Zagzebski on Rationality

This paper examines Linda Zagzebski’s account of rationality, as set out in her rich, wide-ranging, and important book, Epistemic Authority: A Theory of Trust, Authority, and Autonomy in Belief. We briefly describe the account that she offers and then consider its plausibility. In particular, in the first section we argue that a number of Zagzebski’s claims with regard to rationality require more support than she offers for them. Moreover, in the second section, we contend that far from offering Zagzebski a quick way of dealing with radical scepticism, her account of rationality actually seems to be particularly vulnerable to this problem

Using shared goal setting to improve access and equity: a mixed methods study of the Good Goals intervention

Background: Access and equity in children’s therapy services may be improved by directing clinicians’ use of resources toward specific goals that are important to patients. A practice-change intervention (titled ‘Good Goals’) was designed to achieve this. This study investigated uptake, adoption, and possible effects of that intervention in children’s occupational therapy services. Methods: Mixed methods case studies (n = 3 services, including 46 therapists and 558 children) were conducted. The intervention was delivered over 25 weeks through face-to-face training, team workbooks, and ‘tools for change’. Data were collected before, during, and after the intervention on a range of factors using interviews, a focus group, case note analysis, routine data, document analysis, and researchers’ observations. Results: Factors related to uptake and adoptions were: mode of intervention delivery, competing demands on therapists’ time, and leadership by service manager. Service managers and therapists reported that the intervention: helped therapists establish a shared rationale for clinical decisions; increased clarity in service provision; and improved interactions with families and schools. During the study period, therapists’ behaviours changed: identifying goals, odds ratio 2.4 (95% CI 1.5 to 3.8); agreeing goals, 3.5 (2.4 to 5.1); evaluating progress, 2.0 (1.1 to 3.5). Children’s LoT decreased by two months [95% CI −8 to +4 months] across the services. Cost per therapist trained ranged from £1,003 to £1,277, depending upon service size and therapists’ salary bands. Conclusions: Good Goals is a promising quality improvement intervention that can be delivered and adopted in practice and may have benefits. Further research is required to evaluate its: (i) impact on patient outcomes, effectiveness, cost-effectiveness, and (ii) transferability to other clinical contexts

Should one measure balance or gait to best predict falls among people with Parkinson disease?

Introduction. We aimed to determine whether gait velocity is as useful as a balance test, a self-report measure of freezing of gait (FOG), and/or a measure of motor symptom severity for predicting falls among people with Parkinson Disease (PD). Methods. Fifty-six individuals with idiopathic PD completed a baseline assessment consisting of these measures: (1) MDS-UPDRS III, (2) Mini-BESTest, (3) gait velocity (forward, backward, dual task, and fast), and (4) FOGQ. Retrospective fall history was collected at baseline and six months later. Participants were considered fallers if they had two or more falls in the surveillance period. Ability of the tests to discriminate between fallers and nonfallers was determined using ROC curves followed by pairwise statistical noninferiority comparisons (P=.05) of the area under the ROC curve (AUC) for each test. Results. At six months, 22% (n=21) of the sample were fallers. Fallers differed significantly from nonfallers on the MDS-UPDRS III, Mini-BESTest, backward gait velocity, and FOGQ. The Mini-BESTest had the highest AUC and was superior to all gait velocity measures at identifying fallers. Conclusion. A single measure of gait velocity, even in a challenging condition, may not be as effective as the Mini-BESTest in identifying fallers among people with PD

Physical therapy and deep brain stimulation in Parkinson’s Disease: Protocol for a pilot randomized controlled trial

Abstract Background Subthalamic nucleus deep brain stimulation (STN-DBS) reduces tremor, muscle stiffness, and bradykinesia in people with Parkinson’s Disease (PD). Walking speed, known to be reduced in PD, typically improves after surgery; however, other important aspects of gait may not improve. Furthermore, balance may worsen and falls may increase after STN-DBS. Thus, interventions to improve balance and gait could reduce morbidity and improve quality of life following STN-DBS. Physical therapy (PT) effectively improves balance and gait in people with PD, but studies on the effects of PT have not been extended to those treated with STN-DBS. As such, the efficacy, safety, and feasibility of PT in this population remain to be determined. The purpose of this pilot study is to address these unmet needs. We hypothesize that PT designed to target balance and gait impairment will be effective, safe, and feasible in this population. Methods/design Participants with PD treated with STN-DBS will be randomly assigned to either a PT or control group. Participants assigned to PT will complete an 8-week, twice-weekly PT program consisting of exercises designed to improve balance and gait. Control group participants will receive the current standard of care following STN-DBS, which does not include prescription of PT. The primary aim is to assess preliminary efficacy of PT on balance (Balance Evaluation Systems Test). A secondary aim is to assess efficacy of PT on gait (GAITRite instrumented walkway). Participants will be assessed OFF medication/OFF stimulation and ON medication/ON stimulation at baseline and at 8 and 12 weeks after baseline. Adverse events will be measured over the duration of the study, and adherence to PT will be measured to determine feasibility. Discussion To our knowledge, this will be the first study to explore the preliminary efficacy, safety, and feasibility of PT for individuals with PD with STN-DBS. If the study suggests potential efficacy, then this would justify larger trials to test effectiveness and safety of PT for those with PD with STN-DBS. Trial registration NCT03181282 (clinicaltrials.gov). Registered on 7 June 2017

A systematic review and meta-analysis of the effectiveness of pharmacist-led medication reconciliation in the community after hospital discharge

BACKGROUND Pharmacists’ completion of medication reconciliation in the community after hospital discharge is intended to reduce harm due to prescribed or omitted medication and increase healthcare efficiency, but the effectiveness of this approach is not clear. We systematically review the literature to evaluate intervention effectiveness in terms of discrepancy identification and resolution, clinical relevance of resolved discrepancies and healthcare utilisation, including readmission rates, emergency department attendance and primary care workload. DESIGN Systematic literature review and meta-analysis of extracted data. METHODS Medline, CINHAL, EMBASE, AMED, ERIC, SCOPUS, NHS evidence and the Cochrane databases were searched using a combination of Medical Subject Heading (MeSH) terms and free text search terms. Controlled studies evaluating pharmacist-led medication reconciliation in the community after hospital discharge were included. Study quality was appraised using CASP. Evidence was assessed through meta-analysis of readmission rates. Discrepancy identification rates, emergency department attendance and primary care workload were assessed narratively. RESULTS Fourteen studies were included comprising five RCTs, six cohort studies and three pre-post intervention studies. Twelve studies had a moderate or high risk of bias. Increased identification and resolution of discrepancies was demonstrated in the four studies where this was evaluated. Reduction in clinically relevant discrepancies was reported in two studies. Meta-analysis did not demonstrate a significant reduction in readmission rate. There was no consistent evidence of reduction in emergency department attendance or primary care workload. CONCLUSIONS Pharmacists can identify and resolve discrepancies when completing medication reconciliation after hospital discharge but patient outcome or care workload improvements were not consistently seen. Future research should examine the clinical relevance of discrepancies and potential benefits on reducing healthcare team workload