Mario Stefanelli

A telemedicine support for diabetes management: the T-IDDM project

In the context of the EU funded Telematic Management of Insulin-Dependent Diabetes Mellitus (T-IDDM) project, we have designed, developed and evaluated a telemedicine system for insulin dependent diabetic patients management. The system relies on the integration of two modules, a Patient Unit (PU) and a Medical Unit (MU), able to communicate over the Internet and the Public Switched Telephone Network. Using the PU, patients are allowed to automatically download their monitoring data from the blood glucose monitoring device, and to send them to the hospital data-base; moreover, they are supported in their every day self monitoring activity. The MU provides physicians with a set of tools for data visualization, data analysis and decision support, and allows them to send messages and/or therapeutic advice to the patients. The T-IDDM service has been evaluated through the application of a formal methodology, and has been used by European patients and physicians for about 18 months. The results obtained during the project demonstration, even if obtained on a pilot study of 12 subjects, show the feasibility of the T-IDDM telemedicine service, and seem to substantiate the hypothesis that the use of the system could present an advantage in the management of insulin dependent diabetic patients, by improving communications and, potentially, clinical outcomes.

Web-based telemedicine systems for home-care: technical issues and experiences

The use of the Web for telemedicine applications seems nowadays a compulsory solution: the Web has become a standardized infrastructure for giving access to sophisticated telemedicine applications from virtually any machine and operating system. Such standardized communication platform guarantees accessibility and usability advantages to both customers and providers (patients and physicians). However, there are several issues that should be discussed in depth, with particular reference to all the applications related to the provision of care at distance, nowadays called telecare applications. In telecare applications the role of the patient becomes central, since he/she is actively involved in the process of managing care and treatments, and since he/she (or his/her families) is responsible for collecting some measurements and related information. In this paper we will discuss the general architectural and technical issues related to the development of Web-based systems for telecare applications, relying on the experience we gained within the telecare project T-IDDM (Telematic Management of Insulin Dependent Diabetes Mellitus), devoted to assist the management and home-monitoring of Type 1 Diabetes Mellitus patients.

An epistemological framework for medical knowledge-based systems

An abstraction paradigm for unifying different perspectives concerning the analysis and design of knowledge-based systems (KBSs) is presented. The model accounts for all of the conceptual features of knowledge-based systems, thus making clear which features are intrinsic to the problem and which are artifacts of the implementation. The proposal is based on a two-level analysis of knowledge-based systems: an epistemological and a computational level. At the first level, ontology and inference models of a knowledge-based system are defined. At the computational level, methods and formalisms are adopted after the epistemological analysis has been carried out. The study is confined to medicine with three generic tasks identified: diagnosis, therapy planning, and monitoring. The results of this analysis indicate that the generic tasks manage different ontologies, but can be executed exploiting a unique inference model. Computational issues are discussed to argue that the model provides a conceptual view on existing systems and some design insights for future ones. >

A framework for building cooperative software agents in medical applications

Exploiting the information technology may have a great impact on improving cooperation and interoperability among the different professionals taking part to the process of delivering health care services. New paradigms are therefore being devised considering software systems as autonomous agents able to help professionals in accomplishing their duties. To this aim those systems should encapsulate the skills for solving a given set of tasks and possess the social ability to cooperate in order to fetch the required information and knowledge. This paper illustrates a methodology facilitating the development of interoperable intelligent software agents for medical applications and proposes a generic computational model for implementing them. That model may be specialized in order to support all the different information and knowledge related requirements of a Hospital Information System. The architecture is being tested for implementing a prototype system able to coordinate the joint efforts of the professionals involved in managing patients affected by Acute Myeloid Leukemia.

Maternal Oct-4 is a potential key regulator of the developmental competence of mouse oocytes

BackgroundThe maternal contribution of transcripts and proteins supplied to the zygote is crucial for the progression from a gametic to an embryonic control of preimplantation development. Here we compared the transcriptional profiles of two types of mouse MII oocytes, one which is developmentally competent (MIISN oocyte), the other that ceases development at the 2-cell stage (MIINSN oocyte), with the aim of identifying genes and gene expression networks whose misregulated expression would contribute to a reduced developmental competence.ResultsWe report that: 1) the transcription factor Oct-4 is absent in MIINSN oocytes, accounting for 2) the down-regulation of Stella, a maternal-effect factor required for the oocyte-to-embryo transition and of which Oct-4 is a positive regulator; 3) eighteen Oct-4-regulated genes are up-regulated in MIINSN oocytes and are part of gene expression networks implicated in the activation of adverse biochemical pathways such as oxidative phosphorylation, mitochondrial dysfunction and apoptosis.ConclusionThe down-regulation of Oct-4 plays a crucial function in a sequence of molecular processes that leads to the developmental arrest of MIINSN oocytes. The use of a model study in which the MII oocyte ceases development consistently at the 2-cell stage has allowed to attribute a role to the maternal Oct-4 that has never been described before. Oct-4 emerges as a key regulator of the molecular events that govern the establishment of the developmental competence of mouse oocytes.

