SAM: speech-aware applications in medicine to support structured data entry.

In the last two years, improvement in speech recognition technology has directed the medical community's interest to porting and using such innovations in clinical systems. The acceptance of speech recognition systems in clinical domains increases with recognition speed, large medical vocabulary, high accuracy, continuous speech recognition, and speaker independence. Although some commercial speech engines approach these requirements, the greatest benefit can be achieved in adapting a speech recognizer to a specific medical application. The goals of our work are first, to develop a speech-aware core component which is able to establish connections to speech recognition engines of different vendors. This is realized in SAM. Second, with applications based on SAM we want to support the physician in his/her routine clinical care activities. Within the STAMP project (STAndardized Multimedia report generator in Pathology), we extend SAM by combining a structured data entry approach with speech recognition technology. Another speech-aware application in the field of Diabetes care is connected to a terminology server. The server delivers a controlled vocabulary which can be used for speech recognition.

Capturing clinical reports in a large academic medical center: feeding a central patient data repository.

Clinical reports, notes, and other narratives are highly used components in the patient record. Unfortunately, the methods by which these reports are generated are as diverse as the fiscal autonomy of academic clinical departments in a university-based health science center. In this paper, we report on electronically capturing clinical reports, notes, and other text fragments from several hospital sources and many outpatient clinics. The purpose of the capture is to feed the ACIS (Advanced Clinical Information System) central patient data repository that is in use at the University of Utah Health Sciences Center (UUHSC). A survey conducted in early 1994 indicated that about 917,150 reports were generated per year at UUHSC representing about 1.2 million pieces of paper, occupying about 2.3 gigabytes of storage. The most crucial problem encountered in capturing the reports was linking them to the proper patient. Systems that had functioning and well-maintained admit-discharge-transfer (ADT) information performed well, but systems that relied on the human dictator to identify patients, produced patient linkage errors. In our open loop telephone dictation systems this error rate averaged between 6 and 10%. Subsequent to the wide-spread availability of clinical reports on ACIS, this error rate dropped to 3-5%, presumably due to increased demand for on-line availability of this information. From clinical secretaries who use their word processor to create the clinical reports, the linkage error rate was < 1% due to the use of our Advanced Text Upload (ATU) utility. The clinical text component in ACIS contributed significantly to the success of a JCAHO site visit in December 1995.

Sharing and communicating health care information: summary and recommendations.

Sharing and communicating information is a fundamental task in modern medicine. The health care system of the western world is based on teamwork of professionals who participate in the care of patients. Exchange of information (not just data) requires the communicating parties to agree on a communication channel, an exchange protocol, and a common language. The language includes an alphabet, words, phrases, and symbols that express and assign meaning, understood by all. The most common forms of communication are the spoken word and the paper-based patient record. Computers and communication systems improve the sharing of health care information by overcoming the limitations imposed by the dimensions of time and location. However, natural language is still too complex and too ambiguous for current computing devices to handle the complex interactions between health care professional and patients. A simpler 'language' is needed that uses domain specific vocabularies (and/or codes), well-defined exchange protocols for data, information, knowledge, and, in the future, perhaps even wisdom. This simpler 'language' is expected to handle most of the routine information exchange but not eliminate natural language. It is essential that health care information systems preserve and incorporate natural language expressions and integrate them with structured vocabularies. Today, agreeing on standard data exchange protocols and domain specific vocabularies and codes is our greatest challenge. However, standards alone are not sufficient. Acceptance of the standards by the health care professionals, verifications in clinical environments, and implementation agreements by the medical informatics industry are essential. The group on 'Sharing and Communication of Health Care Information' addressed the issues raised above and unanimously recommends a number of steps that will improve the sharing of information. In addition, specific recommendations are offered to governments, health care institutions, and to developers of health care information systems.

Ten years of medical informatics. Introduction.

The discussions of the Tenth Anniversary of the Symposium on Computer Applications in Medical Care (SCAMC) are summarized. Eight different subject areas are addressed: Medical informatics and medical education; Decision making, medical artificial intelligence, modelling and simulations; Image processing, 3-D graphics, and computer networks; Reimbursement policy, legal and regulatory issues; Encoding and representation of medical meaning; Ambulatory medical records systems; Hospital information systems; and Software environments for developing medical information systems. The activities of the 10th SCAMC consisted of Tutorials, Panel Discussions, a Plenary Session, Scientific Demonstrations, and an International Student Paper Competition in Medical Informatics.

