To link to this article: DOI:10.1016/j.eurger.2015.02.011
http://dx.doi.org/10.1016/j.eurger.2015.02.011
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Eprints ID: 14090
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Kamsu-Foguem, Bernard and Tiako, Pierre and Mutafungwa, Edward and
Foguem, Clovis Knowledge-based modelling applied to synucleinopathies.
European Geriatric Medicine. ISSN
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Technology
applied
to
geriatric
medicine
Knowledge-based
modelling
applied
to
synucleinopathies
B.
Kamsu-Foguem
a,*
,
P.F.
Tiako
b,
E.
Mutafungwa
c,
C.
Foguem
daLaboratoryofProductionEngineering(LGP),EA1905,ENIT-INPT,UniversityofToulouse,47,avenued’Azereix,BP1629,65016Tarbescedex,France bCenterforITResearch,LangstonUniversity,OK73050,USA
cAaltoUniversitySchoolofElectricalEngineering,PL13000,00076Aalto,Espoo,Finland d
CenterforFoodandTastesciences(CSGA)–UMR6265CNRS–UMR1324INRA–UniversityofBurgundy,9E,boulevardJeanne-d’Arc,21000Dijon,France
1. Introduction
Thecurrentmedicaldemographyanditsunevendistribution, particularlyin somemedical disciplines,arecreatingsignificant challengesinensuringcontinuityof care.Thishasresultedina pressingneedformedicalfacilitiesinplaceswheretheshortageof specialistsisacute.Telemedicineisatoolthatenablesequalaccess tomedicalexpertiseregardlessofplaceofcare[1].Thispractice allows physicians of regional institutions to ensure access to competencefor differentmedical investigationsorcasesand to benefit from the expertise of their colleagues from different specializations (radiology, surgery, psychiatry or neurology)
[2].Indeed,telemedicinehasalloweddoctorshospitalsandclinics tohavea network for accessingremoteresources and comple-mentaryskills[3].Otherbenefitsoftelemedicineincludepatients whoarelesstiredandstressedandfamilieswhonolongerhaveto travellongdistancestovisittheirdoctors[4].Medicalpractitioners now have in their offices or in their local hospitals capacity identicaltothoseatmajorhospitals.Theseadvancesarepotential safeguard measures to ensure the protection of some local
hospitals. In summary, telemedicine provides impact in three keydimensions[5]:
medical impact through improved medical diagnosis and
treatment,aswellas,theincreasedcompetenceofpractitioners participatinginthenetwork;
territorialimpactbymaintainingskillsandspecializedservices inhospitalsandclinicsinmediumandsmallercities,especially inruralareas;
medico-economicimpactthrough reductioninthenumber of unnecessarytransfersand theincreaseinthenumberof vital transferswithausefulgainforpatientswhilecontrollingcosts. Theeraoftechnologicalnetworksinmedicineisinevitableto improve the quality, safety, and continuity of care, while promotingequalaccesstohighqualitylocalcarebypromoting coordinationandcooperationofallstakeholders.Atthe techno-logical level, further progress can be made in the field of telemedicineifthemainobstaclesareovercome[6].Bydeploying this technology in all remote hospitals or care centers, one improvesconnectivitybysettingapplicationofqualitystandards andbuildingarelationshipoftrust.Telemedicineefficiencyshould allow equitable management of patients. It allows sharing of
Keywords: Telemedicine Ontologicalknowledge Collaboration Semanticmodelling Geriatrics ABSTRACT
Theadoptionoftelemedicinetechnologieshasenabledcollaborativeprogramsinvolvingavarietyof links among distributed medical structures and health officials and professionals. The use for telemedicinefortransmissionofmedicaldataandthepossibilityforseveraldistantphysicianstoshare theirknowledge on given medical cases provides clear benefits,but also raises severalunsolved conceptualandtechnicalchallenges.Theseamlessexchangeandaccessofmedicalinformationbetween medicalstructures,healthprofessionals,andpatientsisaprerequisitefortheharmoniousdevelopment ofthisnewmedicalpractice.Thispaper proposesanewapproachofsemanticinteroperabilityfor enabling mutual understanding of terminologies and concepts used. The proposed semantic interoperabilityapproachisbasedonconceptualgraphtosupportcollaborativeactivitiesbydescribing howdifferent healthspecialists can applyappropriatestrategies to eliminate differential medical diagnosis.Intelligentanalysisstrategiesareusedtonarrowdownandpinpointmedicaldisorders.The modelproposedisfullyverifiedbyacasestudyinthecontextofelderlypatientsandspecificallydealing withsynucleinopathies,agroupofneurodegenerativediseasesthatincludeParkinson’sdisease(PD), dementiawithLewybodies(DLB),pureautonomicfailure(PAF)andmultiplesystematrophy(MSA).
