We will talk about abnormality and the topics related to abnormality in research. Now what does abnormal means?

It is something grossly different from usual if something is slightly different or not similar to another thing, we dont call this thing abnormal, it has to be grossly different. For example lets take the height of people, to which extend do we consider the person very short? Or abnormally tall? To answer this we have to define a range of normality regarding the height, e.g. if a person is above 1.50 we consider him tall, below this he is considered short. This is why abnormality is not a point, it is a range. Saying something is normal is located in a range of normailites and not just on one single point. Distinction between normal and abnormal: Easily identified in obvious cases: it is very easy for example to identify a carious teeth as an abnormal tooth in fact if you had a very carious tooth when you were young, your mother identified as an abnormal tooth. On the other hand looking at a sound tooth we can easily say that this tooth is normal. Needs experience , skills and conceptual; basis when less obvious : In class ll the caries are hidden in the smooth surfaces , in this case you have to be experienced to tell we have caries in here. Most difficult among unselected patients outside of hospitals : Having the patients inside the hospital will lead to a greater chance of finding abnormal then when outside the hospital . Because in the hospital you have very advanced measures and devices that will help you , but outside you dont have that. Therefore , calling clinical findings normal or abnormal is crude and results in some misclassification : As we said , saying something is normal or abnormal is not an easy task , but this leads us to ask ourselves Why to take this crude approach? Consider the following quotes to answer this question: To be perfectly intelligible , one must be inaccurate , and to be perfectly accurate , one must be unintelligible

 Physicians usually choose to be intelligible at the expense of accuracy : As a doctors we give up being 100% accurate at the expense of intelligence If you have the choice of being intelligible or being accurately perfect in your professional life as a doctor, please be intelligible. I must accept some inaccuracy not everything in life is perfect so is diagnoses what is normal from abnormal. Each aspect of clinical work ends in a decision the decision we end up after the clinical visit of your patient is either: Purse evaluation : maybe you want to take another doctor opinion about the dingoes You wait: you want to wait to see the development of the disease for example. Begin treatment : when your diagnoses indicates that your patient is in need of treatment Reassure: Lets consider for example a condition where the patient is worried about the condition he has, but with your knowledge you know this condition is not serious. So you reassure them. Sometimes you have to give Present or absent classication for the disease, which is something very important although this might sound easy, it is not.

Lets consider some examples about obvious abnormal: Missing teeth: anyone can tell if you have missing teeth or not, even can tell. Gingivitis Badly caveated teeth Badly cavited teeth Heavily restored teeth Decisions of abnormality can be difficult :

 Appendicitis vs. Abdominal pain : the patient comes to your clinic suffering from pain in the abdominal rejoin you cant tell very easily if this condition is appendicitis or abdominal pain . Pharyngitis vs. Haemophilus epiglottis

It is important to distinguish between various kinds of abnormality The normal findings require no action: if you find normal results you only have to reassure your patient, ask him to come visit you routinely...etc. Normal vs. within normal limits : which is better to say, This thing is normal or This thing is within normal limits . Actually it is better to say it is within normal limits than saying it is normal. Because as we said in the beginning normality is not a single point it is more of like a range. , when we say a person is 70 KG and this is normal, what about 71 ? Isnt normal too? So the more accurate way is to say for example 70-79 is normal. Unremarkable vs. noncontributory : same thing as above , it is more accurate to always say within the normal range The abnormal findings are the basis for action and set out under a problem list , meaning that the observations you see are the keys for your actions as a doctor and they are in the format of : Impressions : I suspect that the patient is having something , but this belief is not coming from pure diagnoses , Im just giving my opinion about the patient by looking at him and saying that he has abnormal finding Diagnoses: where you actually use a clinical/scientific approach and determent that the patient is having an abnormal finding Decisions about what is abnormal are most difficult among none-patients. This is just a we said earlier, because patients whom are not inside a hospital are difficult to classify as abnormal of normal because you dont have the proper devices and tests to rule out the final diagnoses. This lecture will present some of the ways clinicians 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 This is basically a summary for what we are going to talk about in this lecture, and with this we have finished the introduction.

Clinical measurement: Clinical phenomena are measured by scales , Scales: Are ways of expressing measurements used for describing clinical phenomena We have four types of scales, we already saw them in epidemiology lectures but we will focus on them from another approach: 1. 2. 3. 4. Nominal scale Ordinal scale Interval scale Ratio scale

Nominal scale, Categorical scale: Giving Names to different conditions, not strictly scale at all Examples about these scales are: Tooth is present, tooth is absent , There is gingivitis, there is no gingivitis and Describing pain in the patient if it is low, mild or sever so here we are just implying names. Another example is... (You guessed it!) The research Dr.Ashraf did in timing of tooth and eruption among Jordanians his scale was nominal, he classified the teeth wither they are present or absent Another examples are Dramatic , discrete events : Death ( dead or alive ) , Dialysis ( patient has dialysis or not ) , Surgery ( patient had a surgery or not ) and Stroke ( patient had a stroke or not). Cutoff points of normality are defined by investigator subjectively : meaning that, the same subject differs from investigator and another. Consider this example , if we did a research and one called the findings inflamed and not

inflamed another one said no , I want to call them gingivitis and nongingivitis ~ the subject is the same but the point of views of each observer is different , this is why it is called subjective. Data of two unordered categories : nominal scale uses these types of words to describe the findings, for example: Present /Absent, Yes/No, Alive/Dead and Sound /Carries, this is called Dichotomous or Binary which is: two opposite words that describe the same subject. Keeping that in mind , sometimes nominal scales can have three words to describe the findings , an example about this is when I want to classify students I could say good students , average students and below average students , so not all the time nominal scale uses dichotomous .

