspicuity scores for each pulmonary vein were also very close. Paired t-tests, intraclass correlation coefficients, and quadratic weighted kappa statistics all revealed strong agreement between methods. CONCLUSION: TR-MRA using TWIST produces comparable anatomic images and pulmonary venous dimensions to the more widely used CE-MRA technique. Additionally, the TWIST technique improves arterio-venous separation, does not need exact bolus timing, requires less gadolinium, and gives additional information on vein perfusion.

The relations among cognitive impairment, coping style, and emotional adjustment following traumatic brain injury.

OBJECTIVE: To examine the direct, mediated, and moderated associations among cognition, coping, and emotional adjustment following traumatic brain injury (TBI). DESIGN: Cross-sectional, single-group design. PARTICIPANTS: Ninety-seven participants with mild to severe TBI recruited from their rehabilitation hospital and assessed on average 19 months postinjury. MEASURES: The BIRT Memory and Information Processing Battery, Doors Test from the Doors and People Test, Hayling Sentence Completion Test, Controlled Oral Word Association Test, Trail Making Test, Digit Span, Symbol Digit Modalities Test-Oral Version, Hospital Anxiety and Depression Scale, and the Coping Scale for Adults. RESULTS: Poorer performance on measures of memory, executive functions, and attention and information processing was associated with greater levels of self-reported depression and anxiety. No mediated relation was found between cognition and emotional adjustment. However, the use of adaptive coping strategies was found to moderate the relation between the Hayling A-a measure of information processing speed-and self-reported depression. CONCLUSIONS: Greater impairments in cognition directly predicted higher levels of anxiety and depression following TBI. In addition, the results suggest that the use of adaptive coping strategies has a greater effect on levels of depression for individuals with poor information processing speed.

A cognitive behaviour therapy (CBT) programme for anxiety following moderate-severe traumatic brain injury (TBI): two case studies.

BACKGROUND: CBT is a potentially effective treatment for anxiety disorders following TBI; however, empirical evidence has mainly come from clients with mild TBI. This paper describes a CBT-based anxiety treatment programme adapted for clients with more severe injuries. Two case studies are provided to illustrate the implementation of the programme, as a step toward larger scale testing of the programme's feasibility. METHODS AND PROCEDURES: A manualised adapted CBT treatment manual was used to deliver CBT in a standardised manner to two clients, one with severe and one with moderate TBI. Outcome was evaluated using a single-subject design with repeated measures of anxiety, mood and coping style at pre- and post-CBT. RESULTS: The two clients demonstrated positive treatment response on either a measure of anxiety or a continuous measure of distress. Although neither demonstrated a clinically significant change according to the primary outcome measure (Hospital Anxiety and Depression Scale), they showed significant change in at least one corroborated measure of anxiety. CONCLUSIONS: This study suggests the potential utility of the adapted CBT programme for clients with moderate-severe TBI. Limitations of the single case studies were discussed, while noting how they would be addressed in a follow-up randomised controlled trial.

Expressed emotion and its relationship to anxiety and depression after traumatic brain injury.

Levels of expressed emotion (EE) within the family, particularly criticism and emotional over-involvement, are associated with a patient's psychological outcome in a range of psychiatric and medical conditions. This study aimed to examine the relationship between levels of family EE and anxiety and depression in patients who have sustained a traumatic brain injury (TBI). A further aim was to examine whether family members' levels of psychological distress and attributions of patient symptom controllability, were related to their levels of patient-directed EE. Participants were 43 patients who had sustained a complicated mild to severe TBI three months to five years previously, and their nominated family members. Results indicated that family members' criticism and emotional over-involvement were associated with patients' levels of anxiety and depression. Moreover, family members' levels of anxiety and depression were associated with their levels of patient-directed criticism and emotional over-involvement, whilst their attributions of patient symptom control were not. These findings suggest that levels of EE within the family are associated with psychological adjustment following TBI. Consequently, interventions targeting EE in family members may help to reduce psychiatric difficulties following TBI.

Motivational interviewing and cognitive behaviour therapy for anxiety following traumatic brain injury: a pilot randomised controlled trial.

