FM-Ultranet: a Decision Support System using Case-

Based Reasoning, Applied to Ultrasonography

Ziad El Balaa1, Anne Strauss1, Philippe Uziel1, Kerstin Maximini2 and Ralph
Traphöner3
1
University Pierre and Marie Curie,
75005 Paris, France
{elbalaa, strauss}@ccr.jussieu.fr
philippe.uziel@free.fr
2 Data and Knowledge Management Group, University of Hildesheim, PO Box 101363,

31113 Hildesheim, Germany

k_maximi@dwm.uni-hildesheim.de
3 empolis GmbH arvato Knowledge management, part of Bertelsmann, Europaallee 10,

D-67657 Kaiserslautern, Germany

ralph.traphoener@empolis.com

Abstract. Case-based reasoning (CBR) is a recent approach for many applica-

tions in medicine, particularly in decision support. In this paper we describe the
CBR system FM-Ultranet, used in the domain of ultrasonography. Due to the
hierarchical structure of the model and the definition of a similarity measure,
we achieve an excellent retrieval of similar cases from the case base. Medical
experts have evaluated FM-Ultranet in daily practice and the system has met
their expectations.

1 Introduction

In almost all European countries, the surveillance of pregnant women is done

through ultrasonographic examinations, usually 3 during the 9 months pregnancy.
This technique started to be used in 1975 and there are still few experts in this field;
depending on the country, between 60% and 75% of the malformations remain unno-
ticed in Europe [1]. This is due to the fact that, as compared to almost all other ultra-
sonographic examinations, the examination of the fetus necessitates to carefully
watch not only for the anatomical features of the organs but also for their relationship
as well as the movements of the fetus. The detection of malformations or abnormali-
ties is consequently very difficult and they often remain unnoticed until the birth of
the child. The consequences are manifold; the most common ones are unscheduled
medical or surgical interventions - which might have consequences on the future
health of the child - up to medical termination of pregnancy. To reduce these prob-
lems, reference centers in prenatal diagnosis have been established to offer first level
ultrasonographists, i.e. the practitioners who perform routine screening ultrasounds of
pregnant women, the possibility to ask for expert advice. This adds extra costs and is
far from solving the problem; the number of experts is insufficient and sometimes the
expert is not available where the practitioner needs real-time expertise about a mal-
formation.
In France only, fetal malformations represent about 3%-4% of the cases [2], i.e. 40
000 to 50 000 cases every year. At the European level, this problem concerns a hun-
dred thousand pregnancies [3].
The problems described above are addressed by our work, partly funded by the
European Union within the IST research program under contract no. IST-1999-
20865: Foetal Malformation – Ultrasonography training networking platform (FM-
Ulranet).

2 Case-Based Reasoning in Ultrasonography

When an ultrasonographist detects an abnormality during the morphological examina-

tion, his or her problem is to decide whether this abnormality is a dangerous malfor-
mation; if pregnancy should be terminated, or just a particularity without importance.
To come to his decision, the ultrasonographist can use several knowledge sources: his
“textbooks” medical knowledge in this domain, his “personal memory” of previous
cases (personal experience), and/or the advice and second opinion of an expert. FM-
Ultranet relates those ways to support the ultrasonographist by using Case based
reasoning (CBR) and Expert networking technology.
We improve ultrasound scans interpretation and diagnosis through comparison of
past existing similar cases stored in a database of reference cases and with guidance
by an expert.
The goal of our work within the project was the development of:
− a reference database of clinical cases of foetal malformation,
− a multimedia support dedicated to these malformations making available the data-
base for consultation by first level ultrasonographists and offering them the possi-
bility to submit cases to experts for advice,
− a decision support system that will exploit image analysis and pattern recognition
techniques to provide diagnosis and training to the practitioner.
In this paper we describe how we have achieved this goal and present the architecture
of the FM-Ultranet system. It is an application based on CBR, because this technol-
ogy is able to combine the capacity of the ultrasonographist to solve a problem with
the capacity of an information system. The efficiency of CBR in medicine is proven
in many domains [4,5,6,7] especially in decision support systems [8,9,10]

