Assessing Risk of HIV-Associated Neurocognitive Disorder.

BACKGROUND: People with HIV (PLHIV) are aging, and 20% are at risk of developing a neurological complication known as HIV-associated neurocognitive disorder (HAND). Signs and symptoms of HAND may be subtle; however, treatment can improve clinical outcomes. OBJECTIVE: The aim of the study was to identify and agree on a risk assessment and monitoring process for the regular review of patients at risk of HAND. METHODS: Between March and September 2017, 25 experts from four community healthcare services participated in three rounds of a modified Delphi study to reach consensus on the items, monitoring period, and format of assessment tools to identify risk of HAND in PLHIV in the community. RESULTS: More than 80% consensus was reached at all three Delphi rounds. A flow chart, an initial assessment, and an annual monitoring tool were developed for an ongoing assessment of risk of developing HAND. CONCLUSION: Twenty percent of PLHIV may develop HAND, a treatable condition. The use of a modified Delphi method led to the successful development of two risk assessment tools to identify those at risk of HAND. The initial assessment tool may be used as a precursor to formal assessment by medical and nursing staff, whereas the annual monitoring tool may assist community-based health professionals in their ongoing assessment of risk of HAND in PLHIV, facilitating early formal medical review for this condition.

Voices from Australia- concerns about HIV associated neurocognitive disorder.

This study aimed to determine whether people living with HIV (PLHIV) are concerned about HIV associated neurocognitive disorder (HAND) and would find information and resources for HAND beneficial. An online survey focusing on the experience of HAND was distributed via the website of Positive Life New South Wales: a peak peer-support non-government organization in Australia. Of 126 respondents, 94 (74%) had heard of HAND, 52/94 (55%) had experienced concerns and of these, 48/52 (92%) felt anxiety about discussing the subject. Of those who had experienced concerns, 30/52 (58%) had spoken to someone about these concerns and 23/30 (77%) had received a positive response. Across the entire sample, 74 (59%) had noticed symptoms of cognitive decline in themselves and/or others. Respondents who noted a decrease in their ability to organize were on average five years older than those who had not noticed a decline (p = 0.012, effect size -.54). Forty-nine (39%) indicated that they would like guidance to initiate discussion about HAND with their doctor, caregiver or other PLHIV. The survey findings suggest that increasing awareness of HAND among PLHIV and their caregivers, and providing resources to facilitate discussion about HAND may assist to reduce concerns among PLHIV and enhance the effectiveness of clinical review.

Potential impacts of poor communication on early diagnosis of HIV-associated neurocognitive disorder.

AIM: To ascertain whether community-based healthcare providers were collecting appropriate information to identify patients at risk of HIV-associated neurocognitive disorder and whether related documentation was complete. BACKGROUND: HIV-associated neurocognitive disorder is a treatable neurological condition that can affect more than 20% of those infected with the HIV. Signs and symptoms of cognitive impairment may be subtle; therefore, documentation of medical and social information could be beneficial in identifying those at risk. DESIGN: Cross-sectional descriptive study. METHODS: An audit of patient records was completed by two community-based interdisciplinary teams with particular attention to the documentation of clinical and social indicators for those at risk of HIV-associated neurocognitive disorder. Data were collected over weeks during 2015. RESULTS: Data were retrieved from both electronic medical record systems and hard copy patient records. Documentation was incomplete in every patient record (N = 262), including the absence of important clinical data relating to nadir CD4 + T-cell count (91%), HIV viral load (36%), current caregiver (19%), and living circumstances (14%). Up to 40% of recorded medications and results were unconfirmed by the person's medical practitioner. CONCLUSION: Poor documentation can lead to incomplete information, which can delay early intervention for those at risk of HIV-associated neurocognitive disorder. Collection and recording of patient data needs to be consistent, as complete documentation is essential for integrating care, provision of clinical support and, importantly, for identifying those at risk of developing HIV-associated neurocognitive disorder.

Using Patient-Centered Care After a Prenatal Diagnosis of Trisomy 18 or Trisomy 13: A Review.

