Uncertainty: At the core of general practice

Uncertainty is a core concept of medical activity, especially in general practice, where illness is evaluated at an early stage and available diagnostic tools are limited. In this paper, theoretical aspects of the concept of uncertainty are used to analyze the handling of uncertainty in two areas of the health care system: clinical encounters in primary care and at the public health level. Wynne’s categorizations of risk, strict uncertainty, and ignorance represent one approach that may be useful in acknowledging when a situation is not suitable for an evidence-based approach. Similarly, the concept of post-normal science is valuable in describing situations where uncertainty prevails together with high stakes, values in dispute, and an urgent need for decision making. Accepting that science cannot always reduce uncertainty but it can, rather, be a tool for analyzing an uncertain situation as a prerequisite for attending to uncertainty in a productive way—even when the end results are unfavorable. This paper provides examples of uncertainty in both clinical and public health situations.

Long-term risks of stress and urgency urinary incontinence after different vaginal delivery modes

BACKGROUND: Although operative delivery increases the risk of immediate pelvic floor trauma, no previous studies have adequately compared directly the effects of different kinds of instrumental vaginal deliveries on stress urinary incontinence and/or urgency urinary incontinence. OBJECTIVE(S): The objectives of the study were to estimate and compare the impact of different kinds of vaginal deliveries, including spontaneous, vacuum, and forceps, on stress and urgency urinary incontinence. STUDY DESIGN: All women aged 20 years or older, living in 1 county in Norway were invited to participate in 2 surveys addressing stress and urgency urinary incontinence using validated questions, "Do you leak urine when you cough, sneeze, laugh, or lift something heavy?" and "Do you have involuntary loss of urine in connection with sudden and strong urge to void?" with response options yes or no. Incontinence data were linked to the Medical Birth Registry of Norway. For this study, we included only women who had a history of vaginal birth(s). Case definitions for stress and urgency urinary incontinence were moderate to severe based on Sandvik Severity Index (slight, moderate, severe). We adjusted analyses for age, parity, body mass index, and time since last delivery and addressed effect modification, including an age threshold of 50 years. RESULTS: The final analysis included 13,694 women of whom 12.7% reported stress urinary incontinence and 8.4% urgency urinary incontinence. Among women aged younger than 50 years, there was a statistically significant difference in the risk of stress urinary incontinence for forceps delivery (odds ratio, 1.42, 95% confidence interval, 1.09-1.86, absolute difference 5.0%) but not for vacuum (odds ratio, 0.80, 95% confidence interval, 0.59-1.09) when compared with spontaneous vaginal delivery. Among women aged younger than 50 years, forceps also had increased risk for stress urinary incontinence (odds ratio, 1.76, 95% confidence interval, 1.20-2.60) when compared with vacuum. There was no association of stress or urgency urinary incontinence with mode of delivery in women aged 50 years or older. CONCLUSION: For women aged younger than 50 years, forceps delivery is associated with significant increased long-term risk of stress urinary incontinence compared with other vaginal deliveries.Peer reviewe

Urinary Incontinence and Weight Change During Pregnancy and Postpartum: A Cohort Study

Weight gain during pregnancy may contribute to increased urinary incontinence (UI) during and after pregnancy, but scientific support is lacking. The effect of weight loss on UI postpartum is unclear. From 1999 to 2006, investigators in the Norwegian Mother and Child Cohort Study recruited pregnant women during pregnancy. This study was based on 12,679 primiparous women who were continent before pregnancy. Data were obtained from questionnaires answered at weeks 15 and 30 of pregnancy and 6 months postpartum. Weight gain greater than the 50th percentile during weeks 0–15 of pregnancy was weakly associated with higher incidence of UI at week 30 compared with weight gain less than or equal to the 50th percentile. Weight gain greater than the 50th percentile during pregnancy was not associated with increased prevalence of UI 6 months postpartum. For each kilogram of weight loss from delivery to 6 months postpartum among women who were incontinent during pregnancy, the relative risk for UI decreased 2.1% (relative risk = 0.98, 95% confidence interval: 0.97, 0.99). Weight gain during pregnancy does not seem to be a risk factor for increased incidence or prevalence of UI during pregnancy or postpartum. However, weight loss postpartum may be important for avoiding incontinence and regaining continence 6 months postpartum

Severity of Giardia infection associated with post-infectious fatigue and abdominal symptoms two years after

