Jurnal
Jurnal
Jurnal
Nursing Department, Faculty of Medical Sciences, State University of Campinas, Campinas, SP, Brazil
Center of Fuzzy Systems in Health, School of Medicine, University of So Paulo, So Paulo, SP, Brazil
c Womans Hospital Professor Jos Aristodemo Pinotti, University of Campinas, Campinas, SP, Brazil
d Nursing Department, Federal University of So Paulo, So Paulo, SP, Brazil
b
a r t i c l e
i n f o
a b s t r a c t
Article history:
I).
13 May 2012
Methods: A fuzzy cognitive map (FCM) was structured considering six possible diagnoses:
stress urinary incontinence, reex urinary incontinence, urge urinary incontinence, functional urinary incontinence, total urinary incontinence and urinary retention; and 39 signals
Keywords:
associated with them. The model was implemented in Microsoft Visual C++ Edition 2005
Fuzzy logic
and applied in 195 real cases. Its performance was evaluated through the agreement test,
Urinary incontinence
comparing its results with the diagnoses determined by three experts (nurses). The sensi-
Nursing diagnosis
tivity and specicity of the model were calculated considering the experts opinion as a gold
Differential diagnosis
standard. In order to compute the Kappas values we considered two situations, since more
than one diagnosis was possible: the overestimation of the accordance in which the case
was considered as concordant when at least one diagnoses was equal; and the underestimation of the accordance, in which the case was considered as discordant when at least
one diagnosis was different.
Results: The overestimation of the accordance showed an excellent agreement (kappa = 0.92,
p < 0.0001); and the underestimation provided a moderate agreement (kappa = 0.42,
p < 0.0001). In general the FCM model showed high sensitivity and specicity, of 0.95 and
0.92, respectively, but provided a low specicity value in determining the diagnosis of urge
urinary incontinence (0.43) and a low sensitivity value to total urinary incontinence (0.42).
Conclusions: The decision support system developed presented a good performance compared to other types of expert systems for differential diagnosis of alterations in urinary
elimination. Since there are few similar studies in the literature, we are convinced of the
importance of investing in this kind of modeling, both from the theoretical and from the
health applied points of view.
Limitations: In spite of the good results, the FCM should be improved to identify the diagnoses
of urge urinary incontinence and total urinary incontinence.
2012 Elsevier Ireland Ltd. All rights reserved.
Corresponding author at: Rua Conceico, 552 apto. 25 Centro, 13010-050 Campinas, SP, Brazil. Tel.: +55 19 3521 8831;
fax: +55 19 3521 8822.
E-mail addresses: mhbaena@fcm.unicamp.br, mhbaenaml@yahoo.com.br (M.H.B.M. Lopes).
1386-5056/$ see front matter 2012 Elsevier Ireland Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ijmedinf.2012.05.012
202
1.
i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 8 2 ( 2 0 1 3 ) 201208
Introduction
Scientic and technological advances in medicine and healthcare areas are notable, particularly in the last thirty years.
However, the diagnostic process is still considered an art, being
a complex task due to, among other things, the uncertainties
present in this process. The relationship between a diagnosis
and its symptoms is not always a bi-univocal correspondence,
that is, different diagnoses share one or more symptoms, and
the clinical observations are subject to errors and may be
insufcient for a more precise diagnosis [1,2].
Urinary complaints are common in the general population.
Urinary incontinence (UI), in particular, has high frequency
especially among women, impairing daily activities, social
interactions and self perception of health status [3].
However, one reason because the urinary alterations could
be not diagnosed is the fact that health professionals often are
not prepared to identify, treat or refer people with these problems. In addition, there are many identication uncertainties
in the diagnosis of the different types of urinary incontinence as demonstrated in a study developed in the city of
Campinas, Brazil, which aimed to investigate how physicians
and nurses at primary care units investigate and manage the
cases of female urinary incontinence and if they discriminate
the different types of urinary incontinence. It was veried
that, excluding the gynecologists, doctors and nurses rarely
or never investigate if the woman has incontinence and when
they do so, sometimes they do not know what to do or do not
choose the more adequate conduct [4].
The differential diagnosis of disorders of the urinary elimination is sometimes difcult to be established for nurses who
are not expert in the eld and, for this reason, frequently
they cannot indicate the more adequate treatment [4]. In
the Netherlands, several national reports recommend involving nurse specialists to support general practitioners and to
improve patient care [5]. Thus, it is possible that expert systems can play an important role as tools for decision support
in the diagnosis of UI, and also improving the nursing care to
these patients.
