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PubMed2000

Physician expressions of uncertainty during patient encounters.

Uncertainty is inherent in clinical medicine and may contribute to variability in physician practice patterns, patient satisfaction, and exchange of information. However, research on physician disclosure of uncertainty to patients is sparse. We measured the frequency of physician expressions of uncertainty to patients using audiotapes of visits to 43 physicians by 216 continuity patients in a university-affiliated general medicine clinic. We also analyzed the audiotapes using Roter Interaction Analysis. Physicians completed Gerrity's Physician's Reaction to Uncertainty scale and patients completed the Kranz Health Opinion Survey and a standardized satisfaction questionnaire. Physicians made verbal expressions of uncertainty in 71% of clinic visits. Physicians with greater self-rated reluctance to disclose uncertainty to patients made fewer expressions. Physicians who made more uncertainty expressions also used more positive talk and partnership building, and gave more information to patients. Physicians also expressed more uncertainty to patients with more education, greater desire for information, and more questions. Physician uncertainty expression were associated with greater patient satisfaction, but not independently of other physician verbal behaviors that were also associated with satisfaction.

Adult↗

PubMedDate not supplied

Uncertainty in illness across the HIV/AIDS trajectory.

Uncertainty is a chronic and pervasive source of psychological distress for persons living with HIV. Numerous sources of heightened uncertainty, including complex changing treatments, ambiguous symptom patterns, and fears of ostracizing social response, play a critical role in the experience of HIV-positive persons and are linked with negative perceptions of quality of life and poor psychological adjustment. Currently, research on uncertainty in HIV fails to explicate the uncertainty experience over time. Because the uncertainty of HIV varies over the course of the illness, an explicit consideration of the sources of uncertainty over the HIV illness trajectory is needed to forecast the informational and stress management needs of persons facing uncertainty about HIV illness. A biopsychosocial model developed to characterize the HIV stigma trajectory provides a useful framework modified to depict uncertainty across the HIV illness experience. Uncertainty in four phases of the HIV illness trajectory are differentiated: (a) at risk, (b) diagnosis, (c) latent, and (d) manifest.

Acquired Immunodeficiency Syndrome↗

PubMed2005

Local and global uncertainty analyses of a methane flame model.

Local and global uncertainty analyses of a flat, premixed, stationary, laminar methane flame model were carried out using the Leeds methane oxidation mechanism at lean (phi = 0.70), stoichiometric (phi = 1.00), and rich (phi = 1.20) equivalence ratios. Uncertainties of laminar flame velocity, maximal flame temperature, and maximal concentrations of radicals H, O, OH, CH, and CH(2) were investigated. Global uncertainty analysis methods included the Morris method, the Monte Carlo analysis with Latin hypercube sampling, and an improved version of the Sobol' method. Assumed probability density functions (pdf's) were assigned to the rate coefficients of all the 175 reactions and to the enthalpies of formation of the 37 species. The analyses provided the following answers: approximate pdf's and standard deviations of the model results, minimum and maximum values of the results at any physically realistic parameter combination, and the contribution of the uncertainty of each parameter to the uncertainty of the model result. The uncertainty of a few rate parameters and a few enthalpies of formation causes most of the uncertainty of the model results. Most uncertainty comes from the inappropriate knowledge of kinetic data, but the uncertainty caused by thermodynamic data is also significant.

Journal Article↗

PubMed2003

Estimation of the uncertainty in a multiresidue method for the determination of pesticide residues in fruit and vegetables.

The estimation of uncertainty of an analytical result has become important in analytical chemistry. It is especially difficult to determine uncertainties for multiresidue methods, e.g. for pesticides in fruit and vegetables, as the varieties of pesticide/commodity combinations are many. In the present study, recommendations from the International Organisation for Standardisation's (ISO) Guide to the Expression of Uncertainty and the EURACHEM/CITAC guide Quantifying Uncertainty in Analytical Measurements were followed to estimate the expanded uncertainties for 153 pesticides in fruit and vegetables. Data from in-house validation were used in the estimation of the uncertainty. No significant difference in the relative standard deviation for reproducibility (RSD(R)) were found between the different concentration levels at concentration levels exceeding 2.5 times the detection limit. Therefore, it was possible to pool the RSD(R) within a single matrix. However, a difference in RSD(R) between matrices was seen, thus the poorest RSD(R) of the investigated matrices was chosen for the uncertainty estimation. The expanded uncertainties ranged from 7 to 78% with an average of 32% and median of 32%. Furthermore, only RSD(R) contributed to the uncertainty estimation.