* Correspondingauthor.Tel.:+33624302337;fax:+33562442708. E-mailaddress:[email protected](B.Kamsu-Foguem).
qualityimageviewingstations(adapteddiagnostic),flexibleusage ofresources(possibilityofWebaccess),and,toensurethat the benefitsof suchtelemedicine canbemutual, provides opportu-nities for technology transfer and improved efficiency in the healthcare sectors of partners institutions.The development of telemedicineisbasedonstrengtheningourinnovationcapabilities andrequiressustainedcooperationthatcutsacrossthefieldsof health, industry, research, and defence [7]. A tele-consultation session canshow thevarious documents available:image of a patientorphysician,radiographicimages,andotherclinicaldata. Insomecircumstances,remotebiotechnologytoolscanbeusedto performenricheddiagnosticsbymoleculartechniques,targeting ofpathogens,andidentificationofsensitivitiestodrugsinorderto enhancetreatment[8].
Therestofthepaperisstructuredasfollows.Section2exposes thematerialandmethodswiththeconceptualgraphoperations usedtoimplementthemodellingofexpertrulesincollaborative decision-makingprocesses.Section3presentstheresultswithan illustrative case for the telemedicine management within the geriatricsfieldispresented.Finally,section4providesadiscussion andsection5concludesanddiscusseslessonslearnedandfuture challenges.
2. Materialandmethods
2.1. Knowledgeformalizationwithconceptualgraphs
Theconceptualgraph(CG)formalismisaknowledge represen-tationlanguage, which hasa well-definedsyntaxand a formal semantics that allows one to reason from its representations
[9].Theconceptualgraphformalismisconsideredasacompromise
representation between a formal language and a graphical
language, because it is visual and has a range of reasoning processes[10].Conceptualgraphscanbeusedinmanycomputer science areas, including text analysis, web semantics, and intelligentsystems[11].
A simple conceptual graph is a finite, connected, directed, bipartitegraph consistingofconceptnodes (denotedas boxes), which are connected toconceptual relation nodes (denoted as circles). In the alternative linear notation, concept nodes are writtenwithin []-brackets while conceptualrelation nodes are denotedwithin()-brackets.Theconceptssetandtherelationsset aredisjoint.
A concept is composed of a type and a marker [<type>: <marker>],forexample[Disease:IdiopathicParkinson’sdisease]. Thetypeofconceptrepresentstheoccurrenceofobjectclass.They aregroupedin a hierarchicalstructure calleda conceptslattice showing their inherit relationships. The marker specifies the meaningofaconceptbyspecifyinganoccurrenceofthetypeof concept.
Aconceptualrelationbindstwoormoreconceptsaccordingto thefollowingdiagram:
C1 ½ ðrelation0snameÞ C 2 ½ meaningthat00C 1 isrelatedtoC2 ð bythisspecificrelation00Þ
Intheanalysisoftelemedicinemanagement,themostcommon relationsaredependencyrelations,specifically,causal, condition-al,temporal,andBooleanconnectives,suchasAND,alternating-OR and exclusive-ORrelations. An exampleof conceptual graph is showninFig.1:amedicalactivityistheagentofatelemedicine serviceandits durationis influencedbythediagnosticcriteria. The semantics of the core and extended CGs is defined by a
formal mapping to and from a common abstract syntax and
model-theoreticfoundationforafamilyoflogic-basednotations (ISO/IEC24707)[12].
Aderivationisafinitesequenceoftheseelementaryoperations thathaveaformalsemanticsbasedonalogicalinterpretation.As aresult,themeaningofgraphoperationsisdeterminedinlightof the derivation to be applied, based on a logical interpretation whichgivesfulleffecttothevisualreasoning[13].Thederivation hasoneofthreeconceivablepropertiesonthelogicalrelationship betweenastartinggraphuandtheresultinggraph
v
[14]: 2.1.1. EquivalenceCopyandsimplifyareequivalencerules,whichgenerateagraph
v
thatislogicallyequivalenttotheoriginal:theknowledgeofu isincludedinv
andtheknowledgeofv
isincludedinu(logical meaninguv
andv
u).2.1.2. Specialization
Joinandrestrictarespecializationrules,whichgenerateagraph
v
thatimplies theoriginal:v
contains morespecificknowledge thanu(logicalmeaningv
u).2.1.3. Generalization
Detachandunrestrictaregeneralizationrules,whichgeneratea graph vthat is implied by theoriginal:
v
contains less precise knowledgethanv
(logicalmeaninguv
).Ontological knowledge provides a formal description of the studied system [15] with associated experiences and lessons learned[16,17].