Importance: Patient-centered care (PCC) has been advocated by the Institute of Medicine to improve health care in the United States. Four concepts of PCC align with clinical ethics principles and are associated with enhanced patient/parent satisfaction. These concepts are dignity and respect, information sharing, participation, and collaboration. The objective of this article is to use the PCC approach as a framework for an extensive literature review evaluating the current status of counseling regarding prenatal diagnosis of trisomy 18 (T18) or trisomy 13 (T13) and to advocate PCC in the care of these infants. Observations: Extensive availability of prenatal screening and diagnostic testing has led to increased detection of chromosomal anomalies early in pregnancy. After diagnosis of T18 or T13, counseling and care have traditionally been based on assumptions that these aneuploidies are lethal or associated with poor quality of life, a view that is now being challenged. Recent evidence suggests that there is variability in outcomes that may be improved by postnatal interventions, and that quality-of-life assumptions are subjective. Parental advocacy for their infant's best interest mimics this variability as requests for resuscitation, neonatal intensive care, and surgical intervention are becoming more frequent. Conclusions and Relevance: With new knowledge and increased parental advocacy, physicians face ethical decisions in formulating recommendations including interruption vs continuation of pregnancy, interventions to prolong life, and choices to offer medical or surgical procedures. We advocate a PCC approach, which has the potential to reduce harm when inadequate care and counseling strategies create conflicting values and uncertain outcomes between parents and caregivers in the treatment of infants with T18 and T13.

Does the informal caregiver notice HIV associated mild cognitive impairment in people living with HIV?

HIV associated minor neurocognitive disorder (MND) may be difficult to identify as key signs and symptoms (S & S) may be due to other clinical conditions. Using a self-assessment booklet "HIV and associated MND" we recruited 123 people living with HIV (PLHIV) from three sites: two hospital HIV clinics and a sexual health clinic in Sydney, Australia. Patients may down play S & S. Caregivers may notice subtle changes. By including caregivers, we aimed to find whether the caregivers noticed S & S undetected by the PLHIV. This is a sub-study of a prospective observational multi-site study aimed to validate the usefulness of a patient self-assessment tool (HIV-associated MND booklet). Using the booklet, participants and their caregivers subsequently identified S & S of MND. Sixty-four per cent (79) did not nominate a caregiver to be contacted. Participants from 2 sites 44 (36%) nominated caregivers to be contacted. Twenty-five caregivers identified more than four S & S of MND. S & S reported most by caregivers related to participants being more tired at the end of the day (76%). Participants agreed (77%). Participants also reported that they found it more difficult to remember things such as taking medications or attending medical appointments (67%). The most agreed on symptom was the requirement for increased concentration to get the same things done (Kappa P 0.599 <0.001 and McNemar 0.289). For each question at least one caregiver identified a symptom when the PLHIV did not. Caregivers were more likely than participants to report irritability and communication difficulties. It is important to include caregivers when investigating PLHIV for MND, as caregivers may validate the experience of the patient, and may also be uniquely placed to identify S & S not otherwise identified.

DEVELOPING A CULTURE OF RESEARCH IN COMMUNITY NURSING.

In today's demanding clinical environments it is challenging for nurses to undertake research, Barriers include time, limited self-belief and confidence, commitment, limited knowledge of the research process, and lack of administrative support. Yet nurses are curious and many have ideas to improve clinical care and patient outcomes. This paper discusses how a community nursing service, Sydney District Nursing, has developed a congenial and collegial process to improve the culture of nursing research, and to support its nurses to undertake research and develop quality improvement projects.

The impact of disablers on predictive inference.

People consider alternative causes when deciding whether a cause is responsible for an effect (diagnostic inference) but appear to neglect them when deciding whether an effect will occur (predictive inference). Five experiments were conducted to test a 2-part explanation of this phenomenon: namely, (a) that people interpret standard predictive queries as requests to estimate the probability of the effect in the presence of the cause alone, which renders alternative causes irrelevant, and (b) that the impact of disablers (inhibitory causes) on predictive judgments is underestimated, and this underestimation is wrongly interpreted as cause neglect. Experiment 1 showed that standard predictive queries are frequently interpreted as requests to estimate the likelihood of E given C alone. In Experiment 2, a causal Bayes network overestimated predictive inference when it was queried in the standard way, but this overestimation diminished when predictive inference was queried using an alternative wording. In Experiment 3, participants judged alternative causes to be relevant to diagnostic inference and both disablers and alternative causes to be relevant to predictive inference. In Experiment 4, disablers greatly overshadowed alternative causes in predictive judgments, but their impact on diagnostic judgments was negligible. In Experiment 5, the order of disabler retrieval influenced causal judgments. Taken together, these results indicate that human causal inference cannot be adequately modeled unless the manner in which knowledge is retrieved and applied is taken into consideration.