Due to the linguistic nature of urinary incontinence problem, and the vagueness and uncertainty of the concepts
assessed, fuzzy sets theory presents advantageous characteristics to be used in such a classication task. Fuzzy sets theory
was developed based on the concept of partially true values,
ranging from completely true to completely false, limits of
the classical logic. Fuzzy systems, using fuzzy sets theory, have
been applied with success in several health areas, such as:
diagnostic systems [6,7,8], treatment of images [9], quality of
life evaluation [10], epidemiology and public health [1,11,12].
Fuzzy cognitive map (FCM), a specic type of fuzzy systems, can be understood as the result of the synergy among
fuzzy logic and neural network methodologies, for which the
structure is implemented in a computational environment. In
the FCM theory the systems are described by a symbolic representation (graphs) where concepts interact with each other
through a dynamical process. This structure has been applied
with success in the modeling and control of complex systems,
which is the case of differential diagnosis systems [13]. The
concepts modeled by FCM in differential diagnosis systems are
2.
Methods
In our study we developed a fuzzy cognitive map for the differential diagnosis of alterations in urinary elimination based
on the dynamical structure proposed by Souza et al. [14] and
on the modied proposal of Georgopoulos et al. [13]
First of all, it is important to determine the concepts that
best describe the system, that is, the factors that are crucial
for the modeling of the system [13]. For this, the NANDA-I
i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 8 2 ( 2 0 1 3 ) 201208
203
Table 1 (Continued)
Nursing
diagnosis (ND)
204
i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 8 2 ( 2 0 1 3 ) 201208
At+1
=f
i
n
ji At j ,
(1)
j=1,j =
/ 1
1
.
1 + ex
(2)
Thus, the system was dynamically processed until obtaining a steady-state or a dynamical equilibrium. These cognitive
maps could converge to a xed point, which means that the
values of concepts do not change with the updating, converge
to a periodic cycle, which means that the values are periodically repeated, or a system presents a chaotic behavior [26].
The implementation of this FCM model was performed
using the Microsoft Visual C++ Edition 2005. In addition to
x the values of the symptoms, after testing different scenarios, the best result was obtained with the competition scenario
between diagnoses explained above.
Since the diagnoses in question were not exclusive, i.e. it is
possible that the patient had more than one diagnosis, it was
considered as the response of the model not only the diagnosis with the greatest value at the end of the simulation, as
proposed by Souza et al. [14], but a range of values.
This research was approved by the Research Ethic Committee of the institution and all participants gave informed
consent to the work.
DC1
DC2
DC3
DC4
DC5
DC6
DC7
DC8
DC9
DC10
DC11
DC12
DC13
DC14
DC15
DC16
DC17
DC18
DC19
DC20
DC21
DC22
DC23
DC24
DC25
DC26
DC27
DC28
DC29
DC30
DC31
DC32
DC33
DC34
DC35
DC36
DC37
DC38
DC39
3.
ND1
ND2
ND3
ND4
ND5
ND6
0.75
0.75
0.5
0.3
0.3
1
0.7
0.9
1
0.6
0.9
0
0
0
0.2
0
0.1
0
0.3
0.2
0
0.7
0
0.5
0.2
0
0.5
0.9
0
0.8
0.7
0
0
0.1
0
0
0.1
0
0
0.6
0.1
0
0
0
0.7
0
0
0
0.1
0
1
0
0
0
0
0
0
0.2
0
0
0
0.2
0.3
0
0
0
0
0
0.9
0.9
0.2
0
0
0
0
0.1
0
0
0
0
0
0
0.5
0
0.1
0.6
0.6
0.1
0
0
0.8
0.9
0.9
0.5
0.9
0.5
0.9
0.9
0.9
0.5
0
0
0.5
0
0
0
0
0
0
0
0.2
0
0
0.1
0.2
0
0
0.2
0.8
0
0
0
0
0
0
0
0.2
0
0
0
0
0
0
0
0
0
0
0
0
1
0.8
0.6
0.6
0
0
0
0.1
0
0.2
0
0
0
0
0.1
0.1
0
0
0.2
0
0
0
0
0
0
0
0
0.9
0
0
0
0
0
0
0
0.1
0
0
0
0
0
0
0
1
0.9
0.7
0.7
0.7
0
0
0
0
0
0
0
0
0.5
0
0.6
0.2
1
0
0
0
0
0.5
0
0.2
0
0
0
0.1
0.4
0.4
0
0.9
0
0
0.3
0
0
0
0
0
0
0.1
0
0.9
0.9
0.7
0.7
0.7
0.7
0.9
0.8
Results
i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 8 2 ( 2 0 1 3 ) 201208
Experts
Stress
Urge
Retention
Total
Reex
Functional
Urge + stress
Urge + functional
Urge + stress + functional
Urge + stress + retention
Urge + reex + retention
Urge + total
Urge + retention
Stress + retention
Reex + total
Reex + retention
Total
FCM
54
17
14
12
1
0
97
0
0
0
0
0
0
0
0
0
19
21
9
1
3
0
116
5
8
2
1
3
4
1
1
1
195
195
Total concordance
Partial concordance
Total discordance
121
64
10
62.1
32.8
5.1
Total
195
100.0
Sensitivity
Specicity
Urge
Stress
Reex
Total
Retention
General
1
0.95
1
0.42
1
0.95
0.43
0.93
0.97
1
0.98
0.92
overestimation of the accordance in which the case was considered as concordant when at least one diagnosis was equal;
and the underestimation of the accordance, in which the case
was considered as discordant when at least one diagnosis was
different.