2.2. Exploitationofconceptualgraphsrepresentationinreasoning AformalknowledgemodelledbyCGsinexperiencefeedback processescanbeaveryusefultoolforconveyingaccuratemeaning to a collaborative workenvironment involving domainexperts
[18].Foragivenapplication,severalviewpointsofexpertisemay beengagedincombination.Forexample,someinvestigationsto improve the availability of a geriatric health care system can involveexpertknowledgeintele-expertiseandassociatedremote practices.
During theknowledge modelling phase of the telemedicine rules,theuseofCGpropertieswillhelptoenrichthetelemedicine knowledgebaseinordertoeasetheiraccess,sharingandreuseby themembersofthetelemedicinemanagementintheirindividual andcollectivetasks.Furthermore,experiencegainedandlessons learnedfrominitialproblemsolvingdevelopmentswillbeapplied as soon as possiblein similar situations in othercollaborative telemedicine activities with temporal modelling considerations
[19].
In conceptualstructures, the operations of visual reasoning
with semantic mapping form the bridge from perception to
differentformsofconceptualoperations,rangingfrom specializa-tionandgeneralizationtounification[20].Whentheconceptual graphs operations are used in the visual reasoning, semantic comparisonsaredeployedateverystep,andtheonlydifference betweendeductionandanalogiesisthenatureoftheorientations onthereasoning[21].Particularly,oneconceptualgraphissimilar toanotherifthereisasemanticmapping(graphhomomorphism) fromthefirstgraphtothesecondone.Inthiscontext,the case-basedreasoningcanbeengagedtosearchsomeunknownfeatures ofanewcasefromitsknownfeaturesandpreviouscasesstoredin thecasesbase.In analogicalreasoning,theconceptualstructure thatdescribesknownfeaturesofthenewcaseiscomparedwith thematchingfeaturesoftheconceptualstructuresassociatedto previous cases [22]. The assessment takes into account the determineddegreeofsimilarityandclassifiedalternativeoptions forothercases.Thecasethatprovidesthegreatestcorrespondence
maybeundertakenasthetopbasisofindicationforapproximating theunknownfeaturesofthenewcase.
3. Results
WeillustratetheproposedapproachusingCGswiththecase studyofsynucleinopathiesmostlyneurologicorgeriatricdiseases. Theaccommodationoftheagingpopulationisamajorconcernin healthcareandforfamilies[23].Thecostofmedicalinterventions fortheelderly,whoareoftenfrailandwithrecurringepisodesof chronicdiseases,isincreasing[24].Supportforthesevulnerable people,whoareoftenisolated,requiresthedeploymentofflexible and effective systems to prevent hospitalizations sometimes experiencedbyelderlyasatraumaticeventandenabletheelderly to maintain their living place if possible [25]. Could new technologiesprovidesomesolutions?Theexpectedbenefitsare summarized by economic gain or improvement in the care of elderlypatientsortheirqualityoflife.Alsoarehealthcareteams theyreadytoembracethesenewtechnologies?
3.1. Clinicaloutlineofthesynucleinopathies
Thisapplicationisinthecontextofdecisionsupportinhealth andrelatesparticularlytoneuroscienceandespecially synuclei-nopathies,agroupofneurodegenerativediseasescharacterizedby fibrillary aggregates of alpha-synuclein protein (the major componentsofLewybodies,dystrophic(Lewy)neuritis,andthe Papp-Lantosfilaments)inthecytoplasmofselectivepopulationsof neurons and glia. These disorders include mainly Parkinson’s disease(PD),dementiawithLewybodies(DLB),multiplesystem
atrophy (MSA), and also pure autonomic failure (PAF) and
Hallervorden-Spatz syndrome (HHS) [26]. Clinically, they are characterized by a chronic and progressive decline in motor (mainly Parkinsonism), cognitive, behavioral, and autonomic functions, dependingon thedistributionofthelesions[27]. Al-though there are validated clinical and pathological consensus criteria for PD, DLB, and MSA, because of clinical overlap, differentialdiagnosisissometimesverydifficult[28].Moreover, early diagnosis of these diseases is also difficult [29]. Several approachesandnewbiomarkersarebeinginvestigatedtofacilitate the early ante-mortem diagnosis, as the common hallmark of synucleinopathies is the finding of alpha-synuclein protein on brain biopsy.Amongthesepotentialnewbiomarkers,there are myocardialmetaiodobenzyl guanidine(MIBG)scintigraphy[30], functional cerebral imageries (reduced dopamine transporter activity in some part of the brain), olfaction’s tests threshold revealinghyposmiaandolfactorypathwaypathology[31].Others newdiagnosiscorefeaturesasRapidEyeMovementsleep(REM sleep), behavior disorder, severe neuroleptic sensitivity, some clinical signs, symptoms and biological elements are assessing thestructureofthesefeaturesagainstthecriteriasetoutinthe guideline.However,therediagnosisaccuracyisnotoptimal,but inmostofcases,theycontributetoeliminatedifferentialdiagnosis. Itwillbeusefultoinvestigatednewsapproachesadaptedtothese newneedswithpossibilitytoimprovediagnosiscriteria.
