bluuebunny/crossref_metadata_2025 huggingface dataset:
Linking a Medical Vocabulary to a Clinical Data Model using Abstract Syntax Notation 1
Authors: Rocha R. A. , Solbrig H. R. , Barnes M. W. , Schrank S. P. , Smith M. , Huff S. M.
Published: March 2018

We have created a clinical data model using Abstract Syntax Notation 1 (ASN.l). The clinical model is constructed from a small number of simple data types that are built into data structures of progressively greater complexity. Important intermediate types include Attributes, Observations, and Events. The highest level elements in the model are messages that are used for inter-process communication within a clinical information system. Vocabulary is incorporated into the model using BaseCoded, a primitive data type that allows vocabulary concepts and semantic relationships to be referenced using standard ASN.l notation. ASN.l subtyping language was useful in preventing unbounded proliferation of object classes in the model, and in general, ASN.l was found to be a flexible and robust notation for representing a model of clinical information.
Desiderata for Controlled Medical Vocabularies in the Twenty-First Century
Authors: Cimino J. J.
Published: March 2018

Builders of medical informatics applications need controlled medical vocabularies to support their applications and it is to their advantage to use available standards. In order to do so, however, these standards need to address the requirements of their intended users. Overthe past decade, medical informatics researchers have begun to articulate some of these requirements. This paper brings together some of the common themes which have been described, including: vocabulary content, concept orientation, concept permanence, nonsemantic concept identifiers, polyhierarchy, formal definitions, rejection of “not elsewhere classified” terms, multiple granularities, mUltiple consistent views, context representation, graceful evolution, and recognized redundancy. Standards developers are beginning to recognize and address these desiderata and adapt their offerings to meet them.
A Model for Medical Knowledge Representation Application to the Analysis of Descriptive Pathology Reports
Authors: Smart J. F. , Roux M.
Published: March 2018

A new knowledge-representation system is presented, designed for medical knowledge-based applications and in particular for the analysis of descriptive medical reports. Knowledge is represented at two levels. A definitional level uses a concept-type hierarchy, a relation-type hierarchy, and a set of schematic graphs to define the concepts used and the relations between them, as well as different types of cardinality restrictions on these relations. A set of compositional hierarchies using the classic “has-part” relation as well as a new set-inclusion relation allows concept composition to be precisely defined. An assertional level allows the creation and manipulation of empirical data, in the form of graphs using the concepts, relations, and constraints defined at the definition level. The use of cardinality constraints in graph unification is considered in the context of descriptive medical discourse analysis.
Evaluating Four Diagnostic Methods with Acute Abdominal Pain Cases
Authors: Ohmann C. , Goos K. , Puppe F. , Mootz O. , Puppe B.
Published: March 2018

Contemporary work in medical decision support is characterized by a multitude of methods. To investigate their relative strengths and weaknesses, we built four diagnostic expert systems based on different methods (Bayes, case-based classification, heuristic classification) for analysis of the same set of 1254 cases of acute abdominal pain previously documented in a prospective multicenter study. The results of the comparative evaluation indicate that differences in overall performance are relatively small (statistically not significant). The performance depends more on the quality of the knowledge base and the case data than on the inference methods of the expert systems. Methods relying exclusively on empirical knowledge (Bayes, case-based classification) tend to have slightly higher overall performance scores due to a diagnostic bias toward ordinary and common diseases. By contrast, methods operating with expert knowledge (e. g., heuristic classification) perform slightly worse overall, but are more sensitive toward uncommon (serious) diseases.
Assigning Value to Clinical Information – A Major Limiting Factor in the Implementation of Decision-Support Systems
Authors: de Dombal F. T.
Published: March 2018

This paper deals with a major difficulty and potential limiting factor in present-day decision support - that of assigning precise value to an item (or group of items) of clinical information. Historical determinist descriptive thinking has been challenged by current concepts of uncertainty and probability, but neither view is adequate. Four equations are proposed outlining factors which affect the value of clinical information, which explain some previously puzzling observations concerning decision support. It is suggested that without accommodation of these concepts, computer-aided decision support cannot progress further, but if they can be accommodated in future programs, the implications may be profound.
Structured Data Entry for Reliable Acquisition of Pharmacokinetic Data
Authors: Schromm T. , Frankewitsch T. , Giehl M. , Keller F. , Zellner D.
Published: March 2018

A pharmacokinetic database was constructed that is as free of errors as possible. Pharmacokinetic parameters were derived from the literature using a text-processing system and a database system. A random data sample from each system was compared with the original literature. The estimated error frequencies using statistical methods differed significantly between the two systems. The estimated error frequency in the text-processing system was 7.2%, that in the database system 2.7%. Compared with the original values in the literature, the estimated probability of error for identical pharmacokinetic parameters recorded in both systems is 2.4% and is not significantly different from the error frequency in the database. Parallel data entry with a text-processing system and a database system is, therefore, not significantly better than structured data entry for reducing the error frequency.
A Philosophy for Health Informatics Education in Developing Countries: Nigeria as a Case Study
Authors: Soriyan H. A. , Adagunodo E. R. , Akinde A. D.
Published: March 2018