Table 3 shows the diagnoses determined by experts and by
the FCM. Compared to the experts, the FCM identied less 35
cases of stress urinary incontinence and less 11 cases of total
urinary incontinence.
As shown in Table 4, the model was able to determine
the diagnosis in total or partial agreement with the panel of
experts in 94.9% of cases. In 10 cases (5.1%) the model had a
diagnosis that differed completely from those determined by
experts.
The agreement between the model and the experts was
very good (kappa = 0.92, p < 0.0001) or moderate (kappa = 0.42,
p < 0.0001), considering the overestimation and underestimation of the agreement, respectively.
Table 5 presents the calculation of sensitivity and specicity of the FCM in the determination of each of the diagnoses
205
4.
Discussion
206
i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 8 2 ( 2 0 1 3 ) 201208
Fig. 2 The receiveroperator curve (ROC) of the diagnoses urge urinary incontinence (urge), stress urinary incontinence
(stress), total urinary incontinence (total) and urinary retention (retention), and the measurement of the area.
consensus terminology of the International Continence Society. We believe that a system based on that terminology could
be useful not only for nurses but also for physicians and physiotherapists.
In addition, we developed a program geared to the user who
is able to implement a fuzzy map, regardless of its application.
This program is a rst prototype for the future development
of a specic system for differential diagnosis.
5.
Conclusions
An FCM model was applied to 195 cases of urinary incontinence, following the NANDA-I classication categories. In
spite of its good results compared to the fuzzy system for
differential diagnosis based on the composition of fuzzy
relations, the FCM should be improved to identify the
diagnoses of urge urinary incontinence and total urinary
incontinence.
A great advantage of FCM is that it is able to manipulate
incomplete information, suggesting a diagnosis even when
some data are unavailable and proposing differential diagnoses that could be better investigated. In addition, it can
consider associations among several variables.
Finally, since there are few similar studies in the literature,
we are convinced of the importance of investing in this kind
of modeling, both from the theoretical and from the health
i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 8 2 ( 2 0 1 3 ) 201208
Summary table
What was already known on the topic:
The urinary alterations are often no diagnosed and one
reason is that health professionals are not prepared
to identify, treat or refer people with these problems.
In addition, there are many identication uncertainties in the diagnosis of the different types of urinary
incontinence.
Fuzzy sets theory has become a powerful tool for dealing with vagueness and uncertainty.
Fuzzy cognitive map (FCM) can be understood as the
result of the synergy among fuzzy logic and neural network methodologies, whose structure is implemented
in a computational environment.
The concepts modeled by FCM in differential diagnosis
systems are diseases and symptoms, and the associations between them are described through the graphs
structures. Both qualitative and quantitative data can
be represented in this kind of model.
207
Rosngela Higa: (1) acquisition of data, (2) revising the article critically for important intellectual content, and (3) nal
approval of the version to be submitted.
Heimar de Ftima Marin: (1) the conception and design of
the study and interpretation of data, (2) revising the article critically for important intellectual content, and (3) nal approval
of the version to be submitted.
Conicts of interest
There are no conicts of interest.
Acknowledgments
This work was supported by the National Council of Scientic
and Technological Development CNPq 476854/2004-0.
Dr. Marin was partially supported by grant NIH
D43TW007015, BRIGHT and CNPq 301735/2009.
references
Authors contributions
Maria Helena Baena de Moraes Lopes: (1) the conception and
design of the study, acquisition of data, analysis and interpretation of data, (2) drafting the article, and (3) nal approval of
the version to be submitted.
Neli Regina Siqueira Ortega: (1) the conception and design
of the study, analysis and interpretation of data, (2) revising
the article critically for important intellectual content, and (3)
nal approval of the version to be submitted.
Paulo Srgio Panse Silveira: (1) analysis and interpretation
of data, (2) revising the article critically for important intellectual content, and (3) nal approval of the version to be
submitted.
Eduardo Massad: (1) the conception and design of the study,
(2) revising the article critically for important intellectual content, and (3) nal approval of the version to be submitted.
208
[14]
[15]
[16]
[17]
[18]
[19]
[20]
i n t e r n a t i o n a l j o u r n a l o f m e d i c a l i n f o r m a t i c s 8 2 ( 2 0 1 3 ) 201208