InParkinson’sdisease(PD)forexample,non-motorsymptoms are (described in Table 1): olfactory dysfunction, depression, constipation, pain,genitourinary problems,sleepdisorders, and cognitive impairments. These are often long ignored, and are
common [32]. They sometimes precede motor symptoms and
should be thoroughly investigated because they lead to a
Binar
y
-
Relation
Before DuringTempor
al-relation
Usual-rela
tio
n
Spatial-rela
tion
Log
ical-rela
tion
Agent
Characterization Object Implication Influence
Concept
Diagnosis TreatmentMedical Activity
Diagno
stic
Criteria
Sign Symptom Test resultTele
medicin
e
Teleconsultation Teleexpertise Telemonitoring Teleassistance
Durati
on
Compete
ncy
Direction
Tool
Objec
t
Telemedicine
Medical Activity agent Usual-relation Duration
Diagnostic Criteria influence
Outside Inside
Teleexpertise
Diagnosis: Idiopathic Parkinson'sdisease agent characterization Duration
Test Result influence
Specializatio
n
Generalization
Patient
significantburden on the quality of life and have a significant contributiontothemorbidity ormortalityrates ofPD. Besides, functional imaging using dopaminergic tracers with either PositronEmissionTomography(PET)orSinglePositronEmission Tomography(SPECT)canidentifydopaminedeficienciesbutmay notreliablydifferentiatebetweenParkinson’sdiseaseandother akineticrigiddisorders.Inaddition,evenapathological examina-tioncannotclassifyclinicalsyndromeswithcertainty.Despitethe diagnosticcriteria, a diagnosis of certainty is oftendifficult to establish because it requires a formal demonstration of the characteristicfeaturesofthepresumptivedisease. Clinicopatho-logicalstudieshaveshownthattheaccuracyofaclinicaldiagnosis ofPD isless than 80%.More selecteddiagnosticcriteria would increasetheproportionoftruePDcasesidentifiedtomorethan 90%[33].
Misdiagnosisofasynucleinopathyasanotheroneistherefore potentially extremely dangerous for these patients because of thetherapeuticsimplications.Forexample,inpatientswithPDor withdementia with Lewy bodies (DLB), typical neuroleptic or antipsychoticdrugscouldleadtoneurolepticmalignantsyndrome (NMS),alife-threateningneurologicaldisordermostoftendueto adversereactionsofthesedrugs.NMStypicallyconsistsofmuscle rigidity,fever,autonomicinstability,andcognitivechangessuch as delirium, and is associated with elevated plasma creatine phosphokinase.
Morerecentstudiesadvocatethatlanguage,especially seman-tics,maybeanareaofcognitioncapableofdistinguishing
early-onset synucleinopathy patients from healthy controls and
discriminating between various types of synucleinopathies
[34].Particularly,languagedisturbancesin dementiahavebeen factually attributed to the degradation of stored knowledge, whereasitisfrequentlyassumedthatlanguagedeficitsinstroke aphasiamirror modality-specificimpairment ofaccesstointact conceptual knowledge [35]. These deficits can be an acquired disorderoflanguagecomprehension,production,and/orsymbolic knowledge.In addition tomemory and language impairments,
assessment in other cognitive domains can also highlight the influenceof semanticknowledge,for instance,ondecoding the physico-chemical properties of an odorant [36]. Understanding thesemantics of cognitiveimpairmentsin synucleinopathiesis thusessentialforanumberofarguments.Identifyingsimilarities and differences between synucleinopathies is the first step in evolving tests that are differentially sensitive to the distinct conditions,thusprovidingappropriatescreeningteststosupport clinicaldiagnosis.Understandingthequalityofimpairmentsalso providessignificantinformationforpatients andcarers, helping physicians to elaborate better coping skills and care strategies. Besides,comparingthepropertiesofcognitiveimpairmentbetween patient groups had often contributed to an improvement in a semanticanalysisoftheprocessunderlyingexecutivecontrolfor understandingthenormalorganizationofcognitivefunctions[33]. 3.2. Visualmodellingofanalysisproceduresinsynucleinopathies
Wecanthink aboutthecontributionofartificialintelligence toolsasameansofanalysistosupportmedicaltestsfortheearly diagnosisanddifferentiationofthesepathologies.Particularlyin this context, operations of conceptualgraphscan be crucial to reasoningonknowledgewithvisualexplanations.Thisknowledge can provide evidence and analysis relevant to the activities of diagnosesanditisveryimportantformedicalresearchingeriatrics orneurosciences.Tothatend,weplantoincludetheengagement of reasoningtechniquesto determineby sequential association rules[37]themostsignificantrulestoassistintheestablishment of themost appropriate diagnosisand to eliminate differential diagnoses. Shared practice rules face the challenge of creating a solid foundation to support the cognitive development of collectiveintelligence.Theserulescanbeannotatedusingdomain ontologies andevaluated byotherusers,who mightconsidera form of suggestion using intelligent components based on the annotationsassociatedwithasynucleinopathy.Forexample,given acollaborative actiononasynucleinopathy,decisionsregarding
Table1
Descriptionofnon-motorsymptomsassociatedwithIdiopathicParkinson’sdiseaseadaptedfrom[42].