The use of computers in the health sector has increased significantly during the last few years in Nigeria. This paper addresses the integration of health and informatics education, or health education and informatics education, or informatics education in health care delivery. It gives an introduction to the status of a health informatics programme in the daily practice of computer use. The essence of a health informatics curriculum, the planning and administration of the programme in medical schools, and what informatics education offers the health sector, even in a developing country, are presented. The problems of administering an informatics programme in a conventional medical training curriculum are highlighted. The article describes the philosophy which should underline the framework for the formulation of appropriate national policies and curricula for health informatics education in developing countries, using Nigeria as a case study.
Fundamentals of Modern Telemedicine in Africa
Authors: Adeyinka M. B.
Published: March 2018

The FOMTA (Fundamentals of Modern Telemedicine in Africa) project aims to promote the development of indigenous regional networks between R&D centres and universities of the Developing Countries (DCs) and their European counterparts. While FOMTA prepares the way for the use of broadband technology in Africa, it will also associate the DCs with the generation of knowledge, innovative and appropriate technologies needed to solve some of the specific problems, in order to achieve a sustainable economic development. Designed to eliminate the time-delaying lack of infrastructure, FOMTA will embark on the simulation of the Integrated Service Digital Network infrastructure. FOMTA will adopt measures to increase the awareness and stimulate the participation of the DCs in the telemedicine and health care telematics projects through demonstrations, pilot projects, Workshops, training and exchange activities. This will demonstrate the feasibility of telemedicine services in the DCs, including trial of services in real-life circumstances, and will provide training possibilities for researchers in the use of methods and tools for advanced communication technologies and telematics. Undoubtedly, telediagnosis, teleconsultation and other areas of telemedicine would thrive in Africa both as remote testing grounds and fields of practical applications.
Health-Care Technology Transfer: Expert and Information Systems for Developing Countries
Authors: Kahen G. , Sayers B. McA.
Published: March 2018

Computer-based technologies such as information systems and expert systems have an undoubted contribution to health-care development in developing countries. This paper addresses the appropriateness of these technologies for developing countries, the criteria to be used in selection of the technology to be transferred, and the need for a systematic approach to evaluation. A conceptual model for assessing transferability so as to achieve an effective transfer, has been introduced. This requires not only an attempt to amplify the role of information and expert systems in health-care improvement and for socio-economic development, but the analysis of prior experience in transferring these technologies to developing countries. Following this approach, and using operational research techniques such as the Analytic Hierarchy Process, a subjective assessment model has been described that can systematically guide decision-making about computer-based health-care technology to be transferred to developing countries.
Role of an Effective Hospital Information System in a Depressed Economy
Authors: Olabode J. A. , Osunlaja A. A.
Published: March 2018

This work is based on practical experience acquired in the development of a hospital information system in a university hospital in Nigeria. The paper discusses how accurate, adequate and timely medical data can promote economy in health-care delivery in a depressed economy. Existing constraints are identified and solutions offered for an effective hospital information system. An effort has been made to illustrate how the application of informatics technology can be cost effective in the long-term, by ensuring effective and economic use of facilities and resources. Once an effective hospital information is operative, provision of affordable health care in a depressed economy would be feasible. To this end, the need for cooperation between countries to support technology and manpower is emphasized.
Cluster Analysis of Antigenic Profiles of Tumors: Selection of Number of Clusters Using Akaike’s Information Criterion
Authors: Koziol J. A.
Published: March 2018

A basic problem of cluster analysis is the determination or selection of the number of clusters evinced in any set of data. We address this issue with multinomial data using Akaike’s information criterion and demonstrate its utility in identifying an appropriate number of clusters of tumor types with similar profiles of cell surface antigens.
Classification Methods for Computerized Interpretation of the Electrocardiogram
Authors: Kors J. A. , van Bemmel J. H.
Published: March 2018

Two methods for diagnostic classification of the electrocardiogram are described: a heuristic one and a statistical one. In the heuristic approach, the cardiologist provides the knowledge to construct a classifier, usually a decision tree. In the statistical approach, probability densities of diagnostic features are estimated from a learning set of ECGs and multivariate techniques are used to attain diagnostic classification. The relative merits of both approaches with respect to criteria selection, comprehensibility, flexibility, combined diseases, and performance are described. Optimization of heuristic classifiers is discussed. It is concluded that heuristic classifiers are more comprehensible than statistical ones; encounter less difficulties in dealing with combined categories; are flexible in the sense that new categories may readily be added or that existing ones may be refined stepwise. Statistical classifiers, on the other hand, are more easily adapted to another operating environment and require less involvement of cardiologists. Further research is needed to establish differences in performance between both methods. In relation to performance testing the issue is raised whether the ECG should be classified using as much prior information as possible, or whether it should be classified on itself, explicitly discarding information other than age and sex, while only afterwards other information will be used to reach a final diagnosis. Consequences of taking one of both positions are discussed.
Common Standards for Quantitative Electrocardiography: Goals and Main Results
Authors: Arnaud P. , van Bemmel J. H. , Degani R. , Macfarlane P. W. , Zywietz Chr. , Willems J. L. ,   for the CSE Working Party
Published: March 2018

