Reactivity of Health-Related Quality of Life to Perceived Stress: The Buffering Role of Psychosocial Resources in a Longitudinal Study of Adults with and Without HIV.

People with HIV now have increased longevity; however, their health-related quality of life (HRQoL) still lags significantly compared to people without HIV. Perceived stress negatively impacts HRQoL, whereas psychosocial resources are linked to better HRQoL. This longitudinal analysis aims to explore the buffering role of psychosocial resources on the relationship between HRQoL and perceived stress. Participants (N = 240) included 142 persons with HIV (PwH) and 98 without HIV, M(SD) = 50.9(8.1) years. Multilevel models over four study years examined longitudinal relationships between HRQoL (outcome) and perceived stress (predictor) and potential moderation by psychosocial resources (personal mastery, social support, and resilience) by HIV serostatus. Among PwH only, personal mastery (p = 0.001), social support (p = 0.015), and resilience (p = 0.029) were associated with an attenuated effect of perceived stress (less negative slopes) for physical HRQoL over time. Bolstering personal mastery, social support, and resilience may have relevance for improving physical well-being among PwH.

Characterizing Profiles of TBI Severity: Predictors of Functional Outcomes and Well-Being.

OBJECTIVE: To identify profiles of acute traumatic brain injury (TBI) severity and relate profiles to functional and well-being outcomes. SETTING: Acute inpatient rehabilitation and general community settings. PARTICIPANTS: Three hundred and seventy-nine individuals with moderate-severe TBI participating in the Traumatic Brain Injury Model Systems. DESIGN: Longitudinal observational study. MAIN MEASURES: At discharge-length of stay, Functional Independence Measure (FIM), and Disability Rating Scale (DRS). One-year post-injury-Glasgow Outcome Scale-Extended (GOS-E), FIM, and Satisfaction with Life Scale (SWLS). RESULTS: Latent profile analysis (LPA) was used to identify subgroups with similar patterns across 12 indicators of acute injury severity, including duration of posttraumatic amnesia, Glasgow Coma Scale, time to follow commands, and head CT variables. LPA identified 4 latent classes, least to most severe TBI (Class 1: n = 75, 20.3%; Class 2: n = 124, 33.5%; Class 3: n = 144, 38.9%; Class 4: n = 27, 7.3%); younger age, lower education, rural residence, injury in motor vehicle accidents, and earlier injury years were associated with worse acute severity. Latent classes were related to outcomes. Compared with Class 1, hospital stays were longer, FIM scores lower, and DRS scores larger at discharge among individuals in Class 3 and Class 4 (all P s < .01). One-year post-injury, GOS-E and FIM scores were significantly lower among individuals in Class 3 and Class 4 than those in Class 1 ( P s < .01). SWLS scores were lower only among individuals in Class 3 ( P = .036) compared with Class 1; other comparisons relative to Class 1 were not significant. CONCLUSIONS: Meaningful profiles of TBI severity can be identified from acute injury characteristics and may suggest etiologies, like injury in motor vehicle accidents, and premorbid characteristics, including younger age, rural residence, and lower education, that heighten risk for worse injuries. Improving classification may help focus on those at elevated risk for severe injury and inform clinical management and prognosis.

Suicide Attempts and Ideation Among Veterans/Service Members and Non-Veterans Over 5 Years Following Traumatic Brain Injury: A Combined NIDILRR and VA TBI Model Systems Study.

OBJECTIVE: This study compared rates of suicide attempt (SA) and suicidal ideation (SI) during the first 5 years after traumatic brain injury (TBI) among veterans and service members (V/SMs) in the Veterans Affairs (VA) and the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR) Model Systems National Databases to each other and to non-veterans (non-Vs) in the NIDILRR database. SETTING: Twenty-one NIDILRR and 5 VA TBI Model Systems (TBIMS) inpatient rehabilitation facilities in the United States. PARTICIPANTS: Participants with TBI were discharged from rehabilitation alive, had a known military status recorded (either non-V or history of military service), and successful 1-, 2-, and/or 5-year follow-up interviews completed between 2009 and 2021. The year 1 cohort included 8737 unique participants (8347 with SA data and 3987 with SI data); the year 2 (7628 participants) and year 5 (4837 participants) cohorts both had similar demographic characteristics to the year 1 cohort. DESIGN: Longitudinal design with data collected across TBIMS centers at 1, 2, and 5 years post-injury. MAIN OUTCOMES AND MEASURES: History of SA in past year and SI in past 2 weeks assessed by the Patient Health Questionnaire-9 (PHQ-9). Patient demographics, injury characteristics, and rehabilitation outcomes were also assessed. RESULTS: Full sample rates of SA were 1.9%, 1.5%, and 1.6%, and rates of SI were 9.6%, 10.1%, and 8.7% (respectively at years 1, 2, and 5). There were significant differences among groups based on demographic, injury-related, mental/behavioral health, and functional outcome variables. Characteristics predicting SA/SI related to mental health history, substance use, younger age, lower functional independence, and greater levels of disability. CONCLUSIONS: Compared with participants with TBI in the NIDILRR system, higher rates of SI among V/SMs with TBI in the VA system appear associated with risk factors observed within this group, including mental/behavioral health characteristics and overall levels of disability.

