Using critical consciousness to inform health professions education : A literature review.

PURPOSE: To explore how, in health professions education (HPE), the concept of critical consciousness has been defined and discussed, and to consider and suggest how critical pedagogy could be applied in practice. This exploration responds to increasing calls in the literature for HPE to foster compassionate care and social consciousness through the social sciences and humanities. METHOD: The authors searched Medline/PubMed, ERIC and Web of Science for articles focusing on critical consciousness and/or critical pedagogy involving health professions. A thematic analysis aimed to identify key themes of critical consciousness in HPE literature. RESULTS: The authors included 30 papers in their review. Key themes related to defining and discussing core attributes of critical consciousness in HPE were: 1) appreciating context in education and practice; 2) illuminating power structures; 3) moving beyond 'procedural'; 4) enacting reflection; and 5) promoting equity and social justice. CONCLUSIONS: Critical consciousness may inform an appropriate critical pedagogy for fostering compassionate, humanistic, socially conscious health professionals who act as agents of change. While the authors share critical teaching practices for educators, considerable care must be taken in efforts to use critical pedagogy within the current structures of HPE programmes. The authors suggest attending to the philosophical and theoretical origins of critical consciousness and those of the dominant models of contemporary HPE (e. g. competency-based approaches) in order to ensure the tenets of critical pedagogy can be enacted authentically.

Complex care needs of patients with late-stage HIV disease: a retrospective study.

This retrospective chart review provides a profile of an emerging population of vulnerable HIV patients with complex comorbidities. Data were abstracted from all 83 patients admitted in 2008 to Casey House, a community-based hospital dedicated to supportive and palliative care for persons with HIV in Toronto, Canada. We describe patient characteristics, including medical and psychiatric conditions, and use a Venn diagram and case study to illustrate the frequency and reality of co-occurring conditions that contribute to the complexity of patients' health and health care needs. The mean age at admission was 49.2 years (SD10.5). Sixty-seven patients (80.7%) were male. Patients experienced a mean of 5.9 medical comorbidities (SD2.3) and 1.9 psychiatric disorders (lifetime Axis I diagnoses). Forty patients (48.2%) experienced cognitive impairment including HIV-associated dementia. Patients were on a mean of 11.5 (SD5.3) medications at admission; 74.7% were on antiretroviral medications with 55.0% reporting full adherence. Current alcohol and drug use was common with 50.6% reporting active use at admission. Our Venn diagram illustrates the breadth of complexity in the clients with 8.4% of clients living in unstable housing with three or more medical comorbidities and two or more psychiatric diagnoses. Comprehensive HIV program planning should include interventions that can flexibly adapt to meet the multidimensional and complex needs of this segment of patients. Researchers, policy-makers, and clinicians need to have greater awareness of overlapping medical, psychiatric and psychosocial comorbidities. Inclusion of the needs of these most vulnerable patients in the development of evidence-based guidelines is an important step for effectively treating, preventing, and planning for the future of HIV/AIDS care.

Causes of Death in HIV Patients and the Evolution of an AIDS Hospice: 1988-2008.

This paper reports on the transformation that has occurred in the care of people living with HIV/AIDS in a Toronto Hospice. Casey House opened in the pre-HAART era to care exclusively for people with HIV/AIDS, an incurable disease. At the time, all patients were admitted for palliative care and all deaths were due to AIDS-defining conditions. AIDS-defining malignancies accounted for 22 percent of deaths, mainly, Kaposi sarcoma and lymphoma. In the post-HAART era, AIDS-defining malignancies dropped dramatically and non-AIDS-defining malignancies became a significant cause of death, including liver cancer, lung cancer and gastric cancers. In the post-HAART era, people living with HIV/AIDS served at Casey House have changed considerably, with increasing numbers of patients facing homelessness and mental health issues, including substance use. Casey House offers a picture of the evolving epidemic and provides insight into changes and improvements made in the care of these patients.

The effect of divalproex sodium on HIV replication in vivo.

In vitro data suggest valproate activates HIV replication. This study prospectively assesses whether divalproex sodium causes an increase in HIV replication in patients. Eight participants had their HIV viral load measured over approximately 1 month. The largest increases in viral load occurred in patients without antiretroviral medication. No patients had an increase in Log10 HIV viral load > or = 0.5. Further study is needed to understand implications.