Computer processing of electrocardiograms (ECGs) has over the last 15 years increased rapidly. Still, there are at present no standards for computer ECG interpretation. Different techniques are used not only for measurement and interpretation, but also for transmission and storage of data. In order to fill these gaps, a large international project, sponsored by the European Commission, was launched in 1980 to develop “Common Standards for Quantitative Electrocardiography (CSE)”. The main objective of the first CSE study was to reduce the wide variation in wave measurements currently obtained by ECG computer programs. The second study was started in 1985 and aimed at the assessment and improvement of diagnostic classification of ECG interpretation programs. To this end reference libraries of well documented ECGs have been developed and comprehensive reviewing schemes devised for the visual and computer analysis of ECGs. This task was performed by a board of cardiologists in a Delphi review process, and by 9 VCG and 10 standard 12-lead programs developed by university research groups and by industry. A third action was started in June 1989 to harmonize acquisition, encoding, interchange and storing of digital ECG data. The action thus performed have become internationally recognized milestones for the standardization of quantitative electrocardiography.
Evaluation of ECG Interpretation Results Obtained by Computer and Cardiologists
Authors: Abreu-Lima C. , Arnaud P. , Brohet C. R. , Denis B. , Gehring J. , Graham I. , van Herpen G. , Machado H. , Michaelis J. , Moulopoulos S. D. , Willems J. L.
Published: March 2018

In an international project investigators from 25 institutes are trying to establish a common reference library and evaluation methods for testing the diagnostic performance of various ECG computer programs and of cardiologists, based on ECG-independent clinical information. A first set of 500 validated ECGs was collected and analyzed by fifteen different computer programs and nine cardiologists, seven of who analysed the ECG and five the VCG. A coding scheme was used to map individual diagnostic statements onto a common set. Combined program and referee results were obtained by weighted averaging. Preliminary results indicate that the classification accuracy of several programs can still be improved. However, it was also apparent that the results of the best 12-lead ECG computer programs proved to be almost as accurate as the best of seven cardiologists in classifying seven main disease categories, i.e., normal, left, right and biventricular hypertrophy, anterior, inferior and combined myocardial infarction. Evaluation of rhythm statements and conduction disturbances was not included in the study. The data collection is still being pursued in order to reach over 1,000 cases. In this way a common diagnostic database is being established for comparative testing of diagnostic computer programs. This should lead to consumer protection and improve the accuracy and reliability of computerized electrocardiography.
Evaluation of ECG Interpretation Systems: Signal Analysis
Authors: Zywietz Chr. , van Bemmel J. H. , Degani R.
Published: March 2018

Performance analysis of biosignal processing systems which provide diagnostic statements requires particular care. Besides general accuracy requirements, psychological and legal implications for patient and physician have to be considered on both the development and the user sites. Cybernetics and control engineering have provided the basic methodology for performance analysis of systems: in technical systems often mathematically defined functions and signals can be fed into the system to be tested and its response and output provide the necessary performance characteristics after adequate mathematical analysis. For systems which process biosignals, as for example ECG analysis systems, instead of analytically given signals learning and test sets of data derived from patients have to be applied. The performance analysis is done on a statistical basis. In this paper construction and composition of learning and test data sets as well as methods for performance evaluation of the signal pocessing part of ECG programs are described. Specific reference is made to the European project Common Standards for Quantitative Electrocardiography (CSE) where ten ECG- and nine VCG-programs have been tested. The results of these tests provide reference data and standards for further program development as well as for independent system performance evaluation.
Methodology of ECG Interpretation in the AVA Program
Authors: Pipberger H. A. , Pipberger H. V. , McManus C. D.
Published: March 2018

The AVA program combines a thirty-year history with an approach that remains innovative; namely: multivariate statistical analysis on orthogonal ECG leads. Its diagnostic reference base includes only diagnoses independently verified by non-ECG criteria. The diagnostic module assesses probabilities of nine alternative disease categories, based on QRS-T parameters; or four other categories in case of conduction defects. Probabilities of left or right atrial overload are also computed. The program also recognizes wall injury, T-wave abnormalities, electrolyte disturbances, myocardial ischemia, and makes differential diagnoses between strain and digitalis effects. An arrhythmia classification module can generate any of 40 rhythm statements. Signal recognition is based on the spatial velocity function. The program has been translated to a microcomputer version.
Methodology of ECG Interpretation in the Dalhousie Program; NOVACODE ECG Classification Procedures for Clinical Trials and Population Health Surveys
Authors: Rautaharju P. M. , MacInnis P. J. , Warren J. W. , Wolf H. K. , Rykers P. M. , Calhoun H. P.
Published: March 2018