Non-motorsymptomsassociatedtoIdiopathicParkinson’sdisease Supposedbraindamage Psychological,psychiatricand
cognitivesymptoms
Depression,anxiety,panicattacks,feelinghopeless Locuscoeruleus(norepinephrine),inferiorraphe nucleus(serotonin),amygdala
Apathy,anhedonia,inattention,vegetativesymptomsof depression
Uncertain Psychosis,inappropriatebehaviorandotheradversebehavioral
effectsdisorders,obsessive-compulsivedisorders,delirium
Limbiccortex,amygdala Parkinsonismdementia,confusion,hallucinations(iatrogenic
factor)
Temporallobe,hippocampus,locuscoeruleus, amygdala,nucleusbasalisofMeynert(acetylcholine) Sleepdisturbances Sleep-onsetinsomnia,trueinsomnia,nighttimehallucinations,
rapideyemovementsleepbehaviordisorder,daytime sleepiness,sleepattacks
Subcorticalnucleus(pedunculopontineand subcoerulusnucleus),hypothalamus Sleepfragmentation,sleepapnea(central(CSA),obstructive
(OSA),andcomplexormixedsleepapnea),restlesslegs syndrome(RLS)
Uncertain
Dysautonomicsymptoms Bladder-sphincterdysfunctions(urinaryfrequencyandurinary incontinence,dysuria),excessiveperspiration,abnormalsexual behavior(impotence,hypersexuality),xeropthalmia
Dorsalnucleusofvagusnerve
Orthostatichypotension,post-prandialhypotension Vagusnerve,stellateganglion(orcervicothoracic ganglionorinferiorcervicalganglion)
Gastrointestinalsymptoms Drooling,ageusia(tasteloss),swallowingdisorders,dysphagia, gastroesophagealreflux,vomiting,nausea,constipation,fecal incontinence
Dorsalnucleusofvagusnerve(adrenaline)
Sensorysymptoms Olfactorydisturbance Olfactorybulb Pain,paresthesias Uncertain Others Fatigue,seborrhea(skinandgreasyhair),excessive
perspiration,weightgain,weightloss
thisactioncanbeautomaticallysuggestedbasedonthe annota-tions,providingthemosteffectivedecisionssemanticallyrelated to this action. In addition, an adaptation rule is a form of experientiallearning[38],insofarasitisstudiedintermsofhowto respondtoamismatchbetweentheexpectedsituationand the resultsobserved. This leadsto a learning semantic requiring a differenttypeofconceptualorganizationconsistentwithahigher levelofabstractiontoobtainabetterunderstandingoftheeffects ontherulesandknowledgemanipulated.
We consider now the conceptual graph describing the
collaborative expertise (as shown in Fig. 2). In this graph, the differentspecialistscanapplyappropriatestrategiestoidentify, localize,and(wherepossible)correcttheerrorsintheknowledge modelling.Theconceptualgraphspecifiestheuseofintelligent
analysis strategies to narrow down and pinpoint medical
disorders. Through the medical knowledge base, such crucial expertdescriptionscanbesharedandreusedbythespecialistsin theirindividualandcollectivetasks.Asaresult,bymeansofthe disordersstrategies,fromwhichspecialistslearn,theyareableto transfer the acquired knowledge and lessons learned easily to another similar context, with the goal of preventing disease consequencesorreducingthemtoaminimum.Theywillbeableto
determine whether a context is problematic, whether the
diagnosisor information flow is incorrect, or if theanalysis of thediseasecontextisdefective.