3 Knowledge Representation

For case representation, we have developed an object-oriented, hierarchical model,

which consists of about 140 attributes, organized in 39 concepts and sub concepts to
represent characteristics in a medical sense. Most of the attributes store knowledge
about the anatomical structure of the fetus, like the urinary tract and the morphology
of the head, thorax, or rachis. But to retrieve preferably similar cases to a present case
from the reference case base, the case representation is completed by clinical data of
the mother (medical history), ultrasound imaging, bibliographic references, outcome
of the pregnancy, the status of the child at birth, the result of the autopsy, and the
international classification of diseases code (ICD10).
Each attribute has a data type assigned. The majority of data types are given by
special values like Seen, Not seen, It cannot be seen, and Not yet examined. Numeri-
cal values are used for biometrical information. Some attributes can carry symbolic
value enumerations, e.g., the type Change carries decrease, unchanged, and increase
to indicate the change between the current examination and the last examination for
the same patient.
Figure 1 is an excerpt from the complete hierarchical model. The concept Urogeni-
tal System consists of left and right kidney, adrenal gland and ureter as well as sex,
bladder and the information, whether the renal vessel is found or not. The concept
Kidney and its sub-concepts are shown in detail. Figure 2 shows the decomposition of
our main concept FM. The concept has 23 attributes with different data types: we
distinguish attributes with simple data types (written in italics), attributes with data
types defined by us (written in italics and framed with a grey box) and attributes
whose data type is a concept itself (written bold and having a "+" or "-" in front).

Urogenital System Kidney

-RightKidney : Kidney -AspectOfKidney : SimpleBiometry
-LeftKidney : Kidney -BiometryOfKidney : BiometryOfKidney
-Sex : Sex -KidneyPelvis : Normal/Abnormal
-RightAdrenalGland : Normal/Abnormal -ChangeOfAspectOfKidney : Change
-LeftAdrenalGland : Normal/Abnormal -ChangeOfKidneyPelvis : Change
-RightUreter : Ureter
-LeftUreter : Ureter
-RenalVesselFound : Boolean
-Bladder : Bladder

StatusOfKidney
-KidneyShape : Normal/Abnormal
-Cortico-medullarDifferentiation : Normal/Abnormal
-ChangeOfShapeOfKidney : Change
Types -ChangeOfCortico-medullarDifferentiation : Change
-ChangeOfDuplication : Change
«enumeration» «enumeration» -ChangeOfStatus : Change
Normal/Abnormal Boolean -Duplication : Boolean
+Normal +true -Status : Normal/Abnormal
+Abnormal +false

«enumeration» «enumeration»
Change SimpleBiometry
+decrease +small Vascularisation
+unchanged +normal
+increase +big -...

Fig. 1. Excerpt from Aggregation and Specialization Hierarchy of Concepts

Fig. 2. FM main concept and the different attributes

For each attribute a similarity measure is defined by a mathematical function or a

table, depending on the attribute’s type. For example the similarity measure for the
gestational age is a function that reflects the usual time frame of eight weeks in which
the regular examinations take place, i.e. around week 14, 22 and 34. Figure 3 depicts
this function, where e.g. a case that is from a week that is 4 weeks later than the pre-
sent one is considered as being 50% similar.
Fig. 3. Similarity Measure for Gestational Age

Additional medical background knowledge is expressed in rules. There are rules to

derive the value of attributes from others, ex: if the practitioner enters the value “Ab-
normal ” for the attribute “Kidney Shape“ the system then automatically assigns the
value “Abnormal “ for the attribute “Status “. There are rules to show any changes
between the present examination and the last one of the same patient and others to
generate an alert message if the practitioner fills an error value.

4 Results

FM-Ultranet has been implemented with CBR-Works, a tool provided by empolis, a

firm based in Germany. We have chosen 130 reference cases about malformations of
the urinary tract with their corresponding images as a starting point to evaluate our
system and to build upon; these malformations being very common, most frequent
and often difficult to detect.
To represent these cases we have defined a model, consisting of 140 attributes like
those described in Section 3. The knowledge representation fully covers sane and
normal fetus; according to the representation of malformations, the urinary tract is
fully described, 25% of the heart diseases and 10% of abdomen diseases are covered.
Using an easy interface with five screens only, the ultrasonographist can enter the
necessary data for a normal examination. For an abnormal examination another inter-
face containing all the attributes (Fig. 4), most of the values are automatically derived
by the system, and providing access to the International Classification of Diseases
(ICD10) can be used.
Fig. 4. User interface For an abnormal examination