Neural correlates of causal power judgments.

Causal inference is a fundamental component of cognition and perception. Probabilistic theories of causal judgment (most notably causal Bayes networks) derive causal judgments using metrics that integrate contingency information. But human estimates typically diverge from these normative predictions. This is because human causal power judgments are typically strongly influenced by beliefs concerning underlying causal mechanisms, and because of the way knowledge is retrieved from human memory during the judgment process. Neuroimaging studies indicate that the brain distinguishes causal events from mere covariation, and also distinguishes between perceived and inferred causality. Areas involved in error prediction are also activated, implying automatic activation of possible exception cases during causal decision-making.

Deontic reasoning as a target of selection: reply to Astington and Dack.

In their discussion of young children's deontic reasoning performance, Astington and Dack (2013) made the following claims: (1) Children need more cues to elicit cogent social norm reasoning than adults require, namely, explicit reference to authority; (2) Deontic reasoning improves with age, and this is evidence against a nativist view; (3) All evolutionary explanations of deontic reasoning advantages require positing a ''domain-specific deontic reasoning module."; and (4) young children excel at deontic reasoning because it is easier. Here, I refute each claim. Instead, I argue that (1) Social norm reasoning is one type of deontic reasoning that has been the target of selective pressure; (2) Development does not preclude nativism; (3) Epistemic utterances make no greater processing demands than deontic utterances; and (4) both adult and child norm reasoning performance is strongly influenced by reference to or implication of authority.

A cross-cultural study of noblesse oblige in economic decision-making.

A cornerstone of economic theory is that rational agents are self-interested, yet a decade of research in experimental economics has shown that economic decisions are frequently driven by concerns for fairness, equity, and reciprocity. One aspect of other-regarding behavior that has garnered attention is noblesse oblige, a social norm that obligates those of higher status to be generous in their dealings with those of lower status. The results of a cross-cultural study are reported in which marked noblesse oblige was observed on a reciprocal-contract decision-making task. Participants from seven countries that vary along hierarchical and individualist/collectivist social dimensions were more tolerant of non-reciprocation when they adopted a high-ranking perspective compared with a low-ranking perspective.

Deontic and epistemic reasoning in children revisited: comment on Dack and Astington.

Dack and Astington (Journal of Experimental Child Psychology 110 2011 94-114) attempted to replicate the deontic reasoning advantage among preschoolers reported by Cummins (Memory & Cognition 24 1996 823-829) and by Harris and Nuñez (Child Development. 67 1996 572-1591). Dack and Astington argued that the apparent deontic advantage reported by these studies was in fact an artifact due to a methodological confound, namely, inclusion of an authority in the deontic condition only. Removing this confound attenuated the effect in young children but had no effect on the reasoning of 7-year-olds and adults. Thus, removing reference to authority "explains away" young children's apparent precocity at this type of reasoning. But this explanation rests on (a) a misunderstanding of norms as targets of deontic reasoning and (b) conclusions based on a sample size that was too small to detect the effect in young children.

Emotion and deliberative reasoning in moral judgment.