We can also use this experienced knowledge for dedicated analysisofthespecificstudieddisease(e.g.,Parkinson’sdiseasein
Fig. 3). Thus, in order to assess, interpret, and verify the reasonableness of the modeled knowledge,one would have to ensurethatthevarioustypesoftargetedsituationsareconsistent byusingtheprojectionoperationofCGs.Furthermore,theanalysis shouldnotbeviewedastheproblemofoneexpertisemorethan anotherbutasaglobalproblem,whichallinvolvedmembersofthe collaborativeorganizationwouldaddress.
Weputforwardanontologicalmodelandconceptualstructure looselybasedonthevisualapproachusedtosupportteambased telemedicine collaboration. In the considered medical context,
healthcare involves a variety of specializedexperts in different fields who are often geographically separated. They appreciate collaborativeactionstofixaparticularcomplexproblemforwhich theirbackgroundandtrainingmakethemqualified.Inthiscase study, telemedicine actually helps in the diagnostic decision process,sinceityieldsimprovementintermsofthecostand/or time neededto arriveat a decision. Research and progresson telemedicinecouldbevaluable;especiallyweareactuallytesting itinarealtelemedicineenvironment.
4. Discussion
The mainstream eHealth interoperability enhancement
effortsintheECandkeystandardsdevelopmentorganizations areroughlyclassifiedinto:legalinteroperability,organizational interoperability,technical interoperability,andsemantic inter-operability.Whilepaperobjectivestargetchallengesofsemantic interoperability, the discussions therein also provide heavy coverageonissuesoftechnicalinteroperability(ontelemedicine infrastructure)andtosomeextentonorganization interopera-bility.Furthermore,thereareongoingactivitiestodevelopand/ orharmonizeeHealthinteroperabilitystandards(ledbythelikes ofContinuaHealthAlliance,IHE,IEEE/ISO,ITUeHSCG,IHTSDO, etc.). There is a need forfurther research regarding organiza-tionalchange,incentives,liabilityissues,end-usersHIT compe-tencesandskills,structureandworkprocessissuesinvolvedin realizingthebenefitsfromhealthinformationtechnologies(HIT)
[39].
Under the coordination of the health information systems strategydelegation,aworkinggroupoftheFrenchNationalSteering Committee of Telemedicine has developed a series of concrete recommendationsfortheoperationalimplementationoftechnical systemsunderlyingthetelemedicineprojectsandactivities[40]:
to promote the implementation of a comprehensive and
coherent infrastructure to include the implementation of telemedicineprojectsinacoherenturbanization;
Context: elderlypatient
description
Parkinson Synucleinopathies Component
2 1 2 1 Implication 2 Component
DementiawithLewybodies
Multiple system atrophy Component
1
2
2
Analysis: suggestives features
description
Olfactory Dysfunction 1 OR 2
OR
1 2
Cardiovascular dysfunction: {repeated falls, fainting} Language impairments Depression OR 1 2 OR 1 2 1
Analysis: supportivefeatures
description
Neurolepticsensitivity 1 OR 2
OR
1 2
L-dopa treatment ’s efficiency
Sleeps Disorders (REM) OR 1 2 OR 1 2
Analysis: Core features
description
Features of Motor Decline 1 OR 2
OR
1 2
Inadequate Behavioural Attitude; hallucinations
Autonomic Dysfunction Cognitive Impairment
OR 1 2 OR 1 2 Before 1 2 Before 1 Characterization
2 1 Oculomotor disorder (palsy) OR 2 1 Brain-imagingscans
to conduct a risk assessment relating to the security of informationsystemsthatmayaffectthesuccessful accomplish-mentoftheactivityconcerned;
todevelopaglobalandconsistentmanagementofthetechnical devicestoensurethattheirdiversityreallyisenriching; toprovidetraining,suitablesupportandanadaptedassistance:
supervisedstudyperiodsandtutoringservices;
to establish a conventional setting corresponding to the contracts for the provision of updated technical services in conductingongoingdialoguewithtechnologicalthirdparties.
In practice, this mainly means the capacity to ensure an effectivemanagementofpersonaldata,whileensuringcompliance withdata protection principlesand security of data exchanges between different organizations that are concerned by the telemedicine procedures. Secondly, it is important to prevent risks threateningthe safety of operational devices. To do this, operators need to carefully and constantly apply effective methodologiesandfurtheradvancesinexplorationand develop-menttechniquestoincreasethelikelihoodofdetectingahazard affectingthesafetyofconsidereddevices.Someeventsmaycause undesired operation (namely service interruption, fraudulent interferenceonthepartofa thirdpartyorcomputervirusesor inappropriatetimingoftasksandimpairedsignalsordata)andwe shouldmonitorthesignificantoperationalrisksoftheimplement ofthetelemedicineprocedures,inorder,interalia,toidentifyatan early stage unforeseen adverse effects and to have a look at possiblesolutions(palliative,curativeandpreventiveoptions).