Food Analysis↗

PubMed2000

Removing the effect of statistical uncertainty on dose-volume histograms from Monte Carlo dose calculations.

Dose-volume histograms (DVHs) of the dose distributions calculated by the Monte Carlo method contain statistical uncertainties. The Monte Carlo DVH can be considered as blurred from the noiseless DVH by the statistical uncertainty. The focus of the present work is on the removal of the statistical uncertainty effect on the Monte Carlo DVHs and the reconstruction of the noiseless DVHs. We first study the effect of statistical uncertainty. It is found that the steeper the DVH, the more significant the effect. For typical critical structure DVHs the effect is usually negligible. For the target DVHs the effect could be clinically significant, depending on the value of uncertainty and the slope of the DVH. We then propose an iterative reconstruction algorithm. Using the DVHs and statistical uncertainties from the Monte Carlo simulations, we are able to reconstruct the noiseless DVHs. A hypothetical example and a number of clinical cases have been used to test the proposed algorithm. For each clinical case, two Monte Carlo simulations (denoted A and B) were performed. Simulation A has very large statistical uncertainties (about 10% of dose in the target volume) while simulation B has very small uncertainties (about 1%). DVHs from simulation B were used to approximate the noiseless DVHs. Using the proposed algorithm, the effect of statistical uncertainty can be removed from the DVHs of simulation A. The reconstructed DVHs were in good agreement with the DVHs from simulation B. The proposed approach is expected to be useful in removing the blurring effect on a quickly calculated Monte Carlo DVH when performing the iterative forward treatment planning.

Algorithms↗

PubMed2005

EUD-based radiotherapy treatment plan evaluation: incorporating physical and Monte Carlo statistical dose uncertainties.

The purpose of this work is to quantify the impact of dose uncertainty on radiobiologically based treatment plan evaluation. Dose uncertainties are divided into two categories: physical and statistical. Physical dose uncertainty is associated with the systematic and/or random errors incurred during treatment planning and/or delivery. The dose uncertainty associated with Monte Carlo calculated dose distributions is deemed statistical and noted as artificial with respect to the actual delivered dose. We will refer to all dose uncertainties that arise from either calculation or delivery as stochastic. Both physical and statistical dose uncertainties are considered at the intra- and inter-voxel levels. To account for voxel dose uncertainty, we calculate the mean survival fraction (SF) for the random dose deposition. Mathematically, the expression for the mean survival fraction is identical to that used by Niemierko (1997 Med. Phys. 24 103-10) in defining equivalent uniform dose (EUD). To distinguish between spatial and probabilistic dose variations, we define equivalent stochastic dose (ESD) as a voxel dose that gives the mean expected survival fraction for the randomly deposited dose. For a probability density function f(D), that represents the probabilistic voxel dose, SF(ESD) can be calculated by convolving SF(D) with f(D). In the case where the probability density function follows a Gaussian distribution, an analytic expression is derived for SF(ESD). The derived expression is verified using the Monte Carlo method and ESD values calculated with varied radiosensitivities for cases of 60 and 70 Gy at 2 Gy per fraction. The analytic expression is also extended to account for a multi-voxel dose distribution that incorporates a spatial dose heterogeneity. The results show that survival fraction increases with an increased dose uncertainty. This reduction depends on radiobiological parameters attributed to tissue and tumour. For tissue, ESD drops to 55% of the mean physical dose when the dose has a 10% intra- and inter-voxel dose uncertainty and inhomogeneity.

Body Burden↗

PubMed1993

Uncertainties in predicted radionuclide body burdens and doses from discrete stochastic source terms.