The impact of life stress, psychological resources, and proactive behaviors on quality of life among people living with HIV.

OBJECTIVES: Quality of life (QoL) is an important consideration for people living with HIV (PWH). We investigated the relationship between stress, psychological resources, and proactive behaviors, on QoL (conceptualized as life satisfaction, successful aging, and depressive symptoms) by testing the hypotheses: (1) greater life stress (stress and functional impairment) is associated with poorer QoL; (2) resources (mastery, resilience, and social support) are associated with better QoL, beyond the influence of stress; and (3) proactive behaviors (medication management and leisure activities) mediate the relationship between resources and QoL. METHODS: Secondary analyses were performed (N = 128 PWH). Participants' mean age was 52.3, 83.6% were male, and 53.9 identified as white. Multivariate regressions were performed within the context of path analyses. RESULTS: In series 1, greater stress was associated with poorer life satisfaction (p < 0.001), lower self-rated successful aging (p < 0.001), and greater depression (p < 0.001). Functional impairment was associated with lower successful aging (p = 0.017) and greater depression (p = 0.001). In series 2, which accounted for mastery, resilience, social support, as well as demographic covariates, mastery was associated with greater life satisfaction (p = 0.038). In series 3, stress, functional impairment, leisure activities, and ART management were added to the model and social support was associated with engagement in leisure activities (p < 0.001), which was associated with better successful aging (p = 0.006). Fit indices suggested adequate relative fit. In bootstrapped analyses of indirect effects, social support was indirectly associated with successful aging through leisure activities (p = 0.020). CONCLUSIONS: QoL, as captured by self-rated successful aging, is threatened by stress but positively influenced by social support and engaging in leisure activities. Findings support a model of proactive successful aging for PWH.

Fatigue After Traumatic Brain Injury: A Systematic Review.

OBJECTIVE: To provide a systematic review of published interventions for posttraumatic brain injury fatigue (PTBIF). METHODS: PubMed and OneSearch were systematically searched for PTBIF interventions published between January 1, 1989, and March 31, 2019. Search results were evaluated for inclusion based on an abstract and full-text review. Inclusion criteria were (1) an investigation of an intervention, (2) participant sample including individuals with traumatic brain injury (TBI), (3) report of fatigue outcome data among individuals with TBI, and (4) articles available in English, Spanish, French, German, Afrikaans, or Dutch. A risk of bias assessment was conducted on all included publications. RESULTS: The search resulted in 2343 publications, with 37 meeting inclusion criteria for this review. Categories of PTBIF interventions were pharmacological ( n = 13), psychological ( n = 9), exercise-based ( n = 4), complementary alternative medicine ( n = 5), electrotherapeutic ( n = 3), and multimodal ( n = 3). Only methylphenidate, modafinil, and cognitive behavioral therapy interventions included multiple cohorts. Pharmacological and psychological interventions represented the groups with the lowest risk of bias. CONCLUSIONS: This review includes 37 studies, with 21 studies published after 2014. Methylphenidate and melatonin were the only pharmacological agents found to reduce fatigue in randomized controlled trials. Creatine given to children prospectively at onset of injury reduced fatigue at follow-up. Walking and water aerobics were effective exercise interventions in isolated randomized controlled studies. One multimodal study of children after concussion was more effective at reducing fatigue and postconcussion symptoms than community standard of care. Other interventions had equivocal results. Overall, more work remains to understand and develop treatments for PTBIF.

SCiPad: evaluating telemedicine via iPad facetime for general spinal cord injury care.