Furthermore,itisimportanttoimproveasfaraspossiblecase managementatallcomponentsoftheproposedimplementationof thetechnicalaspectsoftelemedicinedevicesinaglobalframework basedonformalproceduresandfoundedonbestpractices.Inthis context, it would ensure a sufficient level of comprehension, accession and assimilation by the medical actors and health professionalsusingtelemedicinedevicesforthefullregistrationof the remote services in the everyday professional practices. Therefore, it is essential to establish with technological third parties,intheframeworkpartnershipagreementssignedbetween
themandtheProjectManager,requirementlevelsconsistentwith theneedsidentifiedintheagreementswithbusinessstakeholders.
5. Conclusion
In this paper, we have shown that the use of knowledge modelling and formal semantic techniques provide additional supporttotelemedicinetasksbyimprovingtheuser understand-ingofthediseasesbeingtreated.Wemadeacasestudywiththe knowledgemodellingofsynucleinopathiesinelderly.Theresults ofthisstudygaverisetoa seriesofrecommendations,whichin turnwillformthefoundationofthecollaborativeactionplanin response to telemedicine management. Particularly, non-motor symptoms play an essential part in appropriate diagnosis of synucleinopathies and a very insightful and knowledgeable analysisoftheirsystemictemporaldevelopmentschemesshould
more consequently be taken into consideration within the
elaborationofdiagnosticprogrammesinthefieldofhealthpolicy. However, while the motor-based disease (or even cognitive disorder) diagnosis system is described in some detail, the elementsoftheconsiderednon-motorsymptomsevaluationare sketchy,in particular withregard toprocessand management. Such facilities are currently an early stage and for instance, olfactorytests,whichweresupposedtobeautomated,hadtobe executedmanuallyinordertoensurecorrectnessof processing and reports on diagnosticevaluations. Aswell, these processes oftenareheldoveracoupleofhours,requiringtimeinvestments frompatients andhealth professionals.Thisdoes notallowthe medicalactorsresponsiblefortheregularoutpatientconsultations tovalidatesomemedical investigationsanddiagnosisfor acute illness and preventive health care. We will achieve these investigations through the close collaboration of ambulatory carewithinterestedphysiciansandmedicalreferencecenters.It iscurrentlyassociatedwithamovementtoincludeafocusonthe healthofelderlypersonstohelptoverifythatequalityinaccessto healthcareismadeareality.Undercollaborativeactivitiesmadein telemedicine, medical organizationsarepooling their resources andstructurestoimplementasustainableandeffectiveinclusion
Context: elderlypatient description
Parkinson implication 1 2
description Bradykinesia Motorsymptoms description
Resting tremor
OR 2 1 OR 2 1 description Hypertony before2 1 description
Mood disorders: depression Nonmotor symptoms
description
Loss of sense of smell
OR 2 1 OR 2 1 description
Autonomic Dysfunction description
Olfactory Test Supportingfeatures
description Abnormal SPECT/PET OR 2 1 OR 2 1 description before2 1
Brain-imaging scan
OR 2 1 description L-dopa efficiency OR 2 1 description Postural instability OR 2 1 description REM
programmedesigned toguarantee maximumpossible coverage andequalconditionsasregardsaccessandtreatmentforpatients, regardlessoftheirageorplaceofresidence.
Relying on the modelling of expert knowledge through
conceptual graphs operations, we proposed an approach that positivelyimpactsthetelemedicinemanagementplans:
abetteraccesstoavailablebestpracticesandmethodologiesas wellassupporttrainingandtheexchangeofinformationonnew practicaldevelopmentsrelatedtocriticalmedicalactivities. aframeworkofpracticalknowledgeandgoodpracticetoensure
modellingofneededinformation,qualitytutoringandtobring stakeholderstogetheratorganizationandgloballevels. apossibleconceptualmodellingwithreasoningmechanismsfor
theanalysisandexchangeofgoodpracticesonaccesstoservices. To that end, good modelling practice on access to traces of reasoningshouldbepromoted.
If the significant potentials of telemedicine to assist in the managementguidanceandoutpatientcarearetoberealized,then research strategies need to be undertaken to improve disease diagnosis and monitoring. However, the modalities of suchan approach should be clarified so as to allow greater security, flexibilityandergonomicfunctionalities[41]inrespondingtothe pragmaticneeds ofmedicalprocedures[42]and efficientuseof experiencedhealthcareproviders[43–51].
Disclosureofinterest
The authors declare that they have no conflicts of interest concerningthisarticle.