A vocabulary for medical informatics.

The terminology in medical informatics is evolving rapidly. The organizers of MEDINFO and SCAMC have used different sets of keywords to index their documents. Recognizing the limitations of this approach, members of those organizations joined with the National Library of Medicine in the creation of a better terminology for medical informatics. A hierarchical structure was placed on the terms to produce a thesaurus typical of the sort often used in the indexing and retrieving of documents. The building of this thesaurus began with an automatic merging of the thesaurus used by the Association of Computing Machinery and the Information Sciences component of the "Medical Subject Headings." This product was pruned by eliminating terms not related to those in the MEDINFO keyword list or not in the medical informatics literature. Further refinement of the thesaurus resulted from extensive discussions among the authors of this paper. The first major application of this terminology has been to the indexing of the articles in "MEDINFO-86 Proceedings." Major components of this medical informatics thesaurus also have been incorporated into the "Medical Subject Headings." This paper describes the process of preparing the thesaurus and presents an evaluation of its coverage of the "MEDINFO-86 Proceedings."

The third manpower study of thoracic surgery: 1980 report of the Ad Hoc Committee on Manpower of The American Association for Thoracic Surgery and The Society of Thoracic Surgeons.

An ad hoc committee was appointed by The Society of Thoracic Surgeons (STS) in 1977 in order to determine the available manpower and workload of thoracic surgeons in 1976. This committee conducted a survey of the professional activities and geographic location of all known surgeons certified by the American Board of Thoracic Surgery (ABTS) at that time. A summary of this study indicated the available and projected thoracic surgery manpower. The report also determined the present and projected health care needs of the population of the United States through 1993. Because thoracic surgery needs to continue to meet the health care needs of the United States in an appropriate yet economical fashion, the STS and The American Association for Thoracic Surgery (AATS) undertook a joint review to determine again the available manpower and its workload in calendar year 1980. In addition, this study compared its findings with the 1976 report in order to detect changes in the workload and need for thoracic surgical services. A questionnaire was mailed to 3,584 certified thoracic surgeons. There were 2,675 responses. The material was sent to the Academic Computer Services at George Washington University Medical Center for tabulation and data processing. This report summarizes the results of this survey. It also compares these data with those obtained in the 1976 study and, based on this information, attempts to project the thoracic surgery manpower needs in the next decade by using several hypothetical models.

[Causes of abnormal sexual behavior (author's transl)]. / Ursachen von Normabweichungen des Sexualverhaltens.

There is no doubt that there are sexual disorders which are diseases, i.e. they need medical aid. As with every disease, also in sexual disorders investigation of the most probable causes has particular theoretical and practical value. Etiological investigations in this field stumble against special difficulties; compared to other fields of sex research they have been neglected up to now or were too concentrated in one direction. It is suggested that in every sexual disorder requiring treatment etiology should be gone into more deeply than hitherto. From animal experiments and human cases four different etiological possibilities can be deduced.

CNS dysplasia in dysencephalia splanchnocystica (Gruber's syndrome). A case report.

A macrosomic male infant with multiple malformations survived for 4 days. His external dysplasias comprised macrocephalus, cheilopalatoschisis, auricular anomalies, and unilateral hexadactyl; his internal dysplasias included cysts of kidneys and pancreas, and a patent foramen ovale. The child had frequent generalized convulsions and died of bronchopneumonia. Chromosomal analysis was normal. The main neuropathological findings were a cleft foramen magnum, micropolygria and heterotopia of the neocerebrum, hypoplasia of the vermis and central white matter of the cerebellum, diffuse heterotopia of Purkinje cells, and unique heterotopic gray matter in the central cervical cord. The infant's disorder was classified as Gruber's syndrome, and this report may be the first detailed description of CNS malformations in this syndrome which, however, are probably not specific for this syndrome. The neuropathological findings were compatible with a heterochronic pathogenesis. this and the familial occurrence of malformations suggest a genetic nature of the syndrome.

The Society of Thoracic Surgeons manpower survey for 1976: a summary.

The results of a 1977 survey regarding places and types of thoracic surgical procedures performed in the United States are analyzed. Responses gathered from 2,240 thoracic surgeons showed that active thoracic surgeons between 34 and 54 years old performed 195,850 major thoracic or cardiac operations per year. Fifty-four percent of active surgeons responding were in solo practice, 40% practiced in groups of 2 to 5 surgeons, and the reamining 6% were in groups of 6 or more. Community size, regional distribution of services, proportion of professional activities allocated to various procedures, and estimates of additional capacity are also summarized.