Ordinal scale: Listing the condition 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 For example the distance in the ordinal gingivitis scale between no gingivitis to mild and severe gingivitis is the same. cutoff points of normality are defined by investigator subjectively : this is the same as what have been said about nominal scale , although the distance between each distance is fixed but each observer can name the cutoff points the way he feel. Examples: Ranks : Small , medium and large Inherit order: Mild, moderate and sever. Unlike the nominal scale where for example we want to classify the students of Jordan to public schools, private schools and other schools, here we are just putting them in categories that have no relation between them. But in case of Mild, moderate and sever in the ordinal scale there is a relation between them.

 Ordering categories measurable on interval scale when precision is not needed for example : Periodontal pocket depth ; shallow , medium and deep pockets Interval / Numerical / Dimensional: Why do we call it numerical and dimensional? Because here we use numbers. 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 : all the distances between the cutoff points must be exactly the same and they must be defined. Intervals between successive values are equal : Like saying the temperature today is 10, yesterday it was 5. So the amount of 10 is double the 5, so there is a mathematical relationship between the cutoff points. Cutoff points of normality can be decided precisely : meaning that it is not subjective it is objective. The scale has no true zero value, but a negative (-) value can be found. Consider this example: we can say todays temperature is 0 so this is an interval scale, does that mean we have no temperature when it is 0? No, it simply means the temperature when measured is 0.We can also say the temperature is -4. But can we say this person weights 0 KG? We cant say that, 0 KG means no weight, and this leads us to the other scale which is the Raito scale.

Ratio scale: The same as interval scale but has a true zero value , here negative (-) doesnt exist, cutoff points of normality can be decided precisely . As we said in the example earlier, we cant say a person weights 0KG. So always ask yourself when you find a trouble deciding is this a ratio or interval scale, can it have a true zero value or not.

Types of ratio scale: Continues scale: can take any value in a continuum for example weight and blood pressure, meaning that if I hold a stone with my hand it could be 1KG, another stone could be 1.2 KG. So continues can accept decimal points or frictions. Discrete scale : sepsific values expressed as counts for example the number of pregnancies , I have to say I have 300 pregent woman this year , I cant state I have 300.5 pregent woman this year ?! Also the number of births I cant say I have 20.5 birth rate this year , same goes for the number of missing teeth .. Etc. so in the discrete scale they are expressed as integers. With this we have finished our talk about scales and now we turn our attention to another subject.

Performance of measurements: Validity Reliability Lets start our talk with validity: The degree to which the date measure what they were intended to measure , Validity is accuracy, repeated validity checks can be done Lets consider this example, my true blood pressure was 200/80, but when you measure my blood pressure it was 210/80 so we say your result is valid and accurate, because your result was close to the true value.

And about reliability: The extent to which repeated measurement of stable phenomena by different people and instruments at different times and places get similar results Reliability equals reproducibility and precision, lets consider this example you measure my blood pressure today and you will come and measure it tomorrow and the day after that, all of your findings are true. Also you might use different

instruments to measure my blood pressure but always you get the true value this is what reliability is and we say that your results are precious or reproducible. Always remember we rely on repeated measurements not on validity but reliability.

Variation: The range of values that a clinical measurement of the same phenomenon can take it is the, The overall variation or the sun of: 1. Variation due to the act of measurement 2. Variation due to biologic differences: within individuals from time to time or among individuals themselves. Variation due to biologic differences is acceptable, but the variation due to the act of measurement is not acceptable. We need to always have the same measurements techniques and ways and tests.

Role of Validity and reliability : Lack of validity leads to biased results, systematic error. This is not acceptable. And must be removed from your research. Lack of reliability leads to random error, or chance. This is acceptable, but you always have to work hard on your research to reduce it as much as possible. Objective machine measurement vs. subjective human judgment : meaning that the machine is more accurate than humans; objective . So you have to choose wither you want your research to be based on machines or humans. Always try to choose only one examiner to reduce the variation, if there were two there might be variation. There is an error called Inter-Examiner Error and this is when you have more than one examiner and you end up with variation in the research.

You might have Intra-Examiner Error , where there is only one examiner but you still have variation due to the change in his style of observation or instruments he use. At the end of your research you have to supply both the intra and inter errors, in order for your research to be valid. And as we said, you have to lower the variation inside your research as much as possible. Lower all the factors that contribute to the variation like (too much clinical visits, more than one observer and using of different instruments each time you take a sample).

Distribution: Data measured on interval scales can be presented as a frequency distribution Look at the figure slide 25 , here zero means the average or the mean , we have the standard deviations ( -3 , -2 , -1 , +1 , +2 , +3 ) anything normal will be located between -2 to +2 . If for example I measured the height of our class, and it turns out to be 170, I say the normal range is 168-172 anything above this or below this is abnormal. The optimal range in the figure is from -1 to +1; here you can get the best results of your research. We also have something called Percentile, and it is the percentage of people below -2 (look the figure) we found out that 60% are below this point so this is called the percentile (60% is not written on the figure it is just an example) The optimal percentile or the best percentile is when you have it on 0 that means you are normal on 50% of the people.

Done by: Osama Yousef.