The Dalhousie ECG Program was designed specifically for the needs of epidemiologic studies, health surveys, and clinical trials. The program logic is dynamic in that it can accommodate any combination of ECG leads, record length and sampling rate. The NOVACODE module of the program classifies ECGs according to the Minnesota Code, supplemented with new sets of logic criteria for conduction defects, acute myocardial infarction, and serial ECG changes. Improved statistical models are incorporated for enhanced detection of myocardial infarction using the Cardiac Infarction Injury Score, and for quantification of left ventricular mass estimation. It is anticipated that these program improvements will enhance its utility particularly in monitoring progression and regression of cardiac involvement in hypertensive and ischemic heart disease, and in the assessment of the effectiveness of intervention on cardiovascular disease risk factors.
Methodology of ECG Interpretation in the Hannover Program
Authors: Borovsky D. , Gotsch G. , Joseph G. , Zywietz Chr.
Published: March 2018

The Hannover ECG program HES has been designed for measurement and interpretation of resting and (moderate) exercise electrocardiograms. In the signal analysis part the program follows an averaging strategy. For diagnostic classification a hybrid model with decision trees and scoring algorithms, and with multivariate probabilistic tests for derivation of category A statements is applied. The multivariate classification technique allows to adjust sensitivity and specificity for specific application areas without changing the diagnostic criteria.
Methodology of ECG Interpretation in the Lyon Program
Authors: Morlet D. , Fayn J. , Forlini M.C. , Arnaud P. , Rubel P.
Published: March 2018

To provide an in-depth interpretation of the spatial QRS-T contour, we established a set of vectorcardiographic parameters computed octant by octant. For each statement the criteria constitute a model which is closely related to pathophysiological patterns. The diagnostic strategy is of the heuristic type. For each diagnosis a table lists several criteria providing both specific and differential diagnostic information. Inter-table competition is handled by specific logic. The program classifies diagnoses according to the number of non-satisfied criteria. Three versions are available including 124,51 and 7 diagnoses, respectively. The first, intended for interpretation of complex situations, has given satisfactory results in such situations. Rhythm analysis is performed from 8-second recordings.

All functions - acquisition, quality control, choice of a dominant complex, wave recognition, parameter extraction, interpretation, editing, storage -are integrated into a mobile cart. A complementary program performs serial analysis of successive tracings. It highlights with great precision morphological changes in the spatial loops and interval variations.
Methodology of the Modular ECG Analysis System MEANS
Authors: van Herpen G. , van Bemmel J. H. , Kors J. A.
Published: March 2018

The methodology, used in the Modular ECG Analysis System (MEANS) is described. MEANS consists of modules for signal analysis and diagnostic classification. The basic structure of the modular interpretation system remained intact over a period of 20 years, while all modules underwent many changes as a function of experience and insight, and the continuously changing information technology. The article describes the advantages of a modular approach to decision-support systems, the most important ones being easier maintenance of the software package and separate optimization and testing of each module. The overall evaluation of MEANS was done in the CSE study. Evaluation results for modules and for the entire system are presented.
Reference Standards for Software Evaluation
Authors: Wellek S. , Willems J. L. , Michaelis J.
Published: March 2018

The field of automated ECG analysis was one of the earliest topics in Medical Informatics and may be regarded as a model both for computer-assisted medical diagnosis and for evaluating medical diagnostic programs. The CSE project has set reference standards of two kinds: In a broad sense, a standard how to perform a comprehensive evaluation study, in a narrow sense, standards as specific references for evaluating computer ECG programs. The evaluation methodology used within the CSE project is described as a basis for presentation of results which are published elsewhere in this issue.
Value of Scatter-Graphs for the Assessment of ECG Computer Measurement Results
Authors: Rubel P. , Willems J. L. , Morlet D.
Published: March 2018

A new method is presented, different from usual methods, for the discussion of the results of computer ECG measurement programs, based on a new graphical evaluation method. The proposed “scatter-graphs” both highlight the main program results and facilitate the comparison between various wave-recognition algorithms. They allow the distinction between the reliability of an algorithm, which is its capacity to provide a maximum of measurements with a minimum amount of errors, and its precision, i.e., the standard deviation of the differences between its point estimates and the reference.