To make the usage of FM-Ultranet for ultrasonographists even more attractive, we

have also implemented a report generator that helps to shorten examination time.
Based on the currently entered observations made during the examination of the pa-
tient, a medical report can be automatically generated and exported in RTF-format1.
When the system retrieves the similar cases for a new case, the ultrasonographist can
compare the data and the images between cases.
The medical partners in the project evaluated the results provided by FM-Ultranet,
like the quality of the retrieved cases and thus the quality of the knowledge, covered
in the reference case base and the similarity measures. The system has met the ex-
pert's expectations and was evaluated during a 3 months trial by eleven medical doc-
tors and 3 experts, in Hospitals in Nîmes in France and Liège in Belgium.
The product has been distributed to all the participants in the trial under the form
of a package composed as follows:
− A CD-Rom containing the FM-Ultranet system,
− A printed tutorial-manual covering the use of the system, from the installation
phase up to the advanced use of the tool,

1 Rich text Format, a format readable by most word processing packages.

− An evaluation questionnaire filled out after their perusal of the FM-Ultranet sys-
tem. The questions are assembled into nine groups (General information, Usage of
the tool, Satisfaction analysis and perceived usefulness, Impact on your work prac-
tices, Relevance of the data base, On-line training, Technical analysis, Economic
impact of the tool, Conclusion)
The objective of this trial was to experiment an on-the-job training platform for ultra-
sonographists in the field of pregnancy surveillance to improve early detection of
foetal malformation. The training platform aims at helping ultrasonographists to im-
prove their diagnosis skills by comparison with existing clinical cases, exploitation of
their own past experience and means to contact external experts.
The trial addresses the problem of improving foetal malformation detection by the
practitioner, which is a very difficult task for a non-specialist in this domain.
With a unanimous ‘yes’ answer to the question on usefulness and With 45% of the
testing population having acquired new knowledge, the FM-Ultranet system is meet-
ing ultrasonographers needs. Not only training needs directly related to their practice
but also basic organisational needs such as record keeping, statistical, and report
writing.
The possibility offered by the tool to compare situations from both an image stand-
point and clinical data standpoint, the FM-Ultranet system has proven useful in
guiding its users as regards: helping manage the cases, refining the selection of im-
ages, refining diagnosis and prognosis and determining the type of pathology. thus
demonstrating its capacity to improve ultrasonographers practice
The system is perceived as “pedagogic”, its use is offering diagnosis making sup-
port and decision making support. It is also perceived as a good tool for continuing
education.
Concerning the role of the experts the trial has clarified two key points. The ultra-
sonographers wish to have access, on line, to an expert and one of the conclusions is
the role of the expert will become more important over time. This appears to be espe-
cially true with field practitioners whose main activity is not ultrasonography ; such
as MDs specialising in medical imagery working in small urban centres or rural areas.

5 Conclusions and Future

The FM-Ultranet system has proven its feasibility in the work with subject matter
experts and its usability in day-to-day practice.
With the help of the system, data collection turned out to be more complete than
before. In particular, the creation of the reference case base produced a new asset in
itself. The presentation of a relevant reference case during a present examination
leads to quicker and safer decisions, hence improving the confidence level of the
ultrasonographist.
After the trial period the ultrasonographists had two requests: the first one was to
extend the representation of malformations of the fetus, e.g., for the heart, head and
abdomen. The present structure already forms an important step towards standardiz-
ing the description of malformations. The second request is to integrate FM-Ultranet
in an e-learning system. This extension makes FM-Ultranet a teaching assistant sys-
tem built on the decision support system [11].
Recent works [12,13] advocate for the integration of CBR with Image Based Rea-
soning in the domain of In Vitro Fertilization (IVF) analysis. While the human inter-
pretation of images is more flexible, machine interpretation can provide precise and
objective results. The FM-Ultranet feature set should be analyzed according to which
of its features can be extracted from the image data automatically, when the quality of
images increases and when the field of automatic image analysis advances.

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