STUDY DESIGN: Uncontrolled clinical pilot study. OBJECTIVES: To assess usage, perceived impact, and satisfaction with a telemedicine program among individuals with spinal cord injury (tele-SCI). SETTING: Community-based. METHODS: Participants (N = 83) were recruited from acute SCI inpatient rehabilitation and outpatient SCI care at a community hospital to participate in a 6-month tele-SCI intervention administered by SCI subspecialty board-certified physiatrists via iPad FaceTime. In addition to monthly follow up interview calls, psychosocial and Quality of Life (QoL) measures were collected at baseline and post-intervention. A program satisfaction survey was also collected post-intervention. RESULTS: Seventy-five percent of participants engaged in tele-SCI visits (Median [IQR]: 2.5 [2.0, 4.0]) for a total of 198 tele-SCI visits. Bladder and bowel concerns were the leading topics discussed during tele-SCI visits, followed by neurological, pain, and functional concerns. Tele-SCI users resided further away (Median miles [IQR] - 114[73-177] vs. 81[46-116], p = 0.023) and reported seeking more clinical advice (Median [IQR] - 1.5[0-4.0] vs. 0[0-1.0], p = 0.002) compared to non-tele-SCI users. All other clinical utilization, baseline characteristics, psychosocial measures, and QoL did not differ among those who used tele-SCI and those who did not. The satisfaction survey suggested satisfaction with the tele-SCI intervention (89%), study equipment (89%), staff responsiveness (100%), and improved motivation for self-monitoring of health (71%). CONCLUSION: Study findings suggest that tele-SCI is a feasible modality for providing general SCI care. Further research is required to examine longer-term efficacy of remotely-provided care among individuals living with SCI.

Cognitive Profiles Among Individuals With Spinal Cord Injuries: Predictors and Relations With Psychological Well-being.

OBJECTIVES: To examine predictors of profiles of cognitive functioning among individuals receiving acute inpatient spinal cord injury (SCI) rehabilitation, as well as associations between their cognitive functioning and psychological well-being (life satisfaction and depression) 6 months after the baseline assessment. DESIGN: Prospective observational study design, with 2 assessments approximately 6 months apart. SETTING: A rehabilitation unit at a level 1 trauma hospital during acute SCI hospitalization and outpatient setting after discharge. PARTICIPANTS: Individuals (N=89) with SCI. INTERVENTION: None. MAIN OUTCOME MEASURES: Cognitive functioning (assessed by the Repeatable Battery for the Assessment of Neuropsychological Status), life satisfaction (measured by the Life Satisfaction Index A), and depressive symptoms (measured by the Patient Health Questionnaire-9). RESULTS: Latent profile analysis identified 3 classes of individuals with similar patterns of cognitive functioning: class1 (average levels of cognitive performance across all assessed domains; n=48), class 2 (average cognitive performance, except in recall and memory; n=23), and class 3 (low cognitive functioning across multiple domains of cognition; n=18). Fewer years of education, history of smoking, history of substance use other than alcohol, and greater postconcussion symptoms were associated with higher odds of classification in class 3 (P<.05). Six months post baseline, individuals in class 3 reported significantly lower levels of life satisfaction than individuals in class 1 (χ2(1)=5.86; P=.045) and marginally higher depressive symptoms than individuals in class 2 (χ2(1)=5.48; P=.057). CONCLUSIONS: The impact of impaired cognition during acute rehabilitation may persist after discharge and influence the psychological well-being of individuals with SCI. Identifying individuals with cognitive dysfunction and attending to modifiable risk factors and may help ameliorate maladjustment after SCI.

"PrEP"ing for a PrEP demonstration project: understanding PrEP knowledge and attitudes among cisgender women.

BACKGROUND: Prior to implementing a pre-exposure prophylaxis (PrEP) demonstration study, we sought to explore cisgender women's experiences with HIV prevention, PrEP knowledge and attitudes, and anticipated barriers and facilitators for PrEP uptake and adherence in Southern California. METHODS: Three focus groups were held with cisgender women of mixed HIV serostatus in San Diego and Los Angeles between November 2015 and January 2016. Women were recruited through local testing sites, community-based organizations, and social media. Focus groups were audio-recorded and transcripts were analyzed using thematic analysis. RESULTS: Twenty-two women participated in focus groups, with median age 44 (IQR 30-53) and 6 identifying as non-Hispanic Black, 7 non-Hispanic White, 8 Latina and 1 mixed race. Despite limited prior PrEP knowledge and no PrEP experience, participants expressed interest in taking PrEP. Anticipated benefits were freedom from worry about HIV and control over sexual health; however, these were tempered by concerns including the possibility of increased HIV risk behaviors and potential side effects. Cisgender women reported potential barriers to PrEP uptake and adherence barriers, like competing priorities and poor PrEP access. Conversely, PrEP facilitators included utilizing practical tools such as phone apps and pill boxes as well as receiving encouragement from loved ones and support from other cisgender women on PrEP, women living with HIV and their medical providers. CONCLUSIONS: Although PrEP awareness was low, participants recognized the importance of PrEP and ways to facilitate adherence. Exploring perspectives of cisgender women is integral to developing effective interventions to support PrEP uptake and adherence for women at elevated risk for HIV.

