Abnormality

Research Methods Dent 313

Normal vs. abnormal

Abnormal means something grossly different from the usual Distinction between normal & abnormal

Easily identified in obvious cases Needs experience, skills and conceptual basis when less obvious Most difficult among unselected patients outside of hospitals Therefore, calling clinical findings normal or abnormal is crude and results in some misclassification
2

Normal vs. abnormal

Why to take this crude approach
To be perfectly intelligible, one must be inaccurate, and to be perfectly accurate, one must be unintelligible Bertrand Russel

Physicians usually choose to be intelligible at the expense of accuracy

Each aspect of clinical work ends in a decision

Pursue evaluation or wait Begin treatment or reassure

present or absent classification is necessary

Normal vs. abnormal

Examples of obvious abnormal

Missing teeth Gingivitis Badly cavitated teeth Heavily restored teeth

Normal vs. abnormal

Decision of abnormality can be difficult
Examples:

Appendicitis vs. abdominal pain Pharyngitis vs. Haemophilus epiglottitis

Normal vs. abnormal

It is important to distinguish between various kinds of abnormality
The normal findings require no action

normal vs. within normal limits vs. unremarkable vs. noncontributory

The abnormal findings are the basis for action and set out under a problem list

Impressions Diagnoses

Normal vs. abnormal

Decisions about what is abnormal are most difficult among none-patients

Normal vs. abnormal

This lecture will present some of the ways clinicians use to distinguish normal from abnormal by explaining:

how they vary and are distributed among people how biologic phenomena are measured and described how they can be summarized

CLINICAL MEASUREMENT
Clinical phenomena are measured by scales
Scales are ways of expressing measurements used for describing clinical phenomena

Types of scales:
Nominal scale Ordinal scale Interval scale Ratio scale

Nominal scale
Giving names to different conditions
Not strictly a scale at all

Cutoff points of normality are defined by investigator subjectively Examples:

Dramatic discrete events

Death, Dialysis, Surgery, Stroke

Present/Absent, Yes/No. Alive/Dead, Sound/Caries

Data of two unordered categories (dichotomous)

10

Ordinal scale
Listing conditions in some inherent order or rank of severity without attempting to:
define any mathematical relation between categories specify the size of the intervals between categories Cutoff points of normality are defined by investigator subjectively

11

Ordinal scale
Examples:
Ranks:

small, medium, large mild, moderate, severe

Inherent order:

Ordering categories measurable on interval scale when precision in not needed

E.g., Periodontal pocket depth

Shallow, medium, deep pockets

12

Interval scale
Also called numerical or dimensional Listing conditions in inherent order
The numbers used in the measuring scale have a mathematical relation to one another Intervals between successive values are equal The scale has no true zero value and -ve values can exist

E.g., Temperatures F or C

Cutoff points of normality can be decided precisely

13

Ratio scale
The same as interval scale but has a true zero value -ve values do not exist Cutoff points of normality can be decided precisely

14

Two types of Ratio scale

Continuous scale
Can take any value in a continuum

E.g., wt, bp

May take integer values for rounding

Discrete scale
Specific values expressed as counts

E.g., # of pregnancies, # of births with cleft lippalate, # of missing teeth

15

Performance of measurements
Validity Reliability

16

Validity
The degree to which the data measure what they were intended to measure Validity = accuracy Repeated validity checks

17

Reliability
The extent to which repeated measurement of a stable phenomenon by different people and instruments at different times and places get similar results Reliability = reproducibility = precision Established by repeated measurements
18

Validity vs. reliability

19

Variation
The range of values that a clinical measurement of the same phenomenon can take Overall variation
The sum of

Variation due to the act of measurement Variation due to biologic differences

within individuals from time to time among individuals

20

Variation due to measurement

Role of validity and reliability
Lack of validity biased results (systematic error) Lack of reliability random error

Objective machine measurement vs. subjective human judgment

21

Measurement vs. biologic variation

22

Distribution
Data measured on interval scales can be presented as a frequency distribution Central tendency middle of distribution Dispersion how spread out the value are Unimodal distribution one hump Skewed distribution Clinical distribution vs. normal distribution
Not identical although clinical distribution is assumed normal for convenience
23

Normal distribution
Gaussian distribution Symmetrical bell shaped Dispersion is the same on both ends Dispersion is only due to random variation 68.26% fall within 1 SD 95.44% fall within 2 SDs 99.72% fall within 3 SDs
24

Normal distribution

25

Hard and Soft measurements

Hard measurement
Usually applied to data that are reliable and preferably dimensional E.g., laboratory data, demographic data, and financial costs.

Soft measurement
E.g., clinical performance, convenience, anticipation, and familial data

26

Criteria for abnormality

Distinction between normal and abnormal is hard:
Sometimes normal and abnormal are not distinct in population there is a smooth transition from low to high values of dysfunction with overlapping degrees for disease and normal Disease is acquired by degrees (mild vs. severe)
27

Criteria for abnormality

Since there is NO sharp dividing line between normal and abnormal,
the clinician can choose when to consider it disease Based on what ?????? 3 criteria have proven useful

28

Abnormal as Unusual
Normal = most frequently occurring=usual One commonly used way that all values beyond 2 SD from the mean are abnormal Beyond the 95th percentile
X -1SD -2SD +1SD

+2SD

29

Abnormal as Unusual
Situations that unusual is misleading
Frequency of abnormal among different diseases

Not necessarily beyond 95th percentile is abnormal in all diseases Example: WHO blood Hb<12 =anemia.

Clinically 12% below 12 Statistically should be 5% below 12

There is a risk of disease from low normal to high normal with no cutoff point dividing normal from increases risk

Risk of CHD and Cholesterol

30

252 286

Increase risk from 82 to 286 Cases / 1000/24 yr

82

Cholesterol level
31

Abnormal as Unusual
Situations that unusual is misleading
Some extreme unusual ones readings are preferable to more usual ones
E.g., low blood pressure

Statistically normal and clinically diseased

Normal pressure of glaucoma

32

Abnormal as associated with disease

Abnormal are those observations regularly associated with disease, disability, or death Abnormal = any clinically departure from good health
Example: 95.2% of population have uric acid 7mg/100 ml and impossible to develop gouty arthritis

33

Abnormal as Treatable
Considered abnormal when the treatment leads to a better outcome If removal of risk factor does not remove risk it is not necessary to label people abnormal What is considered treatable changes with time
E.g., folic acid level to prevent anemia
34