Factors in AIDS dementia complex trial design: results and lessons from the abacavir trial.

OBJECTIVES: To determine the efficacy of adding abacavir (Ziagen, ABC) to optimal stable background antiretroviral therapy (SBG) to AIDS dementia complex (ADC) patients and address trial design. DESIGN: Phase III randomized, double-blind placebo-controlled trial. SETTING: Tertiary outpatient clinics. PARTICIPANTS: ADC patients on SBG for > or = 8 wk. INTERVENTIONS: Participants were randomized to ABC or matched placebo for 12 wk. OUTCOME MEASURES: The primary outcome measure was the change in the summary neuropsychological Z score (NPZ). Secondary measures were HIV RNA and the immune activation markers beta-2 microglobulin, soluble tumor necrosis factor (TNF) receptor 2, and quinolinic acid. RESULTS: 105 participants were enrolled. The median change in NPZ at week 12 was +0.76 for the ABC + SBG and +0.63 for the SBG groups (p = 0.735). The lack of efficacy was unlikely related to possible limited antiviral efficacy of ABC: at week 12 more ABC than placebo participants had plasma HIV RNA < or = 400 copies/mL (p = 0.002). There were, however, other factors. Two thirds of patients were subsequently found to have had baseline resistance to ABC. Second, there was an unanticipated beneficial effect of SBG that extended beyond 8 wk to 5 mo, thereby rendering some of the patients at baseline unstable. Third, there was an unexpectedly large variability in neuropsychological performance that underpowered the study. Fourth, there was a relative lack of activity of ADC: 56% of all patients had baseline cerebrospinal fluid (CSF) HIV-1 RNA < 100 copies/mL and 83% had CSF beta-2 microglobulin < 3 nmol/L at baseline. CONCLUSIONS: The addition of ABC to SBG for ADC patients was not efficacious, possibly because of the inefficacy of ABC per se, baseline drug resistance, prolonged benefit from existing therapy, difficulties with sample size calculations, and lack of disease activity. Assessment of these trial design factors is critical in the design of future ADC trials.

Lipodystrophy severity does not contribute to HAART nonadherence.

Lipodystrophy severity among 77 people living with HIV/AIDS (PHA) with body fat redistribution was not related to antiretroviral adherence including doses missed during the previous month, categorical rating of maximal adherence, and the PMAQ7 adherence behavior scale. Two thirds of the sample reported submaximal adherence, 19% missing more than two doses, but adherence behavior ratings reflected good overall adherence. Overall symptom burden, convenience of regimen schedule and remembering to organize and take antiretroviral doses, but not regimen adaptation or treatment support, were associated with adherence. Remembering was most strongly related to adherence indicators, retaining statistical significance in adjusted multivariate regression analyses.

Undetectable cerebrospinal fluid HIV RNA and beta-2 microglobulin do not indicate inactive AIDS dementia complex in highly active antiretroviral therapy-treated patients.

OBJECTIVE: To assess whether nonelevated cerebrospinal fluid (CSF) markers could delineate inactive AIDS dementia complex (ADC) in patients receiving highly active antiretroviral therapy (HAART), using neuropsychologic performance change as an indicator of ADC stability. METHODS: We used data from the abacavir (ABC) ADC trial (n = 78) and examined the patients' neuropsychologic performance change with the Reliable Change Index according to 3 cutoff groups: (1) CSF viral load (VL) <100 copies/mL, (2) CSF beta-2 microglobulin (beta2m) <2.2 mg/L, and (3) CSF VL and CSF beta2m below cutoffs. RESULTS: CSF marker cutoff groups did not define neuropsychologic change. Linear regression showed that only CSF VL was a weak predictor of neuropsychologic performance change. CONCLUSION: HAART-treated ADC patients with baseline CSF markers of viral and immunologic inactivity did not necessarily have inactive ADC when followed over 12 weeks. More sensitive CSF markers to judge the activity of ADC are urgently needed, whereas the interpretation of these markers should be considered with caution in HAART-treated ADC patients.

The relationship between lipodystrophy-associated body changes and measures of quality of life and mental health for HIV-positive adults.