According to an influential dual-process model, a moral judgment is the outcome of a rapid, affect-laden process and a slower, deliberative process. If these outputs conflict, decision time is increased in order to resolve the conflict. Violations of deontological principles proscribing the use of personal force to inflict intentional harm are presumed to elicit negative affect which biases judgments early in the decision-making process. This model was tested in three experiments. Moral dilemmas were classified using (a) decision time and consensus as measures of system conflict and (b) the aforementioned deontological criteria. In Experiment 1, decision time was either unlimited or reduced. The dilemmas asked whether it was appropriate to take a morally questionable action to produce a "greater good" outcome. Limiting decision time reduced the proportion of utilitarian ("yes") decisions, but contrary to the model's predictions, (a) vignettes that involved more deontological violations logged faster decision times, and (b) violation of deontological principles was not predictive of decisional conflict profiles. Experiment 2 ruled out the possibility that time pressure simply makes people more like to say "no." Participants made a first decision under time constraints and a second decision under no time constraints. One group was asked whether it was appropriate to take the morally questionable action while a second group was asked whether it was appropriate to refuse to take the action. The results replicated that of Experiment 1 regardless of whether "yes" or "no" constituted a utilitarian decision. In Experiment 3, participants rated the pleasantness of positive visual stimuli prior to making a decision. Contrary to the model's predictions, the number of deontological decisions increased in the positive affect rating group compared to a group that engaged in a cognitive task or a control group that engaged in neither task. These results are consistent with the view that early moral judgments are influenced by affect. But they are inconsistent with the view that (a) violation of deontological principles are predictive of differences in early, affect-based judgment or that (b) engaging in tasks that are inconsistent with the negative emotional responses elicited by such violations diminishes their impact.

False-belief understanding in 2.5-year-olds: evidence from two novel verbal spontaneous-response tasks.

Recent research indicates that toddlers and infants succeed at various non-verbal spontaneous-response false-belief tasks; here we asked whether toddlers would also succeed at verbal spontaneous-response false-belief tasks that imposed significant linguistic demands. We tested 2.5-year-olds using two novel tasks: a preferential-looking task in which children listened to a false-belief story while looking at a picture book (with matching and non-matching pictures), and a violation-of-expectation task in which children watched an adult 'Subject' answer (correctly or incorrectly) a standard false-belief question. Positive results were obtained with both tasks, despite their linguistic demands. These results (1) support the distinction between spontaneous- and elicited-response tasks by showing that toddlers succeed at verbal false-belief tasks that do not require them to answer direct questions about agents' false beliefs, (2) reinforce claims of robust continuity in early false-belief understanding as assessed by spontaneous-response tasks, and (3) provide researchers with new experimental tasks for exploring early false-belief understanding in neurotypical and autistic populations.

Are perceptions of fairness relationship-specific? The case of noblesse oblige.

Research in experimental economics suggests that decision making in strategic interactions is often guided by a concern for fairness. However, experimental economics studies routinely place participants of equal social status and no prior social history in anonymous interactions, a context that would tend to foster the adoption of an egalitarian fairness norm. Extensive research in anthropology (Fiske, 1991) and psychology (Bugental, 2000) suggests that social norms, including fairness norms, are relationship-specific, raising doubts about whether the concern for egalitarian fairness observed in the experimental economics literature would generalize to a wider range of social relations. In this paper we focus on an alternative social norm characteristic of hierarchical relationships: noblesse oblige--the obligation of high-ranking individuals to act honorably and beneficently towards subordinates. In a series of five experiments, we show that the norm of noblesse oblige predicts tolerance of free riding better than individual self-interest does.

Smoking cessation for clients who are HIV-positive.

AIM: To identify smoking prevalence and behaviour in clients who are human immunodeficiency virus (HIV)-positive and to enrol those wanting to stop smoking in a smoking cessation programme. METHOD: A questionnaire consisting of 28 questions on smoking behaviour was developed. Over an eight-week period at the Immunology Clinic, Royal Prince Alfred Hospital, New South Wales, Australia, 68 clients were asked to complete the questionnaire; 23 were ineligible because they were non-smokers. Of the 45 respondents who completed the questionnaire, 39 were current smokers and six were ex-smokers. Twenty seven clients enrolled in the smoking cessation programme. RESULTS: Smoking behaviour did not change due to a diagnosis of HIV or living with HIV. Stress was the main reason for recommencing smoking. At the end of the programme, 22 per cent (n = 6) had ceased smoking and 40 per cent (n = 11) had reduced nicotine intake. CONCLUSION: Smoking behaviour is complex and the reasons clients continue to smoke are multifactorial. Therefore, smoking cessation programmes should reflect this complexity.