The method proves to be a powerful tool for the discussion of individual, as well as the median program results in CSE Measurement Study. It allows to highlight limitations induced in performance assessment by the variability of the reference itself, and to state that the median program is at least as close to the “Gold Standard” as the median of the referees.
Toward Normative Expert Systems: Part II Probability-Based Representations for Efficient Knowledge Acquisition and Inference
Authors: Heckerman E. D. , Nathwani N. B.
Published: March 2018

We address practical issues concerning the construction and use of decision-theoretic or normative expert systems for diagnosis. In particular, we examine Pathfinder, a normative expert system that assists surgical pathologists with the diagnosis of lymph-node diseases, and discuss the representation of dependencies among pieces of evidence within this system. We describe the belief network, a graphical representation of probabilistic dependencies. We see how Pathfinder uses a belief network to construct differential diagnosis efficiently, even when there are dependencies among pieces of evidence. In addition, we introduce an extension of the belief-network representation called a similarity network, a tool for constructing large and complex belief networks. The representation allows a user to construct independent belief networks for subsets of a given domain. A valid belief network for the entire domain can then be constructed from the individual belief networks. We also introduce the partition, a graphical representation that facilitates the assessment of probabilities associated with a belief network. We show that the similarity-network and partition representations made practical the construction of Pathfinder.
Use of Two Online Services as Drug Information Sources for Health Professionals
Authors: Shumwayb J. M. , Jacknowitzc A. I. , Abatea M. A.
Published: March 2018

The utility of the online computer services BRS Colleague and Dialog Medical Connection, when used primarily as drug information sources by physicians, nurses, and pharmacists and attitudes toward their use, are described. Study sites included office-based medical practices, a university clinic family medicine group, and a university clinical pharmacy department. Participants had access to either of the computer services during two 9½-month periods. All searches were automatically recorded and analyzed. A total of 1,112 search sessions were conducted (78% by pharmacists, 16% by nurses, 6% by physicians) by 38 of 65 participants. Information which completely answered questions was found for slightly less than one-third of searches. Errors occurred in about 81% of searches which retrieved incomplete information. Lack of time was a major factor which limited use of the services, and infrequent users felt that the services did not fit in well with their daily work routine.
Graphical Access to Medical Expert Systems: V. Integration with Continuous-Speech Recognition
Authors: Wulfman C. E. , Rua M. , Lane C. D. , Shortliffe E. H. , Fagan L. M.
Published: March 2018

This paper describes three prototypes of computer-based clinical record-keeping tools that use a combination of window-based graphics and continuous speech in their user interfaces. Although many of today’s commercial speech-recognition products achieve high rates of accuracy for large grammars (vocabularies of words or collections of sentences and phrases), they can only “listen for” (and therefore recognize) a limited number of words or phrases at a time. When a speech application requires a grammar whose size exceeds a speech-recognition product’s limits, the application designer must partition the large grammar into several smaller ones and develop control mechanisms that permit users to select the grammar that contains the words or phrases they wish to utter. Furthermore, the user interfaces they design must provide feedback mechanisms that show users the scope of the selected grammars. The three prototypes described were designed to explore the use of window-based graphics as control and feedback mechanisms for continuous-speech recognition in medical applications. Our experiments indicate that window-based graphics can be effectively used to provide control and feedback for certain classes of speech applications, but they suggest that the techniques we describe will not suffice for applications whose grammars are very complex.
MultiLink – An Intermediary System for Multi-Database Access
Authors: Wu G. , Åhlfeldt H. , Wigertz O.
Published: March 2018

The design and implementation is described of MultiLink, a desktop system for direct enduser access to remote bibliographic information. The system is an application of a client-server technique based on a campuswide network, with the objective to assist end-users to accomplish the information — retrieval process by capturing knowledge and expertise for searches in query formulations. MultiLink, via intelligent interfaces, allows users to access several dozens of bibliographic databases. The application integrates regional, national and international resources, and brings library services to the user’s desktop level.
Architectures for Architects
Authors: Musen M. A.
Published: March 2018

Response to Heathfield HA, Wyatt J. Philosophies for the design and development of clinical decision-support systems. Meth Inform Med 1993; 32: 1-8.
Experience from Computer-Based Patient Records for Computer-Assisted Decision Making
Authors: van der Lei J.
Published: March 2018

Response to Heathfield HA, Wyatt J. Philosophies for the design and development of clinical decision-support systems. Meth Inform Med 1993; 32: 1-8.
Evaluating Consensus Among Physicians in Medical Knowledge Base Construction
Authors: Giuse D. A. , MMer R. A. , Bankowitz R. A. , Janosky J. E. , Davidoff F. , Hillner B. E. , Hripcsak G. , Lincoln M. J. , Middleton B. , Peden J. G. , Giuse N. B.
Published: March 2018

This study evaluates inter-author variability in knowledge base construction. Seven board-certified internists independently profiled “acute perinephric abscess”, using as reference material a set of 109 peer-reviewed articles. Each participant created a list of findings associated with the disease, estimated the predictive value and sensitivity of each finding, and assessed the pertinence of each article for making each judgment. Agreement in finding selection was significantly different from chance: seven, six, and five participants selected the same finding 78.6, 9.8, and 1.6 times more often than predicted by chance. Findings with the highest sensitivity were most likely to be included by all participants. The selection of supporting evidence from the medical literature was significantly related to each physician’s agreement with the majority. The study shows that, with appropriate guidance, physicians can reproducibly extract information from the medical literature, and thus established a foundation for multi-author knowledge base construction.
A Modular Knowledge Base for the Follow-Up of Clinical Protocols
Authors: Otero R. P. , Marín R. , Mira J. , Barreiro A.
Published: March 2018

