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A Proposed Model of Soft Computing in Diagnosing Diseases and Prescribing Herbal Prescriptions by Oriental Medicine

Cao Thang1, Eric W. Cooper2, Yukinobu Hoshino3, Katsuari Kamei3


Graduate School of Science and Engineering, Ritsumeikan University thangc@spice.ci.ritsumei.ac.jp 2 21st Century Center of Excellence, Ritsumeikan University cooper@se.ritsumei.ac.jp 3 College of Information Science and Engineering, Ritsumeikan University {hoshino, kamei}@ci.ritsumei.ac.jp
Abstract - In this paper, we present a soft computing model of decision support systems for diagnosing diseases and prescribing herbal prescriptions by oriental medicine. Inputs to the model are severities of observed symptoms on patients and outputs from the model are a diagnosis of disease states and corresponding herbal prescriptions. First, having used fuzzy inferences, the most serious disease state in which the patient appears to be infected is determined. Next, an herbal prescription written in suitable herbs with reasonable amounts for treating that disease state is given by neural networks. Finally, we describe an application of this model in rheumatism diagnoses and show its evaluations. Keywords - Decision support system, expert system, fuzzy inference, neural networks.
I. INTRODUCTION
1

Internal diseases are widespread in all Vietnamese population groups, unfortunately influencing socioeconomic aspects of Vietnam. In Vietnam, therapeutic ways for these diseases are physical methods, western medicine and oriental medicine (OM). Among them, OM is an indispensable part because it has fewer side-effects than western medicine and gives good treatment results. Besides, herbal prescriptions are easy to find and relatively cheap in comparison with western drugs. The number of Vietnamese patients treated by OM is about 50 %. The accurate diagnoses have an important role in treating diseases. Applying suitable computing models and then building successful decision support systems (DSS) based on knowledge from skilled OM physicians will help moderate subjective evaluation in diagnosing and prescribing processes. It will indirectly help physicians to provide the right treatments to the right patients, improving the quality of the health care services as a whole. It also will help qualified and experienced physicians in OM to maintain and share their profound knowledge with colleagues and to assist medical students or young physicians, especially those living and working in rural areas.
II. THE PROPOSED MODEL FOR DIAGNOSING AND PRESCRIBING IN ORIENTAL MEDICINE

Such prescriptions are easily found in medical text books or OM reference books. Infected by a disease state, most of patients have some secondary symptoms together with the disease-specified symptoms. It is much more efficient and effective for the standard prescription if physicians add more suitably additional herbs to it and then adjust all of its herbal amounts. The herbal adjustments are often based on the severities of observed symptoms on the patient, and their effects mainly depend on physicians treatment experience. Only experienced physicians can give patients suitable prescriptions with reasonable adjustments. Fig. 1 shows the process of diagnosing and prescribing diseases by OM doctors. Such a process can be suitably replaced with the proposed DSS model as shown in Fig. 2 [1]. Roles of the functional parts in Fig. 2 are as follows: Knowledge Acquisition: Surveys symptoms, explanations, sample prescriptions and prescribing rules. Knowledge Base: Consists of symptoms, disease states, inference rules, training data and explanations.
FOUR EXAMINATIONS Inspection Auscultati on Interrogat ion Pulse examinatio n

Severities of typical symptoms are clarified

Diagnose

A disease state is determined

Clinical experiences

Consider a suitable standard prescription

Herbal adjustments

FINAL PRESCRIPTI ON Herb 1 x gram Herb 2 y gram .......... Herb k z gram


Fig. 1. Diagram of diagnosing and prescribing diseases by OM doctors

According to OM, a disease has some specified states and each state is cured by a standard herbal prescription.

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corresponding neural network to get an appropriate herbal prescription.


Skilled physicians
Users

Severities of symptoms
Knowledge Acquisition
Prescribing

Disease states Herbal prescriptions Explanations


Explanation

1) Symptom and rule expression Suppose that the considered disease has m clinical symptoms, l disease states. A disease state is determined by n clinical symptoms. O O O Let S O = ( S1 , S 2 ,..., S m ) be a set of observed symptoms on a patient where S iO is a fuzzy proposition representing a symptom. Let H = ( H 1 , H 2 ,..., H l ) be a set of the disease states. Let S
Rj

Interface

Diagnosing

= ( S1 j , S 2 j ,..., S n j ) be a set of symptoms in

Neural Networks

Fuzzy Inference

premise of rule R j ( j = 1, 2, ..., l ) , where R j is generally

described in the following form:


IF S1 j and S 2 j and ... and S n j THEN disease state is H k
R R R

(1)
R

Knowledge Base

Fig. 2. Structure of the proposed DSS model for diagnosing and prescribing diseases by OM