Although cognitive-behavioural therapy (CBT) is the treatment of choice for anxiety, its delivery needs to be adapted for individuals with traumatic brain injury (TBI). It also requires clients' active engagement for maximum benefit. This study was a pilot randomised controlled trial involving an anxiety treatment programme adapted for people with TBI, based on CBT and motivational interviewing (MI). Twenty-seven participants with moderate/severe TBI (aged 21-73 years, 78% males) recruited from a brain injury rehabilitation hospital were randomly allocated to receive MI + CBT (n = 9), non-directive counselling (NDC) + CBT (n = 10) and treatment-as-usual (TAU) (n = 8). CBT and MI were manualised and delivered in 12 weekly individual sessions. Primary outcome was self-reported anxiety symptoms assessed at baseline, at the end of NDC/MI and immediately following CBT. Assessment was conducted by assessors blinded to group assignment. Intention-to-treat analyses showed that the two active treatment groups demonstrated significantly greater anxiety reduction than TAU. Participants receiving MI showed greater response to CBT, in terms of reduction in anxiety, stress and non-productive coping, compared to participants who received NDC. The results provided preliminary support for the adapted CBT programme, and the potential utility of MI as treatment prelude. Longer follow-up data are required to evaluate the maintenance of treatment effects.

Development of a motivational interviewing programme as a prelude to CBT for anxiety following traumatic brain injury.

A brief preparatory programme, based on the principles of motivational interviewing (MI), was developed as a way of engaging clients with traumatic brain injury (TBI) and preparing them for a cognitive behaviour therapy (CBT) programme for anxiety. The MI + CBT programme was delivered to a male client in his early 40s with severe TBI at four months post-injury, using a single-subject design with repeated measures pre- and post-treatment. The client received three sessions of manualised MI, followed by nine sessions of CBT. The MI sessions focused on helping the client to develop more realistic goals and supporting his self-efficacy about his ability to cope with anxiety. Specific strategies were used to accommodate the client's cognitive limitations, such as the use of personally meaningful metaphors and role plays. Re-assessments were conducted at the end of MI, CBT and nine weeks post-treatment, using a semi-structured clinical interview and self-report measures of anxiety, mood and change expectancy. The client showed significant improvement in anxiety following treatment and a significant reduction in subjective units of distress (SUDS) between the MI and CBT phases. The results suggest the potential utility of MI in people with TBI, and the need to evaluate treatment protocols in a controlled trial.

Prediction of functional and employment outcome 1 year after traumatic brain injury: a structural equation modelling approach.

BACKGROUND: Traumatic brain injury (TBI) can cause lasting functional changes and lead to unemployment. The purpose of this study was to create and test a structural equation model (SEM) of the prediction of functional and employment outcome after TBI. METHODS: Participants were 949 individuals with predominantly moderate to severe TBI (74% males, median age 25.7 years) who attended a follow-up interview 1 year post-injury. Outcome (employment and mood, cognitive and behavioural changes) was measured using the Structured Outcome Questionnaire. An SEM, based on existing research, was developed, tested and modified. RESULTS: A comparative fit index of 0.99 and a root mean square error of approximation of 0.03 supported the fit of the final model. Age, education, pre-injury employment, injury severity and limb injuries were direct predictors of employment outcome. Gender, pre-injury psychiatric disorders and limb injuries were related to employment outcome by their association with mood, cognitive and behavioural changes. CONCLUSIONS: The results demonstrate the complex interplay between various factors predicting outcome after TBI and provide evidence for the importance of tailoring rehabilitation to the individual's needs. Further research, including other conditions, can build on this model and include additional predictor and outcome measures.

The temporal relationship between depression, anxiety, and functional status after traumatic brain injury: a cross-lagged analysis.

Poor functional status and high rates of anxiety and depression have been reported in individuals who have sustained a traumatic brain injury (TBI). However, it is unclear whether psychiatric disorders after TBI are a cause or a consequence of functional limitations. The current study aimed to investigate the temporal relationship between anxiety, depression and functional impairment following TBI. The study has a prospective, longitudinal single-group design. Anxiety and depression, assessed using the Structured Clinical Interview for DSM-IV, and functional changes, assessed with the Glasgow Outcome Scale-Extended, were measured six and 12 months post-injury in 122 individuals who had sustained a TBI (79% male, mean age 35 years, mean duration of post-traumatic amnesia 24 days, mean Glasgow Coma Scale score 9.2). Cross-lagged analyses were conducted within a structural equation modelling framework. Functional changes six months post-injury predicted depression and anxiety one year after the injury. Anxiety and depression, in turn, were not predictive of later functional status. This study adds to our understanding of the temporal relationship between depression, anxiety and functional status after TBI. The results indicate the importance of supporting brain injured individuals in coping with the functional consequences of their injury in order promote psychological well-being.

Relationship between psychiatric disorders and 1-year psychosocial outcome following traumatic brain injury.