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BernardKamsuFoguemHehasaPhDinComputerScienceandEngineeringfromthe UniversityofMontpellier2in2004.Hegotthe‘‘accreditationtosuperviseresearch’’, abbreviatedHDRfromUniversityofToulousein2013.Hiscurrentinterestsarein KnowledgeDiscoveryand DataMining,KnowledgeRepresentation,FormalVisual Reasoning,Ontology-basedSemanticAnalysis,KnowledgeExploitationfor Collabora-tion,DecisionSupportSystemsandIntelligentSystems.Applicationdomainsinclude ContinuousImprovementprocessandHealthInformationSystems.Heisareviewerfor alargenumberofinternationalscientificjournalssuchasComputersinBiologyand Medicine,KnowledgeManagementResearch&Practice,InteractingwithComputers, Sensors,EngineeringApplications ofArtificial Intelligence and Knowledge-Based Systems.Heisamemberofthethematicgroup:e-HealthofInterOP-VLab (Interna-tionalVirtualLaboratoryforEnterpriseInteroperability).
PierreF.TiakoHeistheDirectoroftheCenterforInformationTechnologyResearchat LangstonUniversity(USA)andanassistantprofessorofComputerScienceand Infor-mationSystem.HeworkedasavisitingprofessoratOklahomaStateUniversity(OSU) beforethecurrentposition.PriortoOSU,hetaughtcomputersciencecoursesanddid researchatUniversitiesofNancyandRennes(France),andalsoworkedasanexpert engineeratINRIA,theFrenchnationalinstituteforresearchininformationtechnology. Dr.Tiakohasauthoredmorethan50journalandconferencetechnicalpapersand co-editedfourproceedingsvolumes,resultingfromservicesasprogramchairforseveral internationalconferencesandworkshops.HeholdsaPhDinsoftwareandinformation systemsengineeringfromNationalPolytechnicInstituteofLorraine(France).Dr.Tiakois aseniormemberofIEEEandpastChairmanforIEEEOklahomaCityComputerSociety.
EdwardMutafungwaHeisaresearcherandprojectmanagerattheDepartmentof CommunicationsandNetworking(Comnet)oftheAaltoUniversitySchoolof Elec-tricalEngineering.HereceivedtheB.Eng.degreeinElectronicSystemsEngineering andtheM.Sc.degreeintelecommunicationsandinformationsystemsbothfromthe UniversityofEssex,Colchester,U.K.,in1996and1997,respectively,andtheDr.Sc. Tech.degreeinCommunicationsEngineeringfromtheHelsinkiUniversityof Tech-nology(TKK,nowAaltoUniversitySchoolofElectricalEngineering),Espoo,Finland, in2004.Foroveradecade,hehasalternativelybeenalecturer,researcherand projectmanagerinvariousnational(TEKES,AcademyofFinland)andinternational (EU,Celtic)projectsatComnet,AaltoUniversity.Hisresearchinterestsliewithinthe generalfieldsofbroadbandwirelesscommunications,opticalnetworking,ICTfor development(ICT4D)andpublicsafetycommunications.Intheareaoftelemedicine, hehasbeenstudyingtheuseofmobilebroadbandtechnologies(smallcells)for implementationofpersonaltelehealthsystems andemergencytelemedicinein indoorenvironments.
Clovis FoguemHe isanInternal Medicineand Geriatric medicaldoctorand has undertakenaPhDon‘OlfactionandElderly:studyoftheolfactory(CNI)andtrigeminal (CNV)sensitivitiesinteractionsinageriatricpopulation;constantsandpathological specificities’.He isalsoparticularlyinterestedinneurodegenerativediseases (as ParkinsondiseaseorLewyBodydementia),elderlyepilepsyandwhetherpathogenic inflammatoryorautoimmuneresponses cancontributetothesedisordersinthe elderly.Moreoverheisalsointerestedinmedicalknowledgerepresentationand medicalclinicdesignguidelines.Forhisworkon‘OlfactionandElderly’,DrC.Foguem waslaureateofHealthResearchAwardforemerginghealthresearchersfromthe corporatefoundation‘GroupePasteurMutualite´’in2011.Heisgroundedinmedical researchapplicationsofInformationandCommunicationsTechnology.FormerFaculty ofMedicine’sClinicalInstructor,heisnowHospitalPractitionerinFrance.Heis peer-reviewerofmanyscientistjournalsamongwhich:ClinicalInterventionsinAging; DegenerativeNeurologicalandNeuromuscularDisease;InternationalMedicalCase ReportsJournal;NeuroscienceandNeuroeconomics;ClinicalMedicineInsights; Jour-nalofthePancreas;International ScholarsJournals(ISJ);CancerTherapy; Indian JournalofCriticalCareMedicineand,AfricanJournalofEnvironmentalScienceand Technology.