M-HTP: A system for monitoring heart transplant patients

A computer-based assistant for monitoring a patients clinical course requires the use of tools able to handle temporal issues. Thus, methodologies coming from two historically distinct worlds need to be combined: the traditional world of Data Base Management Systems (DBMS) and the world of Knowledge-Based Systems (KBS). This paper describes an intelligent system designed to assist the clinical staff in the management of a monitoring protocol for infections in heart transplant recipients. The system consists of a DBMS designed for the management of patient clinical data and of a KBS which is capable of reasoning about the large amount of data and embodied in a temporal model based on time-points and intervals. Moreover, the system aims at providing a synthetic view of a patients clinical history and some diagnostic and therapeutic suggestions. The KBS retrieves findings stored in the data base and creates a complex taxonomy of objects representing a Temporal Network of important events and episodes noted in the patient history; then, from this temporal representation, it develops its reasoning based on medical knowledge represented using frames and production rules. The system is implemented on a Fourth Generation System tool (4GS) and a KBS shell, both running on an IBM PC AT compatible platform.

Quantitative evaluation of erythropoietic activity in dysmyelopoietic syndromes

Summary. Based on the morphological appearances of the bone marrow and peripheral blood, 43 patients with dysmyelopoietic syndromes were categorized into four types: refractory anaemia with excess of blasts, chronic myelomonocytic leukaemia, primary acquired sideroblastic anaemia and refractory anaemia with cellular marrow, without excess of blasts and/or ring sideroblasts. Ferrokinetics allowed three distinct groups of patients to be defined. All cases of refractory anaemia with excess of blasts and chronic myelomonocytic leukaemia were classified in the same group. They were characterized by relative marrow failure and had a high likelihood of developing acute leukaemia. At the other end of the spectrum, individuals with primary acquired sideroblastic anaemia had high erythropoietic activity which was largely ineffective. They had a benign clinical course without evidence of leukaemic transformation. In the middle group, in terms of erythropoietic activity, lay patients with refractory anaemia with cellular marrow and a few individuals with primary acquired sideroblastic anaemia. Their clinical course and risk of developing acute leukaemia were intermediate between the other two groups. These findings indicate that separate entities may exist within the spectrum of dysmyelopoietic syndromes. In clinical practice, they may be recognized by morphological studies and other simple laboratory means.

The socio-organizational age of artificial intelligence in medicine

The increasing pressure on Health Care Organizations (HCOs) to ensure efficiency and cost-effectiveness, balancing quality of care and cost containment, will drive them towards a more effective management of medical knowledge derived from research findings. The relation between science and health services has until recently been too casual. The primary job of medical research has been to understand the mechanisms of disease and produce new treatments, not to worry about the effectiveness of the new treatments or their implementation. As a result many new treatments have taken years to become part of routine practice, ineffective treatments have been widely used, and medicine has been opinion rather than evidence based. This results in suboptimal care for patients. Knowledge management technology may provide effective approaches in speeding up the diffusion of innovative medical procedures whose clinical effectiveness have been proved: the most interesting one is represented by computer-based utilization of evidence-based clinical guidelines. As researchers in Artificial Intelligence in Medicine (AIM), we are committed to foster the strategic transition from opinion to evidence-based decision making. Reviews of the effectiveness of various methods of guideline dissemination show that the most predictable impact is achieved when the guideline is made accessible through computer-based and patient specific reminders that are integrated into the clinicians workflow. However, the traditional single doctor-patient relationship is being replaced by one in which the patient is managed by a team of health care professionals, each specializing in one aspect of care. Such shared care depends critically on the ability to share patient-specific information and medical knowledge easily among them. Strategically there is a need to take a more clinical process view of health care delivery and to identify the appropriate organizational and information infrastructures to support this process. Thus, the great challenge for AIM researchers is to exploit the astonishing capabilities of new technologies to disseminate their tools to benefit HCOs by assuring the conditions of knowledge management and organizational learning at the fullest extent possible. To achieve such a strategic goal, a guideline can be viewed as a model of the care process. It must be combined with an organization model of the specific HCO to build patient careflow management systems. Artificial intelligence can be extensively used to design innovative tools to support all the development stages of those systems. However, exploiting the knowledge represented in a guideline to build them requires to extend todays workflow technology by solving some challenging problems.

Supporting tools for guideline development and dissemination

Abstract This paper describes a methodology for representing clinical practice guidelines and facilitating their introduction into the medical routine. Since this methodology can be exploited in a www environment, it can represent the basis for sharing clinical guidelines both between different institutions and between human and software agents cooperating within a clinical context. In addition, the proposed guideline formalization is intended to deal with patient and organization preferences. This goal is achieved by augmenting the guideline with decision–analytic models and by linking the guideline with an organizational model of the clinical setting. The designed framework allows guideline development, tailoring and implementation, real-time access to the guideline prescriptions and guideline validation.

A case study in ontology library construction

The goal of our work is to facilitate the development of medical knowledge-based systems by providing a library of reusable ontologies. The availability of such a library reduces the amount of knowledge acquisition required to create knowledge bases of new applications, and makes it easier to connect a knowledge-based system to existing data bases. This article presents a case study in constructing such a library. The emphasis is on studying the principles that underly the internal structure of the library as well as on the process of constructing and using the library. We envision that, in the future, application ontologies can be constructed by the selection and refinement of generic ontologies and domain ontologies from such a library.