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.

Shared Decision-Making—Balancing Between Power and Responsibility as Mental HealthCare Professionals in a Therapeutic Milieu

Abstract Background: Shared decision-making (SDM) is supposed to position patient and expert knowledge more equal, in which will have an impact on how mental healthcare professionals relate to their patients. As SDM has not yet been widely adopted in therapeutic milieus, a deeper understanding of its use and more knowledge of interventions to foster its implementation in clinical practice are required. Aim: To explore how mental healthcare professionals describe SDM in a therapeutic milieu as expressed through clinical supervision. The research question was ‘‘What are prerequisites for mental healthcare professionals to practice SDM in a therapeutic milieu?’’ Methods: A qualitative content analysis of data from focus groups dialogues in 10 clinical supervision sessions where eight mental healthcare professionals participated was performed. Findings: The theme, practicing SDM when balancing between power and responsibility to form safe care, was based on three categories: internalizing the mental healthcare professionals’ attributes, facilitating patient participation, and creating a culture of trust. Conclusion: SDM is a complex and arduous process requiring appropriate interventions. Clinical supervision is necessary for reflection on SDM and for improving practice in a therapeutic milieu.publishedVersio

The effect of urinary incontinence status during pregnancy and delivery mode on incontinence postpartum. A cohort study*

Objective: The objectives of this study were to investigate prevalence of urinary incontinence at 6 months postpartum and to study how continence status during pregnancy and mode of delivery influence urinary incontinence at 6 months postpartum in primiparous women. Design: Cohort study. Setting: Pregnant women attending routine ultrasound examination were recruited to the Norwegian Mother and Child Cohort Study (MoBa). Population A total of 12 679 primigravidas who were continent before pregnancy. Methods: Data are from MoBa, conducted by the Norwegian Institute of Public Health. Data are based on questionnaires answered at week 15 and 30 of pregnancy and 6 months postpartum. Main outcome measures Urinary incontinence 6 months postpartum is presented as proportions, odds ratios and relative risks (RRs). Results Urinary incontinence was reported by 31% of the women 6 months after delivery. Compared with women who were continent during pregnancy, incontinence was more prevalent 6 months after delivery among women who experienced incontinence during pregnancy (adjusted RR 2.3, 95% CI 2.2–2.4). Adjusted RR for incontinence after spontaneous vaginal delivery compared with elective caesarean section was 3.2 (95% CI 2.2–4.7) among women who were continent and 2.9 (95% CI 2.3–3.4) among women who were incontinent in pregnancy. Conclusion Urinary incontinence was prevalent 6 months postpartum. The association between incontinence postpartum and mode of delivery was not substantially influenced by incontinence status in pregnancy. Prediction of a group with high risk of incontinence according to mode of delivery cannot be based on continence status in pregnancy

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

Why do women have stress urinary incontinence?

This article reviews progress made in understanding the causes of stress urinary incontinence. Over the last century, several hypotheses have been proposed to explain stress urinary incontinence. These theories are based on clinical observations and focus primarily on the causative role of urethral support loss and an open vesical neck. Recently these hypotheses have been tested by comparing measurements of urethral support and function in women with primary stress urinary incontinence to asymptomatic volunteers who were recruited to be similar in age, race, and parity. Maximal urethral closure pressure is the parameter that differs the most between groups being 43% lower in women with stress incontinence than similar asymptomatic women having as effect size of 1.6. Measures of urethral support effect sizes range from 0.5 to 0.6. Because any one objective measure of support may not capture the full picture of urethrovesical mobility, review of blinded ultrasounds of movements during cough were reviewed by an expert panel. The panel was able to identify women with stress incontinence correctly 57% of the time; just 7% above the 50% that would be expected by chance alone, confirming that urethrovesical mobility is not strongly associated with stress incontinence. Although operations that provide differential support to the urethra are effective, urethral support is not the predominant cause of stress incontinence. Improving our understanding of factors affecting urethral closure may lead to novel treatments targeting the urethra and improved understanding of the small but persistent failure rate of current surgery. Neurourol. Urodynam. 29:S13–S17, 2010. © 2010 Wiley-Liss, Inc.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/71377/1/20888_ftp.pd