OBJECTIVE: To investigate the relationship of psychiatric functioning with psychosocial functioning at 1 year following traumatic brain injury (TBI), after controlling for relevant demographic, injury-related, and concurrent factors. DESIGN: Prospective 1-year longitudinal study. PARTICIPANTS: Participants were 122 individuals with TBI and 88 proxy informants. SETTING: Rehabilitation hospital. MAIN MEASURES: The Structured Clinical Interview for DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, Text Revision)) Axis I Disorders, Hospital Anxiety and Depression Scale, Sydney Psychosocial Reintegration Scale, and Glasgow Outcome Scale--Extended. RESULTS: At 1 year postinjury, occupational activities were the area of most change after TBI followed by interpersonal relationships and independent living skills, according to the Sydney Psychosocial Reintegration Scale. The majority of participants were rated as having moderate disability on the Glasgow Outcome Scale--Extended. After controlling for relevant background factors, preinjury, acute postinjury, and concurrent psychiatric disorders were significantly related to 1-year psychosocial outcome. CONCLUSION: Screening in the acute postinjury stage for presence of preinjury psychiatric history or current distress may help identify individuals who require more intensive rehabilitation and psychiatric support and more active postdischarge monitoring. Further research exploring potential causal mechanisms for these findings is required.

The relationship between mood disorders and MRI findings following traumatic brain injury.

BACKGROUND: High rates of depression have been reported in individuals with traumatic brain injury (TBI). The purpose of the current study was to investigate the relationship between structural MRI findings and the development of novel cases of post-injury depression in this population METHODS: The study has a cross-sectional design. Assessments were conducted on average 2.2 years post-injury. Participants were 54 individuals (76% male, mean age 35 years, median PTA duration 16 days) who had sustained a TBI. Depression was assessed with the Structured Clinical Interview for DSM-IV (SCID-IV). Structural MRI scans were performed with a 1.5 Tesla machine. RESULTS: The presence of lesions in the frontal, temporal, parietal and the sublobar regions was not related to depression. However, an imbalance of left vs right frontal and parietal viable brain volumes was related to the development of depression. DISCUSSION: These findings are in support of Heller's model of emotion processing, but should be replicated using larger samples. Potential clinical implications are discussed in the manuscript.

Family functioning and emotional state two and five years after traumatic brain injury.

Previous studies have documented poor family functioning, anxiety, and depression in relatives of individuals with traumatic brain injury (TBI). However, few studies have examined family functioning over extended periods after injury. The present study aimed to investigate family functioning and relatives' emotional state 2 and 5 years following TBI, predictive factors, and their interrelationships. Participants were individuals with TBI and their relatives, with 301 seen at 2 years and 266 at 5 years post-injury. Measures included a Structured Outcome Questionnaire, Family Assessment Device (FAD), Hospital Anxiety and Depression Scale, and the Craig Handicap Assessment and Reporting Technique. Results showed that while the group did not differ greatly in family functioning from a normative group, a significant proportion showed unhealthy functioning across most FAD subscales. Both TBI participants and their relatives showed elevated rates of anxiety and depression. There was little difference between family functioning or relatives' anxiety or depression levels at 2 and 5 years post-injury. Path analysis indicated that neurobehavioral changes in the injured individual have an impact on family functioning and distress in relatives even at 5 years post-injury. These findings indicate the need for long-term support of families with a brain-injured member.

The factor structure of the Hospital Anxiety and Depression Scale in individuals with traumatic brain injury.

There is a lack of validated scales for screening for anxiety and depression in individuals with traumatic brain injury (TBI). The purpose of this study was to examine the factor structure of the Hospital Anxiety and Depression Scale (HADS) in individuals with TBI. A total of 294 individuals with TBI (72.1% male; mean age 37.1 years, S.D. 17.5, median post-traumatic amnesia (PTA) duration 17 days) completed the HADS 1 year post-injury. A series of confirmatory factor analyses was conducted to examine the fit of a one-, two- and three-factor solution, with and without controlling for item wording effects (Multi-Trait Multi-Method approach). The one-, two- or three-factor model fit the data only when controlling for negative item wording. The results are in support of the validity of the original anxiety and depression subscales of the HADS and demonstrate the importance of evaluating item wording effects when examining the factor structure of a questionnaire. The results would also justify the use of the HADS as a single scale of emotional distress. However, even though the three-factor solution fit the data, alternative scales should be used if the purpose of the assessment is to measure stress symptoms separately from anxiety and depression.