Pre-frailty predicts cognitive decline at 2-year follow-up in persons living with HIV.

Both HIV disease and frailty syndrome are risk factors for neurocognitive impairment. Longitudinal research among individuals of the general population suggests that frailty predicts future cognitive decline; however, there is limited evidence for these longitudinal relationships among people living with HIV (PLWH). The current study evaluated and compared rates of cognitive decline over 2 years among HIV serostatus and frailty status groups. Participants included 50 PLWH and 60 HIV-uninfected (HIV-) participants who were evaluated at baseline and 2-year follow-up visits. Baseline frailty status (non-frail, pre-frail, and frail) was determined using fried frailty phenotype criteria. Neurocognitive functioning was measured using practice-effect corrected scaled scores derived from a comprehensive neuropsychological battery covering seven cognitive domains. Repeated measures analysis was used to estimate rates of global and domain-specific cognitive change from baseline to 2-year follow-up among each of six HIV/frailty status groups. Among PLWH, the pre-frail group demonstrated consistent declines in global cognitive functioning (B = - 0.029, p = 0.034), processing speed (B = - 0.047, p = 0.031), and motor functioning (B = - 0.048, p = 0.038). Among HIV- participants, pre-frail individuals also declined in global cognitive functioning and processing speed (ps ≤ 0.05). HIV- non-frail participants also declined in the cognitive domains of learning, delayed recall, and motor functioning; however, these declines appeared to be driven by relatively higher baseline scores among this group. Notably, 38% of PLWH changed in frailty status from baseline to follow-up, and those with stable pre-frailty demonstrated higher likelihood for cognitive decline; change in depressive symptoms did not relate to change in frailty status. Current findings highlight pre-frailty as an important clinical syndrome that may be predictive of cognitive decline among PLWH. Interventions to prevent or reduce frailty among vulnerable PLWH are needed to maintain optimal cognitive health.

Greater Levels of Self-Reported Adherence to Pre-Exposure Prophylaxis (PrEP) are Associated with Increased Condomless Sex Among Men Who Have Sex with Men.

The effectiveness of pre-exposure prophylaxis (PrEP) against HIV acquisition depends on treatment adherence; however, within-person associations between levels of PrEP adherence and engagement in condomless sex have not been well studied. In the context of a demonstration project, 372 men who have sex with men received once-daily PrEP and completed six study visits over 48 weeks. Two-part growth mixture modeling was used to examine the longitudinal trajectory of condomless anal intercourse (CAI) and self-reports of PrEP adherence, controlling for relevant covariates. Over time, greater PrEP adherence was contemporaneously associated with both a higher likelihood of engaging in any CAI and with a greater number of CAI acts. Substance use was also associated with a higher likelihood of engaging in CAI. Contemporaneous associations between self-reported PrEP adherence and CAI suggest that adherence behaviors may be motivated by the desire to mitigate risk of HIV infection; however, exact directionality is unknown.

RESUMEN: La eficacia de la profilaxis Pre-exposición (PrEP) contra la adquisición del VIH depende de la adherencia al tratamiento; sin embargo, las asociaciones dentro de la persona entre los niveles de adherencia a PrEP y la participación en el sexo sin condón no han sido bien estudiadas. En un proyecto de demostración, 372 hombres que tienen relaciones sexuales con hombres recibieron PrEP diariamente y completaron seis visitas de estudio durante 48 semanas. El modelado de mezclas de crecimiento en dos partes se utilizó para examinar la trayectoria longitudinal de las relaciones sexuales anales sin condonación (CAI) y los autoinformes de adherencia a PrEP, controlando las covariables pertinentes. Con el tiempo, una mayor adherencia a PrEP se asoció a la misma vez con una mayor probabilidad de participar en cualquier CAI y tambien con un mayor número de CAI. El consumo de sustancias también se asoció con una mayor probabilidad de participar en CAI. Las asociaciones contemporáneas entre la adherencia a PrEP autoinformada y CAI sugieren que los comportamientos de adherencia pueden estar motivados por el deseo de mitigar el riesgo de infección por el VIH; sin embargo, se desconoce la direccionalidad exacta.