From the knowledge engineering point of view, the observation of patients subjected to clinical protocols of therapy constitutes a domain characterized by the existence of strongly structured knowledge. We have approached the problem from the perspective of a homogeneous and modular knowledge representation theory, based on the concept of Generalized Magnitude. This concept arises from identifying and collecting all possible facts of a domain established a priori, and being inspired by the concept of physical magnitudes. The Generalized Magnitudes scheme includes temporal extensions necessary to solve a medical problem for which exists a therapy and a follow-up plan with temporal specifications, and also facilitates the creation of advisory expert systems.
Influence of “Outliers” on the Association between Laboratory Data and Histopathological Findings in Liver Biopsy
Authors: Krusinska E. , Mathiesen U. L. , Franzén L. , Bodemar G. , Wigertz O.
Published: March 2018

Discriminant analysis techniques were used to predict the histopathological findings in liver biopsy specimens in asymptomatic patients with slightly to moderately raised routine liver tests. Moderate to severe fibrosis and/or inflammation were treated as indication for biopsy. Two methods were used to classify patients. One was the dichotomous discrimination between “biopsy necessary” or “biopsy not necessary” groups of patients. The other involved combining two discriminant functions trained separately for recognition of fibrosis or inflammation, and then combined to predict the biopsy necessity. Detection of outliers by standard techniques, directly available in the SPSS-X package, was performed before starting discrimination procedures. Both “sharp” assignment rules and continuous scoring rules were applied to the classification problem. The correct classification rate reached over 85% for the algorithms tested. In the majority of cases the classification was found to be “non-doubtful”. Elimination of outliers (especially by standardized residuals) improved the global correct classification rate, but only slightly improved assignment to the “biopsy necessary” group. Routine and complementary laboratory findings were found to be the most discriminating; answers to questionnaire and ultrasound examination were less important. Selection of the most diagnostic features based on “clean” data without outliers enabled us to find interesting medical associations, which were previously masked by extremely asymptomatic values outlying from the main body of the “biopsy necessary” group.
User Evaluation of an Integrated Medical Workstation for Clinical Data Analysis
Authors: Timmeis T. , van Bemmel J. H. , van Mulligen E. M.
Published: March 2018

Results are presented of the user evaluation of an integrated medical workstation for support of clinical research. Twenty-seven users were recruited from medical and scientific staff of the University Hospital Dijkzigt, the Faculty of Medicine of the Erasmus University Rotterdam, and from other Dutch medical institutions; and all were given a written, self-contained tutorial. Subsequently, an experiment was done in which six clinical data analysis problems had to be solved and an evaluation form was filled out. The aim of this user evaluation was to obtain insight in the benefits of integration for support of clinical data analysis for clinicians and biomedical researchers. The problems were divided into two sets, with gradually more complex problems. In the first set users were guided in a stepwise fashion to solve the problems. In the second set each stepwise problem had an open counterpart. During the evaluation, the workstation continuously recorded the user’s actions. From these results significant differences became apparent between clinicians and non-clinicians for the correctness (means 54% and 81%, respectively, p = 0.04), completeness (means 64% and 88%, respectively, p = 0.01), and number of problems solved (means 67% and 90%, respectively, p = 0.02). These differences were absent for the stepwise problems. Physicians tend to skip more problems than biomedical researchers. No statistically significant differences were found between users with and without clinical data analysis experience, for correctness (means 74% and 72%, respectively, p = 0.95), and completeness (means 82% and 79%, respectively, p = 0.40). It appeared that various clinical research problems can be solved easily with support of the workstation; the results of this experiment can be used as guidance for the development of the successor of this prototype workstation and serve as a reference for the assessment of next versions.
Health Information, the Fair Information Principles and Ethics
Authors: Kluge E.-H.W.
Published: March 2018

If advanced electronic patient records are construed as epistemic patient analogues in information space, then the traditional property-model of patient records is longer appropriate. A new paradigm is required. This paper suggests a new paradigm, examines its ethical implications and explores ways in which these could be reflected in legal and regulatory mechanisms. Special attention is paid to privacy, security and access relative to the so-called “fair information principles”.
Computerized Databases for Emergency Care: What Impact on Patient Care?
Authors: Pugh G. E. , Tan J. K. H.
Published: March 2018

A field-based evaluation is conducted of a Clinical Computerized Information System (CCIS™). Following training, the use of the CCIS™ database, word processing and other programs by thirteen full-time practicing emergency physicians in two urban emergency departments of a University-associated teaching hospital was studied over a one-year period. A tracking program automatically logged frequency and duration of use by the physicians, and user satisfaction was assessed by a reliable and validated questionnaire instrument. Based on utilization data and verbal reports of these physicians, CCIS™ database searching was not only found to be easy-to-leam but was readily accessible during emergency shifts. Individual physicians were found to perform an average of 3.5 searches per month lasting a mean search time of 8 min. Positive notes about the CCIS™ system included ease-of-use, accuracy of data, accessibility of system, and value of output while negative perceptions included a lack of integration with other systems, a lack of system completeness, and a high subscription cost. It was suggested that a less costly telephone link to a high-volume Centre would be desirable in actual implementation of the system.
Terminology of the Thalamus and its Representation in a Part-Whole Relation
Authors: Axer H. , Niemann K.
Published: March 2018