OBJECTIVES: To investigate the relationship between lipodystrophy-specific symptom severity and wellbeing. METHODS: HIV-positive adult patients with body fat redistribution (lipodystrophy syndrome) associated with antiretroviral therapy reported their total non-lipodystrophy symptoms and side effects and completed measures assessing body fat changes (yielding Atrophy, Hypertrophy and Total Lipodystrophy scores), mental health and quality of life. Effects of total symptom complex and lipodystrophy severity on quality of life and mental health were analyzed using Spearman's rho correlations. Logistic regression analyses were utilized to determine the relative-odds of depression produced by overall symptom count and lipodystrophy score increments. RESULTS: Mean ratings for Hypertrophy and Atrophy corresponded to 'very mild' and 'mild' degrees of severity, respectively. The total symptom complex was associated with ratings for most of the mental health and quality of life measures. Patient-perceived body image scores were the sole study variable responsive to lipodystrophy severity ratings. In comparison to reference norms, a pronounced degree of body image impairment was evident. CONCLUSION: Although responsive to the total symptom profile, psychosocial measures typically utilized for evaluating quality of life and mental health status in HIV disease lacked sensitivity and specificity for measuring the consequences of lipodystrophy-associated fat distribution changes alone. Lipodystrophy severity did impact negatively on body image.

The impact of neuropsychological impairment and depression on health-related quality of life in HIV-infection.

Neuropsychological impairment and depression are common among individual with HIV-infection, resulting in significantly altered everyday functioning. The objective of this study was to examine the impact of these two important neurobehavioural complications on health-related quality of life in adults with HIV-infection. Participants (n = 155) received a 3-hours comprehensive neuropsychological examination, the Beck Depression Inventory, and the Medical Outcomes Study HIV Quality of Life instrument. Four groups were formed based on the presence or absence of depression and neuropsychological impairment. Results suggest that neuropsychological impairment and depression can differentially affect dimensions of health-related quality of Life. Specifically, depression has a significant impact on mental health dimensions of health-related quality of life. Some evidence exists for an impact of neuropsychological impairment, or a combined impact of depression and neuropsychological impairment, on the Physical Health dimensions of health-related quality of life. These results confirm the importance of depression as a determinant of health-related quality of life in HIV/AIDS and provide a potential avenue for improving health-related quality of life in adults with HIV-infection.

Fatigue in HIV/AIDS is associated with depression and subjective neurocognitive complaints but not neuropsychological functioning.

Fatigue and depressive symptoms are common in HIV-infection. The relationship between these symptoms and neuropsychological functioning is poorly understood, particularly in symptomatic infection/AIDS. This study examined the associations among fatigue, depressive symptoms, subjective neurocognitive complaints, and objective neuropsychological performance in HIV/AIDS. Sixty-eight men with HIV-infection (27 adults with HIV-infection but not AIDS and 41 with AIDS diagnosis) completed a neuropsychological test battery and self-report measures of fatigue (Fatigue Severity Scale), depressive symptoms (Beck Depression Inventory), and subjective neurocognitive complaints (Patient's Assessment of Own Functioning). High levels of fatigue were endorsed by participants. Fatigue severity was related to depressive symptoms but not to AIDS diagnosis or medication status. Verbal learning and motor function was worse in participants with AIDS, but neuropsychological functioning was not significantly correlated with fatigue or depressive symptoms. Subjective neurocognitive complaints were predicted by both depressive symptoms and fatigue. Our results suggest that adults with fatigue and HIV-infection (with or without AIDS) should be screened for depression. Neither fatigue nor depressive symptoms appear to affect neuropsychological functioning in HIV/AIDS. Future research is needed to develop and evaluate instruments and methods to differentiate depression-related fatigue from fatigue that may reflect underlying medical disease. Such research will further the development of effective treatments for fatigue associated with HIV-infection.

Working memory performance predicts subjective cognitive complaints in HIV infection.

The authors examined the contribution of working memory performance to subjective cognitive complaints in HIV infection beyond the influence of depressive symptoms. Thirty-six adults with HIV infection were administered neuropsychological (NP) tests of working memory, complex psychomotor efficiency, verbal learning, delayed recall, and questionnaires measuring depressive symptoms and cognitive complaints. Working memory performance, depression scores, and complex psychomotor efficiency were most strongly associated with self-reported cognitive complaints, whereas verbal learning scores and simple psychomotor efficiency showed more modest associations. Regression analyses revealed working memory performance to be the strongest NP predictor of self-reported cognitive complaints, comparable with depression scores in the amount of variance explained. These results suggest that working memory performance may be well suited to reflect how patients function in their everyday environment.