[Nuclear spheroids in neurons of the human hypothalamus]. / Uber "Kernkugeln" in Nervenzellen des menschlichen Hypothalamus.

Morphological structure, distribution and frequency of the so-called "nuclear spheroids" have been studied in the human hypothalamus. The following results were obtained: 1. By light microscopy, the nuclear spheroids turned out to be small or large spheroid bodies inside the nucleus. They are almost homogeneous, rarely granular, vacuolar or reticular and occasionally they are multiple. They are best stained with the cresyl-violet technique. They do not exhibit any histochemical pecularities. Aside from typical nuclear spheroids, irregularly shaped nuclei were frequently seen, associated with increased nuclear folds, transitional stages between nuclear folds and nuclear spheroids were also present. Certain microscopic features suggest invagination and displacement of nuclear membrane and cytoplasm into the karyoplasma. 2. By electron microscopy, the nuclear spheroids consist of nuclear membranes and cytoplasmic constituents. They, therefore, actually represent cytoplasm protruding into the cell nucleus. 3. The nuclear spheroids occur almost regularly and most frequently in the ventromedial field of the tuber cinereum, foremost in the infundibular (= arcuate) nucleus. They numerically increase during life. They are rarely found in the ventromedial nucleus but do occur in most of the adults. In the paraventricular nucleus, the supraoptic nucleus, the lateral nuclei tuberis, and in lateral hypothalamic nucleus, they are found by far less often. They scarcely develop in the preoptic area, in the dorsal field, in the tubero-mamillar complex, in the parafornical nuclear groups, in the premamillary nucleus and in the mamillary nuclei. 4. Within the infundibular (= arcuate) nucleus, the nuclear spheroids are particularly numerous in the basal and basolateral regions, whose neurons, under certain functional conditions--such as the Sheedan syndrome, in the menopause and in association with pituitary neoplasms-, appear hypertrophic. Within the hypertrophic neurons of this region, which we designate the subventricular part of the infundibular nucleus, nuclear spheroids are definitely more frequent, and they are of the large type. 5. A separation of the subventricular part based on the distributional pattern of the nuclear spheroids indicates a pathological karyoarchitectonics which supplements the normal karyoarchitectonics (Bachmann, 1948). 6. The nuclear spheroids seem to be associated with increased neuronal activities, for their frequently strongly correlates with the neuronal hypertrophy which expresses enhanced neuroendocrinological activity.

[Cerebral degeneration in Down's syndrome]. / Vorzeitiges Gehirnaltern bei Down-Syndrom.

Clinical and neuropathological findings of a 63-year-old male and a 25-year-old female with Down's syndrome are presented. Neuropathological examination of the older patient revealed intense features of Alzheimer's disease or senile dementia, including congophilic angiopathy and extensive mineral deposits in the globus pallidus and in the white matter of the cerebellum. In the hippocampus of the younger patient, plaque-like bodies and a few neurofibrillary tangles were found. From a survey of the cases hitherto reported in the literature it appears that among patients over 50 years of age it is common to encounter pathological features typical of Alzheimer's disease or senile dementia, that plaque-like bodies may occur in the second decade, neurofibrillary tangles in the third decade and a congophilic angiopathy in the fourth decade. The congophilic angiopathy is a frequent finding. Due to their high frequency, calcium or calciumlike deposits are regarded as important histopathological substrates of Down's syndrome. The clinical symptomatology of the long-surviving patients with Down's syndrome is that of a non-characteristic brain aging process and differs from that of the typical Alzheimer's disease. Organic dementia is not regularly found. Altogether, the anatomical findings in adult patients with Down's syndrome indicate a premature aging of the brain, which becomes more significant and widespread with increasing age.