<p>Abstract</p> <p>Background</p> <p>A high rate of post-infectious fatigue and abdominal symptoms two years after a waterborne outbreak of giardiasis in Bergen, Norway in 2004 has previously been reported. The aim of this report was to identify risk factors associated with such manifestations.</p> <p>Methods</p> <p>All laboratory confirmed cases of giardiasis (n = 1262) during the outbreak in Bergen in 2004 received a postal questionnaire two years after. Degree of post-infectious abdominal symptoms and fatigue, as well as previous abdominal problems, was recorded. In the statistical analyses number of treatment courses, treatment refractory infection, delayed education and sick leave were used as indices of protracted and severe <it>Giardia </it>infection. Age, gender, previous abdominal problems and symptoms during infection were also analysed as possible risk factors. Simple and multiple ordinal logistic regression models were used for the analyses.</p> <p>Results</p> <p>The response rate was 81% (1017/1262), 64% were women and median age was 31 years (range 3-93), compared to 61% women and 30 years (range 2-93) among all 1262 cases. Factors in multiple regression analysis significantly associated with abdominal symptoms two years after infection were: More than one treatment course, treatment refractory infection, delayed education, bloating and female gender. Abdominal problems prior to <it>Giardia </it>infection were not associated with post-infectious abdominal symptoms. More than one treatment course, delayed education, sick leave more than 2 weeks, and malaise at the time of infection, were significantly associated with fatigue in the multiple regression analysis, as were increasing age and previous abdominal problems.</p> <p>Conclusion</p> <p>Protracted and severe <it>giardiasis </it>seemed to be a risk factor for post-infectious fatigue and abdominal symptoms two years after clearing the <it>Giardia </it>infection.</p

Translation, transcultural adaptation, reliability and validation of the pelvic organ prolapse quality of life (P-QoL) in Amharic

Abstract Background The Prolapse Quality of Life (P-QoL) is a disease-specific instrument designed to measure the health-related quality of life in women with prolapse; however, there is no Amharic version of the instrument. The aim of this study were to translate the P-QoL into Amharic and evaluate its psychometric properties among adult women. Methods We followed an intercultural adaptation procedure to translate and adapt the P-QoL. A forward–backward translation, face validity interviews with experts and cognitive debriefing of the translated version with ten adults from the target group were performed. The Amharic version was then completed by 230 adult women with and without POP symptoms. All women were examined using a simplified Pelvic Organ Prolapse Quantification (SPOP-Q) system. We examined internal consistency (Cronbach’s alpha) and test–retest reliability (intraclass correlation coefficient = ICC). Confirmatory factor analysis (CFA) was conducted and model fit was discussed. We extracted a new factor structure by exploratory factor analysis (EFA). Criterion validity was also assessed against the SPOP-Q stage. Results The translated measure was found acceptable by the experts and target group, with only minor adaptations required for the Amharic context. It had high internal consistency (α = 0.96) and test–retest reliability (ICC = 0.87; p <  0.001). In CFA results, the model fit indices were unacceptable (CFI = 0.69, RMSEA = 0.17, SRMR = 0.43, TLI = 0.65, and PCLOSE = 0.00). EFA extracted three-factor with satisfactory convergent and discriminant validity. The P-QoL median scores were significantly higher in symptomatic women (Mann-Whitney U Test; p <  0.001). The score was also significantly correlated with stage of prolapse (Spearman’s correlation coefficient = 0.42 to 0.64, p <  0.001). Conclusions The P-QoL scale was successfully translated to Amharic and appears feasible, reliable and valid for Amharic-speaking women. Factor analysis confirmed a three-factor structure, inconsistent with the original English version. Further studies are needed to evaluate responsiveness of the Amharic P-QoL score

Women’s higher likelihood of disability pension: the role of health, family and work. A 5–7 years follow-up of the Hordaland Health Study

Abstract Background Women’s higher risk of disability pension compared with men is found in countries with high female work participation and universal welfare schemes. The aim of the study was to examine the extent to which self-perceived health, family situation and work factors explain women’s higher risk of disability pension. We also explored how these factors influenced the gender difference across educational strata. Methods The population-based Hordaland Health Study (HUSK) was conducted in 1997–99 and included inhabitants born in 1953–57 in Hordaland County, Norway. The current study included 5,959 men and 6,306 women in paid work with valid information on education and self-perceived health. Follow-up data on disability pension, for a period of 5–7 years, was obtained by linking the health survey to a national registry of disability pension. Cox regression analyses were employed. Results During the follow-up period 99 (1.7%) men and 230 (3.6%) women were awarded disability pension, giving a twofold risk of disability pension for women compared with men. Except for a moderate impact of self-perceived health, adjustment for family situation and work factors did not influence the gender difference in risk. Repeating the analyses in strata of education, the gender difference in risk of disability pension among the highly educated was fully explained by self-perceived health and work factors. In the lower strata of education there remained a substantial unexplained gender difference in risk. Conclusions In a Norwegian cohort of middle-aged men and women, self-perceived health, family situation and work factors could not explain women’s higher likelihood of disability pension. However, analyses stratified by educational level indicate that mechanisms behind the gender gap in disability pension differ by educational levels. Recognizing the heterogeneity within gender may contribute to a deeper understanding of women’s higher risk of disability pension.</p