Expressions are derived in three cases for the expectation and uncertainty of body burdens and doses calculated from a linear model of environmental transport and human metabolism in terms of expectation and uncertainty in inputs of discrete, stochastic random variables. Three cases are compared to determine the relationship of the expectations and uncertainties under varying assumptions. In the constant input case, the input is selected randomly at the outset of the simulation period [O,T] from the distribution to which the population is exposed and then is held constant throughout [O,T]. In the two time-varying cases, random and autoregressive, it was assumed that N discrete stochastic exposures to the input were made uncorrelated and partially correlated, respectively. Each exposure was constant during each time interval of length T/N. The expectation values of the body burdens and doses in the constant input case were identical to those in the random case and the autoregressive cases for stationary inputs. The uncertainties of the body burdens and the doses in the constant input case were identical in the limit of rapid metabolism to those of the random case and the autoregressive cases for stationary inputs. In the limit of slow metabolism, the uncertainties of the body burdens and the doses in the constant input case were N1/2 and (3N/4)1/2, respectively, greater than those in the random case and were ((1 + alpha)/[(1 - alpha)N])1/2 and (4(1 + alpha)/[3(1 - alpha)N])1/2, respectively, greater than those in the autoregressive case for stationary inputs and autocorrelation coefficient alpha. That is, increasing the number of sampling periods decreases the uncertainty and increasing the autocorrelation increases the uncertainty. In an example application for ingestion of 137Cs at Bikini Island, a weak form of both slow and rapid metabolism limits apply and give the result that the uncertainty of the body burden in the constant input case is 18 times greater than the random case. For alpha = 0.5, the uncertainty of the body burden in the autoregressive case is 1.7 times greater than the random case. The smooth transition of the autoregressive case from the random case to the constant input case is shown as alpha increases from 0 (random) to 1 (constant).

Adolescent↗

PubMed2002

A concept analysis of uncertainty in illness.

PURPOSE: To examine the concept of uncertainty in illness and to propose an alternate model of uncertainty in the illness experience. ORGANIZING CONSTRUCT AND METHODS: Following a review of the literature, Morse's description of concept analysis by critically appraising the literature was used as a guideline in examining the concept of uncertainty. FINDINGS: Characteristics of the illness situation--ambiguity, vagueness, unpredictability, unfamiliarity, inconsistency, and lack of information--underlie the process of uncertainty. Three attributes of the concept of uncertainty were identified as probability, temporality, and perception. Loss of personal control is often erroneously equated with uncertainty. CONCLUSIONS: Uncertainty is a multidimensional concept that in its purest form is a neutral cognitive state and should not be mistaken for its emotional outcomes. To clarify the concept of uncertainty, further research is needed to determine the relationship of uncertainty to loss of control and psychosocial outcomes.

Attitude to Health↗

PubMed1992

Spatial uncertainty in stereoacuity tests: implications for clinical vision test design.

In an attempt to design a new stereo vision test we found that the spatial uncertainty effect had substantial impact on the measured stereo acuity thresholds. This effect is present whenever there is uncertainty of where the critical information occurs in a visual target. We studied the spatial uncertainty effect for stereo acuity and for line length estimation. In addition, we determined the temporal uncertainty effect in a stereoacuity test. In foveal vision, uncertainty effects increased visual thresholds, sometimes dramatically. For example, for an uncertainty factor of 25 (i.e., the critical information occurred randomly in any of 25 positions) stereo thresholds increased more than four-fold compared to those obtained without uncertainty. Although the uncertainty effect has been well described theoretically, we think that it is not always appreciated in the design of clinical or experimental visual tests. In tests aimed at determining visual thresholds, spatial and temporal uncertainty factors should be minimized.

Adult↗

PubMed1998

Dimensions of subjective uncertainty in social identification and minimal intergroup discrimination.

Social categorization under minimal group conditions reliably produces intergroup discrimination. It is proposed that this might be because the minimal group paradigm engenders high levels of subjective uncertainty among participants, which causes them to use the categorization to define self and thus identify with the minimal group. Uncertainty is generally an aversive state which may be resolved by identification (Hogg, 1996; Hogg & Abrams, 1993). Thus, people may identify with social categories (and express discrimination) when identification resolves uncertainty. To investigate this idea a standard minimal group experiment was conducted, in which the three independent variables of categorizations, task uncertainty and situational uncertainty were manipulated in a 2 x 2 x 2 factorial between-subjects design. Point distribution strategies were measured along with in-group identification, self-esteem, social awareness and, at three occasions, uncertainty about the task and situation. As predicted, under conditions of high task or situational uncertainty, categorized participants identified more with their minimal in-group and exhibited more intergroup discrimination than other participants. There was also some evidence that identification reduced uncertainty. There was only partial support for the mediational role of identification, and similarly, for self-esteem as a derivative motive. These findings are interpreted as supporting an uncertainty reduction model of social identification and group motivation.