In stereotaxic neurosurgery, a variety of operative procedures focus on thalamic targets. The nomenclature of thalamic nuclei and sub-nuclei, however, has not yet been settled. In clinical and laboratory environments several terminologies coexist. This is an obstacle to both communication and a better understanding of recent electrophysiological findings. In the late 1980s, the application of new histochemical and immunohisto-chemical methods led to a deeper insight into existing correlations between the nomenclatures. As a uniform terminology of the thalamus is still lacking, we created a knowledge-based system (thalamus) which gives a comprehensible survey about the most important terminologies. The different nomenclatures are related to each other by organizing them in a component-integral relation. This part-whole relation contains both the knowledge on the subdivisions of the thalamus as well as the knowledge on the correlations between the various nomenclatures.
Therapie und Monitoring neuromuskulärer Repeat-Erkrankungen
Authors: Schneider-Gold C. , Petri S.
Published: March 2018

Repeat-Erkrankungen sind hereditäre durch pathologische Expansionen sich wiederholender Triplettoder Multiplett-DNA-Sequenzen (Repeats) hervorgerufene, in der Regel multisystemische Erkrankungen. Bevorzugt das neuromuskuläre System betreffen die myotonen Dystrophien Typ 1 und 2 (DM 1, 2), die okulopharyngeale Muskeldystrophie (OPMD), die spinobulbäre Muskelatrophie (SBMA, auch Kennedy-Syndrom) und eine Form der ALS, die durch Repeat-Expansionen im C9ORF72-Gen verursacht wird. Zunehmendes Verständnis der molekularen Pathogenese dieser Erkrankungen bildet die Grundlage für neue kausale Therapiestrategien, die sich überwiegend noch im präklinischen Stadium befinden oder in ersten klinischen Studien getestet werden. Das Monitoring und die Therapie von neurologischen und internistischen Symptomen (wie respiratorischer Insuffizienz oder kardialer Mitbeteiligung) erfordert eine interdisziplinäre Betreuung.
Mitochondriale Erkrankungen
Authors: Büchner B. , Kornblum C. , Klopstock T.
Published: March 2018

Mit einer Gesamtprävalenz von 1:5 000 zählen mitochondriale Erkrankungen zu den häufigsten hereditären Stoffwechselerkrankungen. In den letzten Jahren kam es zu enormen Fortschritten in der Diagnostik und im Verständnis der molekularen Mechanismen bei diesen Krankheitsbildern. Die Entwicklung ursächlicher Therapieansätze war demgegenüber lange unbefriedigend, hat aber deutlich an Dynamik gewonnen. Mit Idebenone bei Leberscher hereditärer Optikusneuropathie (LHON) ist seit 2015 das erste Medikament zur Behandlung einer mitochondrialen Erkrankung zugelassen. Zahlreiche weitere therapeutische Ansätze befinden sich in der fortgeschrittenen klinischen Entwicklung, darunter auch eine Gentherapie für LHON. Das deutsche Netzwerk für mitochondriale Erkrankungen (mitoNET) trägt mit seinen Strukturen erheblich zu diesen Fortschritten in der mitochondrialen Medizin bei.
Neues zur Amyotrophen Lateralsklerose
Authors: Dorst J. , Ludolph A. C.
Published: March 2018

Auch wenn die Therapieoptionen der Amyotrophen Lateralsklerose (ALS) nach wie vor unbefriedigend sind und Riluzol das einzige Medikament ist, das den Krankheitsverlauf beeinflusst, so gibt es doch vielfältige neue Forschungsergebnisse hinsichtlich Genetik, Biomarkern und Pathogenese, welche auf die Entwicklung neuer Therapieansätze hoffen lassen. Zudem gibt es Fortschritte auf dem Gebiet der symptomatischen Therapie. In diesem Artikel sollen die wichtigsten Erkenntnisse der ALS-Forschung der vergangenen Jahre zusammengefasst werden.
The Measurement of Performance in Probabilistic Diagnosis IV. Utility Considerations in Therapeutics and Prognostics
Authors: Habbema J. D. F. , Hilden J.
Published: March 2018

It is argued that it is preferable to evaluate probabilistic diagnosis systems in terms of utility (patient benefit) or loss (negative benefit). We have adopted the provisional strategy of scoring performance as if the system were the actual decision-maker (not just an aid to him) and argue that a rational figure of merit is given by the average loss which patients would incur by having the system decide on treatment, the treatment being selected according to the minimum expected loss principle of decision theory.