Let the following fuzzy values in S iO and S i j be defined S O [0, 1] : truth value of S iO given by
i

doctors when diagnosing, where S O = 1


i

Fuzzy Inference: Checks rules, calculates weights and advises the most serious disease state. Neural Networks: Gives prescriptions with reasonable amounts of herbs. Interface: Obtains symptoms and their severities from users and shows inferential results. Explanation: Helps users to understand the diagnosed diseases and explains the results. A. Fuzzy Inference In OM, physicians usually give herbal prescriptions based on severities of clinical symptoms such as high fever, slightly numb joints etc. These fuzzy expressions of symptoms make it unsuitable for traditional quantitative approaches to build DSS in OM. Fuzzy sets, known for their abilities to deal with vague variables using membership functions rather than with crisp values, have proven to be one of the most powerful approaches to resolve this problem. They also enable developers to use linguistic variables and build a friendly user interface. OM physicians usually explain diagnosing and prescribing procedures with such expressions as this patient has these typical symptoms with these severities, so I prescribe these herbs with these amounts. These expressions can be represented quite naturally in IF-THEN fuzzy rules. In addition, fuzzy rules can give expert-like explanations, making it easier for doctors to understand the DSS. So far, based on fuzzy logic many practical applications in medicine including OM have been built [2 - 6]. In our model, first in the diagnosing stage, based on observed severities, fuzzy inference is used to decide which disease states the patient has. Then in the prescribing stage, the fuzzy severities will be put into a

means S iO clearly appears on the patient,

S O = 0 means S iO does not appear on the


i

patient, and 0 < S O < 1 means S iO appears on


i

the patient with the severity S O


i

S R j [0, 1] : importance value of S i j for the


i

prescription of disease state H j given by skilled doctors via survey in advance, where

i =1

Si

Rj

=1

(2)

S R j = 0 means S i j totally does not affect H j ,


i

S R j = 1 means S i
i

Rj

is the most significant symptom


Si
Rj

affecting H j , and 0 <

< 1 means S i j affects H j


Si
Rj

with the fuzzy importance

2) Fuzzy inference process If an observed symptom S iO is found in the premise of rule R j , premise weight wSj of S iO in R j is
i

calculated as:
w j = SO
Si
i

Si

Rj

(3)

where is a t-norm operator. If symptoms in S


Rj

of R j match with observed

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symptoms SO, weight wR of R j is calculated as:


j

wR j =

Si{S

R
j

S O }

wj

Si

(4)

Get input symptoms S O observed on the patient

START

where is a t-conorm operator, this t-conorm should be compatible with (2) Then the most serious disease state H* having the largest wR j value among l disease states will be determined: H * = {hk | wRk = max wR j }
j

inputs are not enough to match with any disease state ?


Yes

No

inputs are matched with more than one disease state ?


Yes

No

(5)

Fig. 3 shows the diagram of the inference procedure. When the input severities of symptoms are matched with one or more disease states, system finds the most serious state H* corresponding with these inputs. If the inputs are not matched with any state, system gives an advice about the closest state. In this case, patient may have diseases other than the considered disease. B. Neural Networks (NN) and Prescribing Process NN is an effective technique to help doctors to analyze, model and make sense of complex clinical data across a broad range of medical applications [7]. It enables intelligent systems to learn from experience, examples and clinical records, improving performance of the systems over time. Based on knowledge accumulated from experienced doctors and hospital information systems, NN can wisely give doctors good decisions, helping to moderate subjective evaluation in diagnosing and prescribing processes. A trained NN can give herbal prescriptions with reasonable amounts. Fig. 4 illustrates steps of applying NN into prescribing applications in OM. An important point in preprocessing training data is to select the right sets of input and output features. Raw data are prescribing rules, and herbal treatment prescriptions with typical observed severities gathered from experienced doctors. Features should be reasonably chosen so that they could be learnt by NN and from trained NN we can get appropriate prescriptions in accordance with observed symptoms and diagnosed disease states. In our model, each disease state uses a dedicated NN. Input data to NN are severities of the state-specified symptoms and outputs are coefficients of herbal amounts for treating the disease state. For the inputs, there are two types of symptoms. The first type is associated with Boolean values: Yes (true, coded by 1) and No (false, coded by 0). Observed severities in the second type are associated with 5 linguistic values in company with fuzzy intervals: no (0.00), slightly (0.25), moderately (0.50), relatively (0.75), clearly (1.00). There are two kinds of herbs in the final prescription, standard and additional herbs. Standard herbs cure the main disease states while additional herbs treat the secondary symptoms that may occur with these states. Amounts of both standard and additional herbs are adjusted by severities of the observed symptoms.