Analysis of Variance↗

PubMed2003

A systematic study of imaging uncertainties and their impact on 125I prostate brachytherapy dose evaluation.

In order to calculate the dose distribution delivered by a prostate brachytherapy implant, the seed positions and prostate volume are normally identified on post-implant CT images. We have systematically considered the impact of uncertainties in contouring the prostate, seed localization, and visualization of all the seeds on the calculated dose distributions, dose-volume histograms, and predicted radiobiological outcome. This study was done for a collection of 27 clinical 125I prostate brachytherapy implants, performed at the London Regional Cancer Centre during our early adoption of this technique. For these clinical dose distributions, the median D90 was 76% of the prescription dose, or 110 Gy, and the median V90 was 80%. We calculated the changes in these dosimetric indices (D90 and V90) and radiobiological outcome (SF2 TCP) as a function of contouring uncertainty, seed localization uncertainty, inability to localize all of the seeds, and binary combinations of these three. The results are presented for a range of uncertainties, which allows the possible application of these results to a variety of imaging modalities that have differing spatial resolutions. We found that both contouring uncertainties and seed localization uncertainties had a large impact on the predicted radiobiological outcome, but that seed localization uncertainties of 6 mm had the largest impact on the dosimetric indices. We also found that the variability in both the predicted radiobiological and dosimetric outcome was largest for contouring uncertainties of 4-8 mm. We conclude that accounting for contouring uncertainties is crucial in accurately deducing the DVHs for post-implant prostate brachytherapy, and hence enabling valid correlation with ultimate clinical outcome.

Brachytherapy↗

PubMedDate not supplied

Assessment of uncertainty and risk in modeling regional heavy-metal accumulation in agricultural soils.

Present agricultural land use and atmospheric deposition may lead to heavy-metal accumulation rates in soils that may violate soil quality standards in the future. To undertake suitable preventive measures against heavy-metal enrichment, flux balances in agroecosystems and their uncertainties have to be assessed. For this reason we developed an empirical stochastic model, PROTERRA-S, that considers heavy-metal inputs through agricultural management as well as outputs by crop removal and leaching on a regional scale. In this manuscript we describe application of PROTERRA-S to the Sundgau region in Switzerland. Considering uncertainty in informational and natural variability, large variations of the aggregated regional cadmium and zinc balances were found, with standard deviations that were of the same order of magnitude as their average values. Uncertainty in the simulated net zinc flux originated mainly from uncertainty in the zinc concentrations of manure and crops and from uncertainty in atmospheric deposition of zinc. For cadmium, the main contribution to the total uncertainty came from uncertainty in crop concentration, regression functions to estimate Freundlich parameters, atmospheric deposition, and from spatial variation of soil pH and cation exchange capacity (CEC). For both zinc and cadmium, informational uncertainty in input data were large, indicating that significant uncertainty reduction could be achieved by additional data collection campaigns. A monetary risk value for the regional zinc accumulation rate in Sundgau was calculated to be on the order of 22 million Euro.

Agriculture↗

PubMed1999

Diagnostic uncertainty expressed in prostate needle biopsies. A College of American Pathologists Q-probes Study of 15,753 prostate needle biopsies in 332 institutions.