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

Caesarean section for non-medical reasons at term

Background: Caesarean section rates are progressively rising in many parts of the world. One suggested reason is increasing requests by women for caesarean section in the absence of clear medical indications, such as placenta praevia, HIV infection, contracted pelvis and, arguably, breech presentation or previous caesarean section. The reported benefits of planned caesarean section include greater safety for the baby, less pelvic floor trauma for the mother, avoidance of labour pain and convenience. The potential disadvantages, from observational studies, include increased risk of major morbidity or mortality for the mother, adverse psychological sequelae, and problems in subsequent pregnancies, including uterine scar rupture and greater risk of stillbirth and neonatal morbidity. An unbiased assessment of advantages and disadvantages would assist discussion of what has become a contentious issue in modern obstetrics. Objectives: To assess, from randomised trials, the effects on perinatal and maternal morbidity and mortality, and on maternal psychological morbidity, of planned caesarean delivery versus planned vaginal birth in women with no clear clinical indication for caesarean section. Search methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (April 2009). Selection criteria: All comparisons of intention to perform caesarean section and intention for women to give birth vaginally; random allocation to treatment and control groups; adequate allocation concealment; women at term with single fetuses with cephalic presentations and no clear medical indication for caesarean section. Data collection and analysis: We identified no studies that met the inclusion criteria. Main results: There were no included trials. Authors' conclusions: There is no evidence from randomised controlled trials, upon which to base any practice recommendations regarding planned caesarean section for non-medical reasons at term. In the absence of trial data, there is an urgent need for a systematic review of observational studies and a synthesis of qualitative data to better assess the short- and long-term effects of caesarean section and vaginal birth

Changes in self-assessment of continence status between telephone survey and subsequent clinical visit

Aims To explore variance in reporting continence information obtained by telephone survey with face-to-face clinician interview in a clinical setting. Methods As part of a cross-sectional, epidemiologic study of incontinence prevalence among Black and White women aged 35–64 years, randomly selected households were contacted from geographic areas of known racial composition. Of 2,814 women who completed a 20-min, 137-item telephone interview, 1,702 were invited for future components of the study. A subset of these women was recruited for a clinical evaluation that was conducted within a mean of 82 days (SD 38 days) following the interviews. Prior to urodynamics testing, a clinician interview was conducted inquiring about continence status. The criterion for incontinence for both the telephone interview and the clinician interview was constant: 12 or more episodes of incontinence per year. Women whose subjective reports of continence information differed between telephone and clinician interviews were designated as “switchers.” Results Of the 394 women (222 Black and 172 White) who completed the clinical portion, 24.6% (n = 97) were switchers. Switchers were four times more likely to change from continent to incontinent (80.4%, N = 78) than from incontinent to continent (19.4%, N = 19; P  = 0.000) and nearly three times more likely to be Black (69%, N = 67) than White (31%, N = 30; P  = 0.001). Telephone qualitative interviews were completed with 72 of the switchers. The primary reason for switching was changes in women's life circumstances such as variation in seasons, activities of daily living, and health status followed by increased awareness of leakage secondary to the phone interview. Conclusion One-time subjective telephone interviews assessing incontinence symptoms may underestimate the prevalence of incontinence especially among Black women. Neurourol. Urodynam. 29:734–740, 2010. © 2010 Wiley-Liss, Inc.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/77449/1/20827_ftp.pd

Buying seafood: Understanding barriers to purchase across consumption segments

Most consumers have positive attitudes toward seafood and consider it to be an important part of a healthy and balanced diet. However when purchasing seafood, consumers also weigh up various risks which may act as barriers to consumption. In this paper, the findings of an online survey of Australian consumers (. n=. 899) which explored both drivers and barriers to seafood consumption are discussed. The primary focus of this paper is to explore the perceived risks of seafood consumption and how these vary across consumption levels. Perceived risks associated with seafood consumption include functional, social, physical, psychological, and financial risk. With the exceptions of physical and financial risk, perceptions of risk varied across regular, light and very light seafood consumption segments. Lighter fish consumers were more likely to perceive functional risk associated with being less informed and less familiar with fish, experience more difficulties with selecting fish, recognising if fish is fresh, and preparing and serving fish than more regular fish consumers. Regular seafood consumers were less likely than lighter seafood consumers to perceive social risk arising from other members of their household not liking fish. Moreover, regular seafood consumers were less likely to perceive psychological risks associated with unpleasant past experiences or unpleasant sensory qualities, such as not liking the smell of fish and not liking to touch fish. Based on these results strategies for reducing perceived risks as a means of stimulating fish consumption are proposed for further investigation. © 2012