Find the closest disease state having maximum w R j fuzzy value

Find the matched disease state H * having maximum w R j fuzzy value

Give explanations about the closest disease state

Put the severities to NN corresponding to the matched disease state

- Get prescription from outputs of NN


END

- Get explainnation about the disease state - Display results

Fig. 3. Diagram of inference procedure

For the same disease state, prescriptions by different doctors might not look similar because some doctors use some herbs but others prefer equivalent herbs that also give the same effects but come in different amounts. To avoid using many equivalent herbs for the same prescriptions in training data, lists of herbs in the standard prescriptions from OM text books are used and clarified by experienced doctors. For user reference, equivalent herbs are written in the description part of sample prescriptions. Depending on each prescription, the amounts of an herb in prescriptions often vary from 2 to 60 grams. The error in the adjusted amounts of an herb accepted by doctors is usually 0.5 gram for small amounts and 1.0 gram for large amounts. Since the output range of NN is chosen from 0 to 1. Amounts of herbs are normalized as coefficients. The coefficient ck of amounts of herb k in training data, and the actual amount WkP of herb k in the prescriptive results is calculated as: (6) c k = WkT /W * (7) W P = c W *
k k

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- Typical herbal prescripti ons from experience d doctors - Prescribing rules

INPUT LAYER

OUTPUT LAYER HIDDEN LAYER Coefficien ts of amounts of herbs

S1

I1 H1

O1

c1

Feature extraction

S2
Training data
Feature vectors

I2

H2

O2

c2

Sm

Hl
Im

Op

cp

Fig. 4. Neural Network for prescribing applications in OM

where WkT is amount of herb k in training data and W * is the maximum amount of a herb in the prescription. C. Explanation One of indispensable features of a DSS is capabilities to offer explanations. In diagnosing diseases, logical explanations of the DSS can help users, especially young doctors or medical students, to deeply understand inference results. Explanations also make it easier for experienced doctors to revise related sample cases in training data. In our model we propose general and detailed explanations. General explanation: after fuzzy inference process, from the knowledge base, system obtains a general explanation about the most appropriate disease state, then shows a fuzzy graph of all related states and fuzzy weights wR j of rules. Detailed explanation about similar cases: in training data, system finds similar cases that have the same infected disease states and closest severities of observed symptoms with the diagnosed patient, then shows prescriptions of these cases and their explanations from experienced doctors.
III. AN APPLICATION OF THE PROPOSED MODEL

specific symptoms that affected herbal adjustments, then generated 5,000 doctor-like prescriptions with combinations of severities of the state-specified symptoms using doctor-prescribing rules and linear methods with ranges of herbal adjustments. Training data for NN are the generated prescriptions together with 460 real rheumatic prescriptions from the experienced doctors. There are 12 networks corresponding with 12 rheumatic states. Each NN has 3 layers as shown in Fig. 5. Input data to NNs are state-specified symptoms S iO (i = 1,2,..., m) with S O and outputs are coefficients
i

c k (k = 1,2,..., p ) of herbal amounts. The number of neurons in the hidden layer is equal to the number of output neurons. NNs are back-propagation networks adopting sigmoid or hyperbolic tangent activated functions. Adaptive learning and momentum term are also used. B. Evaluation Combining NN and fuzzy inferences, we can have a more powerful and effective DSS with learning and reasoning capabilities for diagnosing and prescribing.
HIDDEN LAYER OUTPUT LAYER INPUT LAYER Herbal amount coefficien ts Severities of specific symptoms c1

A. RETS We applied this proposed model to rheumatism and built a DSS called RETS: Rheumatism Evaluation and Treatment System by OM. Rheumatism is an arthritis disease accounting for 15% of all soft tissue diseases in Vietnam [8]. According to OM, it primarily consists of 12 disease states, 44 typical clinical symptoms, and the number of rheumatic treatment herbs is 63 [9]. First, based on the text books, a preliminary survey and real rheumatic prescriptions from experienced doctors in Thaibinh OM College, we have assessed important fuzzy values of symptoms in rheumatic states, chosen standard prescriptions from the OM text books, clarified additional and equivalent herbs, selected

S1

I1 . . .

H1 . . .