OBJECTIVE: To determine the rate of diagnostic uncertainty in rendering diagnoses on prostate needle biopsies and to examine pathology practice variables that influence that rate. DESIGN: Anatomic pathology departments participating in the College of American Pathologists Q-Probes laboratory quality improvement program retrospectively reviewed their last 50 consecutive prostate needle biopsy diagnoses. For each diagnosis, participants provided information concerning patients' prostate-specific antigen levels; number, locations, and laterality of biopsy specimens; number of tissue levels examined; performance of high-molecular-weight cytokeratin immunoperoxidase staining; and acquisition of consultations from general pathologists or experts in prostate pathology. Characteristics of pathology practices included yearly surgical and prostate needle biopsy caseloads, number of pathologists rendering biopsy diagnoses, use of standard descriptive checklists, access to patients' prostate-specific antigen and digital rectal examination results, percentages of prostate needle biopsies routinely submitted for internal consultations, and presence of departmental experts in prostate pathology. SETTING AND PARTICIPANTS: Three hundred thirty-two public and private institutions located in the United States (n = 318), Canada (n = 6), Australia (n = 5), United Kingdom (n = 2), and Guam (n = 1). MAIN OUTCOME MEASURE: The rate of diagnostic uncertainty in prostate needle biopsy diagnoses. RESULTS: Participants submitted diagnoses on a total of 15 753 prostate needle biopsy cases, of which 33.4% were adenocarcinoma; 55.5% were benign; 3.9% were carcinoma in situ, prostatic intraepithelial neoplasia, or both; and 7.1% were diagnostically uncertain. The median rate of diagnostic uncertainty was 6%, ranging from 0 at the 10th percentile to 14% at the 90th percentile of all participating laboratories. Performing high-molecular-weight cytokeratin immunoperoxidase staining resolved diagnostic uncertainty in 68% of cases in which it was performed, and obtaining intradepartmental and extradepartmental consultations resolved diagnostic uncertainty in 70% to 87% of cases for which they were obtained. Knowledge of patients' prostate-specific antigen results and examining multiple biopsy cores had marginal effects on the rate of uncertainty. Thoroughness of prostate gland sampling and examination of multiple tissue block levels were not associated with the aggregate rate of diagnostic uncertainty. We found no particular pathology departmental practices or institutional demographic characteristics associated with institutional rates of diagnostic uncertainty. CONCLUSIONS: Use of high-molecular-weight cytokeratin immunoperoxidase staining and obtaining intradepartmental and extradepartmental consultations may be effective in reducing diagnostic uncertainty in prostate biopsies.

Adenocarcinoma↗

PubMed2001

[Uncertainty and anxiety in patients with initial attack of myocardial infarction: the effect of coping methods].

Myocardial infarction is a life threatening disease. Patients, especially those with a first time attack, experience a great deal of uncertainty and emotional disturbance which depend on the effectiveness of coping methods. Four questions were addressed in this study: (1) the degree and sources of uncertainty, (2) the coping methods used, (3) the degree of anxiety, (4) the relationship among uncertainty, coping methods and anxiety, and (5) the effect of coping methods on the relationship between uncertainty and coping methods. Fifty patients with first time attack in a teaching hospital participated this study. The instruments were Chinese versions of Mishel's Uncertainty in Illness Scale, the Revised Ways of Coping Check List and Spielberger's State Anxiety Inventory. The results showed that only 2% of patients experienced high uncertainty and 10% experienced anxiety; the average of uncertainty and anxiety were between sometimes and fairly often. "It is not clear what is going to happen to me" was the first source of uncertainty. The most often used coping method for these patients was seeking social support. Finally, the results showed that emotion-oriented coping had both positive main effect and mediating effect on the relationship between uncertainty of complexity and anxiety. The findings of this study suggest nurses should help patients utilize different coping methods, according to individual difference, in order to achieve optimal emotional state.

Adaptation, Psychological↗

PubMed1993

Uncertainty, and appraisal in patients diagnosed with abdominal aortic aneurysms.

The purpose of this study was to describe the uncertainty of subjects diagnosed with abdominal aortic aneurysms and to examine the relationship between uncertainty and subjects', positive or negative appraisals of uncertainty. Twenty-seven subjects who had a definitive diagnosis of abdominal aortic aneurysms were surveyed using the Mishel Uncertainty in Illness Scale (MUIS), the Folkman and Lazarus Restructured Appraisal Scale, and a demographic questionnaire. Findings from the study suggested that the level of uncertainty among patients with abdominal aortic aneurysms was similar or higher than the level of uncertainty that has been reported for patients with myocardial infarctions (M = 91.9, S.D. = 19.56). There was no significant relationship between uncertainty and appraisal of uncertainty as a danger (r = .21, p = .14) or opportunity (r = .14, p = .25). Implications for further research include examining patients uncertainty levels and appraisal at repeated intervals during their illness trajectory.

Adaptation, Psychological↗

PubMed2006

Illness uncertainty, partner caregiver burden and support, and relationship satisfaction in fibromyalgia and osteoarthritis patients.