A similar approach is taken to the problem of evaluating probabilistic prognoses, but the fundamental differences between treatment selection skill and prognostic skill and their implications for the assessment of such skills are stressed. The necessary elements of decision theory are explained by means of simple examples mainly taken from the acute abdomen, and the proposed evaluation tools are applied to Acute Abdominal Pain data analysed in our previous papers by other (not decision-theoretic) means. The main difficulty of the decision theory approach, viz. that of obtaining good medical utility values upon which the analysis can be based, receives due attention, and the evaluation approach is extended to cover more realistic situations in which utility or loss values vary from patient to patient.
GENDIAG: A Computer-assisted Facility in Medical Genetics Based on Belief Functions
Authors: Gouvernet J. , Caraboeuf M. , Ayme S.
Published: March 2018

The method is based on a diagnosis data base, each diagnosis being identified by a list of signs indexed by à rough estimation of their relative frequency. Signs are terms of a tree-structured thesaurus, the relationship child – father being equivalent to implication. Furthermore, any sign is weighted according to the possibility of it being a variant characteristic rather than a pathological one. The patient’s description being provided, the credibility of each diagnosis is computed according to Glenn Shafer’s theory of belief functions, and the most plausible diagnoses are proposed for the clinician’s choice. The results obtained during a validation phase were satisfying so that we have been routinely using the model for assistance in diagnosing uncommon genetic syndromes observed in our hospital or submitted by other centers.
Computer Image Analysis of the Ocular Fundus
Authors: Pe’er J. , Zajicek G.
Published: March 2018

Photographic transparencies of the ocular fundus were scanned with an image dissector under computer control. The image is digitized into 400 X 400 points each exhibiting 256 gray level values. During analysis, the computer stores in its buffer only five consecutive lines upon which image processing is performed; only then is the first line projected on the scope and the following line (the sixth in the original image) introduced into the buffer. In this setup, digitization may be manipulated on-line in real time.
A Computer-Based I.V. Admixture System
Authors: Pope R. A. , Mattson Carmen , Janousek J. P. , Slack W. V.
Published: March 2018

A computer-based i. v. admixture program, which forms part of a general hospital information system, has simplified Beth Israel Hospital pharmacy functions and information processing and allowed the pharmacy to increase output without hiring additional employees. It minimizes clerical functions, incorporates new and discontinued orders into the work flow, sorts medications for batch preparation, provides billing information, and allows interactive retrieval of prescriptions and related clinical data.
The Reliability of Medical History and Physical Examination in Patients with Acute Abdominal Pain
Authors: Brynitz S. , Bjerregaard B. , Holst-Christensen J. , Jess P. , Kalaja Eeva , Lund-Kristensen J. , Thomsen C.
Published: March 2018

The reliability of medical record information is of fundamental importance to the certainty with which a diagnosis can be made. 40 patients were chosen at random and each was examined by four clinicians. The information and a tentative diagnosis were written on a special record form. The results were judged by means of the coefficient kappa. The clinicians disagreed more on symptoms than on diagnoses. The diagnoses made by an automatic diagnosis system showed lower precision and lower accuracy than the clinicians’ diagnoses. The results of the study might explain why computer assistance in diagnostics is of limited value.
Staging Cancer: TNM Literature 1963—1982
Authors: Wagner G. , Posner G. , Wolf T.
Published: March 2018

The prognosis of a malignant tumour largely depends on the stage of the disease at the beginning of a specific therapy; statistics of therapy are comparable only if they show the distribution of the cases to the different stages of the disease. Aiming to improve the comparability of the data and findings acquired from the cancer patient, the UICC has, for more than 30 years, been endeavouring to develop uniform rules for acquiring the stage of the disease and the degree of spread with malignant tumours. For this purpose, UICC has developed the TNM system which makes it possible to state accurately and in a reproduceable form the stage of the primary tumour (T) and the regional lymphatic nodes (N) as well as the possible existence of metastases (M). The third edition of the TNM rules appeared in English in 1978, in the following years in numerous other languages. Today the TNM system represents the only basis for the documentation of the cancer stage which has been introduced worldwide. However, it is by no means »complete«; for some forms of cancer proposals for TNM classification are still outstanding (e.g., tumours of the pancreas, the central nervous system, the bones and the soft tissues). Moreover, malignant lymphomas cannot be classified according to the principles of TNM. Here the so-called »Ann Arbor Classification« from the year 1971 is recommended.

The UICC has called upon its national committees to check the classification proposals available so far as to their usefulness and practicability. Corresponding field studies are under way in several countries. This bibliography covers a section of the TNM literature of the last 20 years. From a total number of about 2,000 publications, applying the TNM system, we selected 300 which discuss the system critically and, in most instances, make suggestions for its improvement. The first part of the bibliography contains an alphabetically arranged list of the titles according to authors’ names; the second part differentiates the tumors dealt with by their site.

We thank Mrs. L. Blumenthal, Mrs. I. Schäfer and Mrs. U. Wolber for their cooperation in setting up this bibliography.