O1

. . .
w jk

Si

Ii
. . .

wij

Hj
. . .
Hq

Ok

ck

. . .
Op
cp

Sm

Im

Fig. 5. One NN in prescribing stage

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The inference rule given by (1) is equivalent to the following rule form: IF fuzzy severities of symptoms

S1 j is

S1

Rj

and ... and S n j is

Sn

Rj

(8)

THEN rheumatic state is H j with certainty factor wR j A DSS using the rule form (8) may need thousands of inference rules with many combinations of symptoms in premises. Not only do they take much time for developers to accomplish rule acquisition but also much effort for domain experts to revise all of the rules. In our model RETS uses just 12 inference rules by using the rule form (1) with (2). Experienced physicians have confirmed that it was easy to review the knowledge presented by the rules. With NN in our experiment, we randomly split training data into two parts of 80% and 20%, used the former for training and the later for testing. All of nonlinear relations (real prescriptions and rules of prescribed herbs) as well as linear relations (ranges of herbal adjustments) were well learnt by NN. Depending on the number of inputs and outputs, each NN can learn about 500 prescriptions within an accuracy of 10-2 mean squared error with both training and testing data (equivalent to error of 0.1 gram for each herb). In case of unknown inputs, RETS shows fuzzy graph of infected rheumatic states, recommends the most proper state in which the patient seems to be infected and gives explanations by fuzzy inference, then shows the advised prescription with appropriate herbal amounts by NN. Most of these prescriptions are completely compatible with the real prescriptions, prescribing rules and ranges of herbal adjustments in the training data. In the evaluation with doctors in Hanoi Oriental Medicine Institute, we asked the doctors for considering and then giving 50 rheumatic cases including real cases that they have treated, then compare RETS results with the doctors opinions. All prescriptions from RETS could be practically used said by doctors. About herbal adjustment including additional herbs and amounts of herbs in the final prescriptions, 94% prescriptions from RETS are totally agreed and 6% are fairly accepted. It was also interesting when experienced doctors used RETS to illustrate treatments of clinical rheumatism cases for medical students.
IV. CONCLUSIONS

knowledge of human philosophy [10]. If a patient has other diseases, doctors cannot solely rely on this system since they do not have evidence to control potential effects of the herbal remedies on the other concurrent diseases. Hence, it is recommended that the system be used only for patients with the specific disease alone, not for those with other concurrent diseases.
ACKNOWLEDGMENT

The preliminary survey was conducted by physicians Hoan V.T and Lam. P.Q in Hanoi OM Institute. The real rheumatic prescriptions were prescribed by physicians Hoan V.T, Hong N.T.M, Hoa N.T, Ngoc P.T in Thaibinh OM College. And the results was evaluated by physicians in Hanoi OM Institute. We would like to thank all of the physicians for their valuable supports.
REFERENCES

[1] John Durkin, Expert System, Design and Development, Prentice Hall Inc, New York 1994. [2] Maysam F. Abbod, DiedrichG. von Keyserlingk, Derek A. Linkens; ., Mahdi Mahfouf, Survey of utilization of fuzzy technology in Medicine and Healthcare. Fuzzy Sets and Systems 120 (2001) 331349 [3] D.A. Linkens, M.F. Abbod and M. Mahfouf, Intelligent systems in biomedicine, ESIT 2000, September 2000, Aachen, Germany [4] Nguyen Hoang Phuong, Nguyen Thanh Thuy, Cao Thang, Duong Trong Hieu. Building a fuzzy expert system for syndrome differentiation in the oriental traditional medicine, The International Symposium on Medical Informatics and Fuzzy Technology, August, 1999, Hanoi, Vietnam [5] M. Belmonte-Serrano, C. Sierra, R. Lopezde-Mantaras, RENOIR: an expert system using fuzzy logic for rheumatology diagnosis, Internat. J. Intell. Systems 9 (11) (1994) 9851000 [6] K. Boegl, F. Kainberger, K.P. Adlassnig, G. Kolousek, H. Leitich, G. Kolarz, H. Imhof, New approaches to computer-assisted diagnosis of rheumatologic diseases, Radiologe 35 (9) (1995) 604 610 [7] Richard Dybowski and Vanya Gant, Clinical applications of Artificial neural networks, Cambridge University Press 2001 [8] Le Anh Ba, Treating reality rheumatism, Medicine and pharmacy journal HCMC, June 2001 [9] Tran Thuy, Pham Duy Nhac, Hoang Bao Chau, Hanoi Medical University - Lectures in Oriental Medicine, Medicine Pub. Hanoi 2002 (2), 160-165 [10] Michael Negnevitsky, Artificial Intelligence A Guide to Intelligent Systems, Pearson Education Limited 2002, 12

We proposed a model of soft computing in diagnosing diseases and prescribing herbal prescriptions by OM, then applied this model to RETS: Rheumatic Evaluation and Treatment System. Then we could confirm that this model has high performances and high applying abilities for diagnosing diseases and prescribing herbal prescriptions. Unfortunately, like other DSS often restricted to a narrow domain of expertise, the above model developed for diagnosing and prescribing a specific disease only. It lacks much real

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