OBJECTIVE: Fibromyalgia syndrome (FMS) is characterized by uncertainty in diagnosis, treatment, and outcome. This study assessed the role of uncertainty of illness in relationship satisfaction in patients with FMS and osteoarthritis (OA). METHODS: A total of 51 patients with FMS responded to self-report instruments assessing their uncertainty about their illness, functional ability, average pain, and relationship satisfaction. Their partners independently reported on their sense of caregiver burden and their supportiveness toward the patients. Thirty-two patients with OA and their partners served as a control group. RESULTS: Patients' functional ability and pain were related to partner caregiver burden. Partner caregiver burden was related to lower levels of partner supportiveness for the FMS dyads, but not for the OA dyads. Relationship satisfaction of patients with FMS was related to their higher levels of uncertainty of illness in interaction with their functional disability and pain and their partners' supportiveness. Under high levels of uncertainty of illness, low levels of partner supportiveness were related to lower patient relationship satisfaction, whereas low levels of uncertainty of illness were significant interacting variables in the OA sample. CONCLUSION: The results suggest that uncertainty of illness is a prominent feature affecting patients with FMS in their relationships with their partners. Suggestions for additional research to explore the role of uncertainty of illness in social relationships are presented, and the therapeutic implications for patient/partner relationships are explored.

Activities of Daily Living↗

PubMed2004

A Deweyan case for the study of uncertainty in health geography.

John Dewey long ago challenged the philosophical tradition by arguing that uncertainty is a central, but undertheorized, trait of existence. His challenge to philosophy is also a challenge to the social sciences, including those that focus on health. In this paper, I set out to accomplish two goals. One is to present Dewey's view on uncertainty and thereby develop an argument for an underappreciated theoretical construct. The second is to explore the congruence of uncertainty and health geography with a focus on uncertainty's meaning and validity for inquiry in a health geography context. I begin with an explication of Dewey's position on uncertainty and assess it within a larger philosophical milieu. I then discuss various implications of this view for health geography and argue that the Deweyan case for uncertainty fits the discipline well. In the final part of the paper, I share an analysis of assisted living for older persons that displays different forms of uncertainty playing important roles in the health and place experience. I conclude that Dewey's philosophical position on uncertainty is a potentially important avenue for further inquiry into health and place.

Aged↗

PubMedDate not supplied

Uncertainty, symptom distress, anxiety, and functional status in patients awaiting coronary artery bypass surgery.

OBJECTIVE: The study's objective was to (1) describe uncertainty, anxiety, the symptom distress experience, and functional status of patients on a coronary artery bypass graft (CABG) waiting list and express the relationship between these concepts; (2) explore whether length of time waited has an influence on the psychosomatic condition of patients; and (3) explore the use of semistructured interviews within the context of a theoretic framework and compare open-ended responses to quantitative results. DESIGN: A descriptive, correlational, cross-sectional design was used with supplementary telephone interviews using semistructured questions. Quantitative data were collected with a mailed questionnaire. Study instruments included the Mishel Uncertainty in Illness Scale (Community), Symptom Frequency and Symptom Distress Scale, Graphical Anxiety Rating Scale, and Kansas City Cardiomyopathy Questionnaire (Physical and Social Limitation). The Mishel Uncertainty in Illness Theory was used as the guiding theoretic framework. SETTING: The study took place in one large tertiary care hospital in Winnipeg, Manitoba, Canada. SAMPLE: The study included a convenience sample of 42 patients undergoing first-time elective CABG only, 25 of whom participated in the telephone interview. RESULTS: Average uncertainty and anxiety were present at moderate levels and were associated with moderate deterioration of functional status. Reported symptom distress was low; however, presence of symptoms showed a strong relationship with anxiety (P=.0002), and this relationship was confirmed through semistructured interviews. Although the relationship between uncertainty and anxiety was nonsignificant, the interviews suggest positive views of uncertainty as an opportunity may have muted the relationship between uncertainty and anxiety, and that it is possible to experience uncertainty as a danger and an opportunity simultaneously. No statistically significant relationship was found between the study variables and waiting time; however, there was a nonsignificant trend toward deterioration of psychologic and physical condition with longer waits, which may be clinically significant. CONCLUSION: Psychosocial distress and physical condition among patients on CABG waiting lists should be continually assessed in all patients regardless of how long they have been waiting. Each patient will have a unique presentation of symptoms and a corresponding unique psychologic response.

Aged↗