[Ventromedial field of human tuber cinereum. Mechanical morphometry]. / Das ventromediale Feld des menschlichen Tuber cinereum. Ergebnisse maschineller Morphometrie

A quantitative structural analysis of the ventromedial area of the human hypothalamus was performed using an automatic image analysing computer. We divided the ventromedial area into two nuclei, nucleus ventromedialis (N. vm.) and nucleus infundibularis (N. inf.). N. vm. was studied in 6 cases, N. inf. in 7 cases. The following findings were obtained: 1. No significant differences of cell population became apparent between the left and right sides of both nuclei. Aside from a female case above 80 years of age, so far, no correlation with cellular distribution of age and sex, respectively, could be established. 2. In N. vm. the distribution of large and small nerve cells depends on the region within this nucleus. Small nerve cells appear more frequent in the medial region than in the central and in the lateral regions. On the other hand, significant distributional differences of nerve cells in the dorsal, central, and basal regions as well as in oro-caudal direction are absent. Data of individual cases and their mean value are conforming. Cell density (cell number/volume) does not show any regional dependence both in the frontal plane and in the oro-caudal direction; it amounts to approximately 170/mum3 in the entire nucleus. 3. In the frontal plane plane N. inf. does not disclose marked regional differences of cell population. Large neurons are slightly more frequent in the basal-medial region as compared to the dorsal region. An 81-year-old woman displayed a conspicuous increase of large nerve cells in the basal and centrolateral regions, obviously hypertrophy of the potential "subventricular nucleus" as described by SHEEHAN and KOVACS, which is, in our opinion, a part of the N. inf. In young subjects (below the age of 40 years) the frequency of large nerve cells decreases in oro-caudal direction. Identical cell populations suggest that the cuadal end of N. inf. extends to the floor of the mammillary recessus. Cell density in the frontal plane appears higher in the centrolateral region (230/mum3) compared to the dorsal and basal regions (190-200/mum3). Cell density increases in oro-caudal extent; it decreases, however, in the most caudal part.

[Indications for stereotaxic neurosurgery of patients with multiple sclerosis (author's transl)]. / Indikationen zur stereotaktischen Operation bei Patienten mit multipler Sklerose

The long-term results of 12 stereotaxic operations on 11 multiple sclerosis patients with incapacitating intention tremor were evaluated and compared with the experiences of other authors. The selection of the patients, the criteria applied for the success and the length of the follow-up period influenced the reported results. Considering not only the relief of the intention tremor but the overall performance after the operation only a certain group of patients seemed to profit by neurosurgical treatment. Applying this criterion of overall performance and evaluation only 3 out of 11 patients in our series had real benefit from the operation. The reasons for this small number of good or moderate results are given with brief discussion of some of the cases. History, course and fatal outcome of one patient are presented in detail together with the neuropathological findings. According to the literature and the limited number of our own cases the following indications for stereotaxic operations on MS patients can be established: 1. Tremor and hyperkinetic movements should be the dominant features of the symptomatology. 2. The overall performance should be essentially improved by the operation. 3. Patients in the terminal stage of the disease gain little from the procedure, whereas patients with longstanding more benign course are the best candidates.

[Planimetric volumetry of human brains]. / Planimetrische Volumetrie an menschlichen Gehirnen

1) Coronal sections measuring exactly 4 mm in thickness of 106 human brains (212 cerebral hemispheres) were cut with the Göttinger Hirnmakrotom. Planimetric volumetry of various macroscopically delineated structures was performed on photographs of the sections. 2) The volumes ovtained from 58 "normal cases" were used for determining preliminary standards as well as mean values and standard deviations for age and sex. The female-male ratio of the structures measured varies between 86 and 92%. Comparing right and left a predominance of the left pallidum for both sexes is apparent showing an error probability of less than 5%. In "normal" men a significant predominance of the rightsided frontal structures, located anterior to the anterior commissure, have been found (error probability of less than 1%). 3) Regarding the 48 "abnormal cases", striatum and pallidum show a uniform picture in Huntington's disease, namely an extreme shrinkage. The pallidum shrinks to a similar extent as the striatum, although its neurones are not substantially affected by this system atrophy. Other structures do not display similarly uniform changes in this disease. 4) In Parkinson's syndrome a tendency of the pallidum to enlarge -- though statistically not significant -- is seen. This raises the question whether a constitutional hyperplasia of this structure is sometimes involved in the pathogenesis. 5) In Pick's disease, it is not only the histologically impressive centers of shrinkage of the cerebral cortex that are atrophic, but, to a somewhat lesser degree, also the whole telencephalon. 6) In an 18-year-old girl with malignant obsessional neurosis (schizophrenia?) the volume of the striatum was highly above average values enlarged. 7) Bibliographical data of macroscopic-quantitative brain research reveal many problems which can be solved today due to improved methods.